The Role of Distraction Osteogenesis in Children with Secondary Craniosynostosis after Shunt Operation in Early Infancy

Abstract

Background: Secondary craniosynostosis rarely develops within several months in infants or children after shunt operations in early infancy. However, conventional operations (CO) such as fronto-orbital advancement and total skull reshaping have not been efficient enough to expand the intracranial volume in children with secondary craniosynostosis. Recently, distraction osteogenesis (DO) was reported to be effective in treating most craniosynostosis cases. Methods: We compared 9 children treated with DO and 3 children treated with CO who developed secondary craniosynostosis after shunt operation in early infancy. We measured the preoperative and follow-up head sizes with regard to head circumference, cephalometric intracranial volume, and intracranial volume estimated from the 3-dimensional computed tomogram. Results: The mean intracranial volumes expanded by 10.5% in the DO group 1 month after surgery and by 13.1% in the CO group on the immediate postoperative day. Further expansion was observed 6 months postoperatively, i.e. 10.3 and 4.7% in the DO and CO groups, respectively. Operation time and anesthesia time were significantly shorter in DO compared to CO patients, and the volumes of the blood transfusions were also less for DO patients. Conclusion: We suggest that DO is probably more efficient and safer than CO in expanding the intracranial volume in children with secondary craniosynostosis.

Cranial vault expansion by distraction osteogenesis

“…The median gain in volume in patients with craniocephalic disproportion was 13%, which is comparable to that reported by Park et al 44 The patients who had monobloc facial advancement, which included forward translation of the forehead and hence expansion of the anterior cranial fossa, experienced a median volumetric gain of 12%. For many patients, the bony translations required to achieve these gains far exceeded what is reasonably and safely achievable with single-stage operations and were accomplished with acceptably low morbidity.…”

“…47 Cranial vault expansions and monobloc facial advancements achieved by distraction osteogenesis are reported to require shorter surgical time and to entail less operative blood loss than single-stage procedures. 1,12,35,37,44,59 Estimations of surgical blood loss recorded by surgeons and anesthesiologists are less than ideally accurate; nevertheless we believe that the combined blood loss in the 2 procedures required for distraction osteogenesis is considerably less than in single-stage cranial expansions, and comparison of our data with that of Meling and colleagues 37,38 and of Akai et al 1 is consistent with this conclusion. The median combined blood loss for the 2 operations in our patients who underwent only vault expansion was 450 ml and for those with monobloc facial advancement with anterior vault expansion it was 800 ml.…”

“…Distraction osteogenesis is less technically difficult, less invasive, requires shorter operative time, is less dangerous, and results in less scarring and fewer bony defects than does single-stage structural expansion. 9,44,59 Less osseous devascularization is required and, very importantly, there is no postsurgical extradural dead space. 12,51,59 At the completion of the distraction process, patients actually have more bone than when the distracters were implanted, and the new bone is vascularized and it is in the correct location, has grossly correct shape and, of course, is autologous.…”

The Total Calvarial Remodeling with Transsutural Distraction Osteogenesis of 21 Cases of Craniosynostosis: New, Efficient, Safe and Natural Method in Craniosynostosis Surgery

“…Consequently, patients more than 2-3 years of age should undergo the older extensive craniotomy and remodeling method than minimal surgery such as DO and endoscopic craniectomy. Therefore, the posterior cranial DO and rotating DO were developed in the late 2000s, which were applicable to children aged older than 2-3 years and produced more generalized cranial correction and expansion [5,6,10,14,23,26]. However, the surgery duration, bleeding volume and transfusions in the posterior cranial DO and rotating DO was still considered to be uncomfortable although these had decreased markedly compared to craniotomy and remodeling [10,14,26].…”

“…This distraction osteogenesis (DO) procedure has been conducted in the mid-1990s, which although entailing disadvantages of a secondary procedure, also has advantages such as short surgery duration, less bleeding and a low risk of postoperative infection, and absence of a dead space [2]. These surgical merits have led to the development of various DO applications such as classical DO, rotating DO, anterior cranial DO, posterior cranial DO and transsutural distraction osteogenesis (TSuDO) [3,4,5,6,7,8,9,10,11]. However, the majority of surgical DO techniques developed to date consist of localized cranial expansion which may result in localized subdural space expansion while brain pressure is unrelieved in those portions where expansion is absent, resulting in insufficient brain development and uneven skull and brain growth that may produce developmental delay and poor cosmetic results.…”