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Reformation of Suture Following Surgery for Isolated Sagittal Craniosynostosis   Deepak Agrawal, Paul Steinbok, D Cochrane...
ISOLATED SAGITTAL CRANIOSYNOSTOSIS   <ul><li>BASIS FOR MANAGEMENT </li></ul><ul><li>Isolated entity in a normal child </li...
ETIOLOGY <ul><li>Moss’s Hypothesis </li></ul><ul><li>Abnormality at cranial base </li></ul><ul><li>Moss, M. L. (1959). &qu...
ETIOLOGY <ul><li>Babler’s Hypothesis </li></ul><ul><li>Abnormality is in the affected calvarial sutures  </li></ul><ul><li...
<ul><li>Reformation of sagittal suture should similarly be expected in children with isolated sagittal synostosis </li></ul>
OBJECTIVE <ul><li>To determine the incidence of reformation of the sagittal suture following surgical procedures for sagit...
MATERIALS AND METHODS <ul><li>Retrospective study 1987-2000 </li></ul><ul><li>Children with isolated sagittal craniosynost...
Operative Procedure <ul><li>Minimum of vertex and parietal craniectomies </li></ul><ul><li>(removal of the sagittal suture...
Assessment of resynostosis <ul><li>POST-OP  SKULL RADIOGRAPHS </li></ul><ul><li>Suture morphology </li></ul><ul><li>Patenc...
RESULTS <ul><li>114 children operated for isolated sagittal craniosynostosis in the above period. </li></ul><ul><li>42 chi...
RESULTS <ul><li>Median age at surgery- 3.9 months </li></ul><ul><li>  (1.9 to 7.6 months) </li></ul><ul><li>Mean follow up...
RESULTS <ul><li>Only 7/42 (16.7%) reformed the suture </li></ul><ul><li>35/42  (83.3%) had resynostosis of the sagittal su...
 
 
 
<ul><li>These findings are contrary to the results from animal experiments </li></ul><ul><li>WHY THE DISCREPANCY? </li></ul>
DISCUSSION <ul><li>Both dura mater and pericranium have osteogenic properties </li></ul><ul><li>Dura-source of central new...
DISCUSSION <ul><li>In Sag synostosis surgery-central strip of bone with the attached pericranium removed </li></ul><ul><li...
DISCUSSION <ul><li>Common practice to coagulate the bleeding points on the dura </li></ul><ul><li>This again could impair ...
DISCUSSION <ul><li>Primary aim of surgery is cosmetic </li></ul><ul><li>Persistence of bony defects and uneven contour of ...
OUR HYPOTHESIS <ul><li>Limiting coagulation on the dura & replacing  pericranium could potentially result in consistent bo...
OTHER POTENTIAL FACTORS <ul><li>GENETIC BASIS </li></ul><ul><li>Inclusion of undiagnosed syndromic patients </li></ul><ul>...
CONCLUSIONS <ul><li>We found a very high incidence of resynostosis following surgery for sagittal craniosynostosis </li></...
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Reformation of suture following surgery for isolated sagittal craniosynostosis

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Reformation of suture following surgery for isolated sagittal craniosynostosis

