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University Research for Developing Minimally Invasive Surgery Can Provide Treatment Where It Was Once Not Available

Author(s): C. Sanger*1, L. R. David1
Affiliation(s): 1Plastic and Reconstructive Surgery, Wake Forest University, Winston-Salem, USA
Keywords: Craniofacial surgery, international educational exchange, minimally invasive surgery, scientific advances
Background:

When one or more of the cranial sutures fuse before the brain has had time to grow it is called craniosynostosis. Normal brain growth relies on the major cranial sutures remaining open until the late adolescent and adult years. Craniosynostosis affects as many as 5 infants in 10,000 and can lead to serious irreversible damage if not corrected in a timely manner. In the mid 1900s, surgeons began to perform complex cranial vault remodelling to release the intracranial pressure. This was done by removing the entire calvaria, expanding the bone segments and replacing them with plates and screws. The operation lasted the entire day necessitated blood transfusions and long hospitalizations. From that time to the turn of the century no significant progress was made to offer a safer procedure for the treatment of craniosynostosis. We now have a minimally invasive technique that provides infants treatment without the high risks previously encountered.

Summary/Objectives:

In 1998, the craniofacial centre in Sweden began to perform spring mediated cranioplasty where only the prematurely fused suture was removed and a stainless steel spring was placed at the craniectomy site. The spring provided lateral distraction which provided brain growth and skull shape normalization. The procedure was new but the early results were profound. In July 2000, Wake Forest University launched the research project to study the technique. Institutional Board Review (IRB) approval was obtained for the animal study which then transitioned to the prospective infant study. The study resulted in Food and Drug Administration (FDA) approval for spring mediated cranioplasty for the treatment of craniosynostosis. A single craniectomy is performed at the site of premature fusion. The inexpensive stainless steel spring is placed at the craniectomy site which causes lateral expansion slowly over three to five months. This prevents premature re-fusion without significant blood loss or pressure on the brain. The objective was to offer patients a safer procedure with no need for blood transfusions and significantly reduced hospitalizations.

Results:

We now have patients with seven years follow up and are excited with the sustained normalization of the skull shape and improvement in the intracranial pressure. The children no longer need blood transfusions and are able to return home after only one night in the hospital. We are now sharing this procedure with other countries and find it particularly beneficial for countries with limited technology and supportive services. Extensive cranial vault remodelling requires extensive equipment for monitoring the infants in the operating room and postoperatively. The safety and cost of blood transfusions required for traditional surgery often makes it impossible to offer to infants. Since spring mediated cranioplasty is comparatively much safer, it is now possible for treatment to be provided for patients that would otherwise not have any options available. The procedure has been performed in several countries around the world with successful results.

Lessons learned:

Surgeons from different countries are able to share ideas for improving patient treatments for complex deformities. Once institutionally approved studies have been performed the advances can be shared around the world to improve the lives of children worldwide.

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