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Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
Reformation of suture following surgery for isolated sagittal craniosynostosis
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Reformation of suture following surgery for isolated sagittal craniosynostosis

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  • he debate regarding the etiology of craniosynostosis has primarily revolved around Moss’s hypothesis of a primary abnormality at the cranial base (Moss 1958; Moss 1959; Moss 1972; Moss 1975), versus Babler’s hypothesis that the abnormality is in the affected calvarial sutures (Babler, Persing et al. 1982). With syndromic craniosynostosis, it has become reasonably clear that the primary abnormality involves the cranial base, and that cranial base alterations affect the dural reflections, which somehow predisposes to premature closure of the sutures. As surgery does not correct the underlying pathology, it is not surprising to have recurrent synostosis in these cases.
  • In contrast, the etiology of nonsyndromic, single suture synostosis is usually ascribed to compressive intrauterine forces that act on individual sutures and recurrent synostosis is less likely, since the surgery usually removes the pathological suture (Hudgins, Cohen et al. 1998). Support for this hypothesis comes from animal experiments which have shown that when the calvaria is excised and discarded, a new calvaria forms with time and sutures redevelop in their normal anatomic positions (Mabbutt and Kokich 1979; Mabbutt, Kokich et al. 1979)
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    • 1. Reformation of Suture Following Surgery for Isolated Sagittal Craniosynostosis Deepak Agrawal, Paul Steinbok, D Cochrane Division of Pediatric Neurosurgery, UBC and BC Children’s Hospital, Vancouver, BC
    • 2. ISOLATED SAGITTAL CRANIOSYNOSTOSIS
      • BASIS FOR MANAGEMENT
      • Isolated entity in a normal child
      • Operative Intervention-Improve cosmesis
    • 3. ETIOLOGY
      • Moss’s Hypothesis
      • Abnormality at cranial base
      • Moss, M. L. (1959). "The pathogenesis of premature cranial synostosis in man." Acta Anat (Basel) 37 : 351-70.
      • Proven for syndromic craniosynostosis
    • 4. ETIOLOGY
      • Babler’s Hypothesis
      • Abnormality is in the affected calvarial sutures
      • Babler, W. J., J. A. Persing, et al. (1982). "Compensatory growth following premature closure of the coronal suture in rabbits." J Neurosurg 57 (4): 535-42.
      • Support from animal experiments
      • Mabbutt, L. W. and V. G. Kokich (1979). "Calvarial and sutural re-development following craniectomy in the neonatal rabbit." J Anat 129 (2): 413-22.
    • 5.
      • Reformation of sagittal suture should similarly be expected in children with isolated sagittal synostosis
    • 6. OBJECTIVE
      • To determine the incidence of reformation of the sagittal suture following surgical procedures for sagittal synostosis that involved a minimum of sagittal strip craniectomy
    • 7. MATERIALS AND METHODS
      • Retrospective study 1987-2000
      • Children with isolated sagittal craniosynostosis
    • 8. Operative Procedure
      • Minimum of vertex and parietal craniectomies
      • (removal of the sagittal suture + 1.5 - 2.5 cm piece of adjacent parietal bone with the attached pericranium)
      • Children who had the bone flap replaced were excluded from the study
    • 9. Assessment of resynostosis
      • POST-OP SKULL RADIOGRAPHS
      • Suture morphology
      • Patency of coronal and lambdoid sutures
    • 10. RESULTS
      • 114 children operated for isolated sagittal craniosynostosis in the above period.
      • 42 children composed the study group.
    • 11. RESULTS
      • Median age at surgery- 3.9 months
      • (1.9 to 7.6 months)
      • Mean follow up - 32.2 months
      • (6 to 144 months)
    • 12. RESULTS
      • Only 7/42 (16.7%) reformed the suture
      • 35/42 (83.3%) had resynostosis of the sagittal suture
    • 13.  
    • 14.  
    • 15.  
    • 16.
      • These findings are contrary to the results from animal experiments
      • WHY THE DISCREPANCY?
    • 17. DISCUSSION
      • Both dura mater and pericranium have osteogenic properties
      • Dura-source of central new bone
      • Pericranium- enhances peripheral new bone formation
      • Gosain AK, Santoro TD, Song LS, et al: Osteogenesis in calvarial defects: contribution of the dura, the pericranium, and the surrounding bone in adult versus infant animals. Plast Reconstr Surg 112: 515-527, 2003
    • 18. DISCUSSION
      • In Sag synostosis surgery-central strip of bone with the attached pericranium removed
      • Removal of this pericranium could potentially impair bony regeneration as well as suture reformation
    • 19. DISCUSSION
      • Common practice to coagulate the bleeding points on the dura
      • This again could impair the osteogenic capacity of the dura
    • 20. DISCUSSION
      • Primary aim of surgery is cosmetic
      • Persistence of bony defects and uneven contour of the bony regrowth may result in patient dissatisfaction, rarely culminating in repeat surgery
    • 21. OUR HYPOTHESIS
      • Limiting coagulation on the dura & replacing pericranium could potentially result in consistent bone regeneration with smooth contour and reformation of a normal suture.
      • Further prospective studies would be required to prove this hypothesis
    • 22. OTHER POTENTIAL FACTORS
      • GENETIC BASIS
      • Inclusion of undiagnosed syndromic patients
      • Genetic predisposition to synostosis
    • 23. CONCLUSIONS
      • We found a very high incidence of resynostosis following surgery for sagittal craniosynostosis
      • The variability in reformation of the suture after surgery suggests a heterogeneous etiology and pathogenesis of isolated sagittal synostosis.
    • 24. THANK YOU

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