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10 Year Experience with Spring Assisted Surgery for Craniosynostosis
Lisa R. David, M.D.1, Claire Sanger, D.O.1, Daniel Couture, M.D.1, Steve Glazier, M.D.2.
1Wake Forest University, Winston-Salem, NC, USA, 2Medical University of South Carolina, Charleston, SC, USA.
Purpose: Spring Assisted Surgery (SAS), since its innovative beginnings in Sweden by Dr. Claes Lauitzen, has seen increasing utilization in a variety of craniofacial deformities. Current applications include both expansion and contraction in children with multiple suture synostoses, posterior expansion for brachycephaly, and its initial application for single suture craniosynostosis. We review the outcome of our ten years of utilization of this treatment modality for craniosynostosis.
Methods: We began utilizing springs for the treatment of Craniosynostosis at Wake Forest University 10 years ago. Surgical procedures are done as a team approach with our pediatric neurosurgical colleagues. A strip craniectomy is performed of the synostotic sutures and 1 to 4 springs placed. Spring design is dependent on age at surgery, type of craniosynostosis, and bone thickness. Postoperative analysis includes cephalometric analysis, cephalic index, cranial volume calculations utilizing a scanning laser analysis, as well as developmental outcome studies.
Results: We have treated 136 children (91 males, 45 females) at a mean age of 4.4 months at the initial surgery and mean age at removal of 9.3 months (mean duration 4.9 months) for scaphocephaly. In addition we also utilized SAS to treat 5 children with unicoronal craniosynostosis, 6 children with bicoronal craniosynostosis, 4 children with metopic craniosynostosis, and 5 children with multiple suture synostoses. In the cases of scaphocephaly, the cephalic index improved significantly from a mean pretreatment value of 65.33 to 75.44 and this has continued to improve and be maintained over a mean follow up time of 60 months. Mean OR time, blood utilization, hospital stay, and cost are all significantly decreased in comparison to children treated with cranial vault reconstruction during the same time period. Developmental outcome analysis has identified delay in only 3 of the study children. There has been minimal morbidity and no mortalities associated with this treatment protocol.
Conclusions: Since beginning our clinical study in 2001, SAS has become our treatment of choice for children 7 months or younger with scaphocephaly. This technique works to dynamically reshape the calvarium in three dimensions by both direct and indirect means. The direct outward force of the spring applied at the bone edges leads to an immediate increase in cranial width on the operating table that continues over time due to expansion of the spring and brain growth. Secondly, because the coronal and lambdoid sutures retain their attachment to the parietal bones, the springs create an indirect pull inward that works to shorten the AP length of the skull. This results in a dynamic three dimensional correction of the skull. In addition in the appropriately selected cases, spring assisted surgery is also appropriate for the fusion of other sutures in isolation or in combination with cranial vault reconstruction. Spring-assisted surgery offers a safe, effective, and less invasive option for the treatment of craniosynostosis. In addition, dynamic remodeling forces achieve good clinical results which are maintained over long term follow up.
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