  1. 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. 2. ISOLATED SAGITTAL CRANIOSYNOSTOSIS <ul><li>BASIS FOR MANAGEMENT </li></ul><ul><li>Isolated entity in a normal child </li></ul><ul><li>Operative Intervention-Improve cosmesis </li></ul>
  3. 3. ETIOLOGY <ul><li>Moss’s Hypothesis </li></ul><ul><li>Abnormality at cranial base </li></ul><ul><li>Moss, M. L. (1959). &quot;The pathogenesis of premature cranial synostosis in man.&quot; Acta Anat (Basel) 37 : 351-70. </li></ul><ul><li>Proven for syndromic craniosynostosis </li></ul>
  4. 4. ETIOLOGY <ul><li>Babler’s Hypothesis </li></ul><ul><li>Abnormality is in the affected calvarial sutures </li></ul><ul><li>Babler, W. J., J. A. Persing, et al. (1982). &quot;Compensatory growth following premature closure of the coronal suture in rabbits.&quot; J Neurosurg 57 (4): 535-42. </li></ul><ul><li>Support from animal experiments </li></ul><ul><li>Mabbutt, L. W. and V. G. Kokich (1979). &quot;Calvarial and sutural re-development following craniectomy in the neonatal rabbit.&quot; J Anat 129 (2): 413-22. </li></ul>
  5. 5. <ul><li>Reformation of sagittal suture should similarly be expected in children with isolated sagittal synostosis </li></ul>
  6. 6. OBJECTIVE <ul><li>To determine the incidence of reformation of the sagittal suture following surgical procedures for sagittal synostosis that involved a minimum of sagittal strip craniectomy </li></ul>
  7. 7. MATERIALS AND METHODS <ul><li>Retrospective study 1987-2000 </li></ul><ul><li>Children with isolated sagittal craniosynostosis </li></ul>
  8. 8. Operative Procedure <ul><li>Minimum of vertex and parietal craniectomies </li></ul><ul><li>(removal of the sagittal suture + 1.5 - 2.5 cm piece of adjacent parietal bone with the attached pericranium) </li></ul><ul><li>Children who had the bone flap replaced were excluded from the study </li></ul>
  9. 9. Assessment of resynostosis <ul><li>POST-OP SKULL RADIOGRAPHS </li></ul><ul><li>Suture morphology </li></ul><ul><li>Patency of coronal and lambdoid sutures </li></ul>
  10. 10. RESULTS <ul><li>114 children operated for isolated sagittal craniosynostosis in the above period. </li></ul><ul><li>42 children composed the study group. </li></ul>
  11. 11. RESULTS <ul><li>Median age at surgery- 3.9 months </li></ul><ul><li> (1.9 to 7.6 months) </li></ul><ul><li>Mean follow up - 32.2 months </li></ul><ul><li> (6 to 144 months) </li></ul>
  12. 12. RESULTS <ul><li>Only 7/42 (16.7%) reformed the suture </li></ul><ul><li>35/42 (83.3%) had resynostosis of the sagittal suture </li></ul>
  13. 16. <ul><li>These findings are contrary to the results from animal experiments </li></ul><ul><li>WHY THE DISCREPANCY? </li></ul>
  14. 17. DISCUSSION <ul><li>Both dura mater and pericranium have osteogenic properties </li></ul><ul><li>Dura-source of central new bone </li></ul><ul><li>Pericranium- enhances peripheral new bone formation </li></ul><ul><li>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 </li></ul>
  15. 18. DISCUSSION <ul><li>In Sag synostosis surgery-central strip of bone with the attached pericranium removed </li></ul><ul><li>Removal of this pericranium could potentially impair bony regeneration as well as suture reformation </li></ul>
  16. 19. DISCUSSION <ul><li>Common practice to coagulate the bleeding points on the dura </li></ul><ul><li>This again could impair the osteogenic capacity of the dura </li></ul>
  17. 20. DISCUSSION <ul><li>Primary aim of surgery is cosmetic </li></ul><ul><li>Persistence of bony defects and uneven contour of the bony regrowth may result in patient dissatisfaction, rarely culminating in repeat surgery </li></ul>
  18. 21. OUR HYPOTHESIS <ul><li>Limiting coagulation on the dura & replacing pericranium could potentially result in consistent bone regeneration with smooth contour and reformation of a normal suture. </li></ul><ul><li>Further prospective studies would be required to prove this hypothesis </li></ul>
  19. 22. OTHER POTENTIAL FACTORS <ul><li>GENETIC BASIS </li></ul><ul><li>Inclusion of undiagnosed syndromic patients </li></ul><ul><li>Genetic predisposition to synostosis </li></ul>
  20. 23. CONCLUSIONS <ul><li>We found a very high incidence of resynostosis following surgery for sagittal craniosynostosis </li></ul><ul><li>The variability in reformation of the suture after surgery suggests a heterogeneous etiology and pathogenesis of isolated sagittal synostosis. </li></ul>
  21. 24. THANK YOU

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