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A Craniometric Analysis Of Posterior Cranial Vault Distraction Osteogenesis
Jesse A. Goldstein, MD1, J T. Paliga, BA2, Jason Wink, BA2, Scott Bartlett, MD1, Jesse Taylor, MD1.
1University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA, USA, 2University of Pennsylvania, Philadelphia, PA, USA.

PURPOSE: Posterior cranial vault distraction osteogenesis (PVDO) has replaced fronto-orbital advancement in some centers as the first-line treatment in patients with syndromic craniosynostosis citing this procedure’s safety profile, reliability, increased ability to expand intracranial volume, and ability to delay frontal surgery. Despite this fact, little has been written about the craniometric effects of PVDO on children with syndromic craniosynostosis. We present craniometric outcomes on the largest series of PVDO cases to date.
METHODS:An IRB approved retrospective review of all patients who have undergone PVDO at our center was performed. Patient demographic, pre- and post-operative data, and pre- and post-op CT scans performed as part of normal patient care were reviewed. Volumetric and craniometric indices were calculated and measured using commercial 3D imaging software.
RESULTS:From 2008 to 2012, 22 patients (8 males and 14 females) with syndromic craniosynostosis underwent PVDO at our institution for concerns of intracranial hypertension (11 patients) or severe turribrachicephaly (11 patients). Diagnoses included Apert syndrome (3 patients), Muenke syndrome (2 patients), Saethre-Chotzen syndrome (5 patients), Crouzon syndrome (4 patients), Pfeiffer syndrome (2 patients), VACTERL syndrome (1 patient). 5 patients had unique genetic syndromes. In 13 patients, this was the first cranial vault procedure performed, while 8 had previous fronto-orbital advancement, and 1 had parieto-occipital reshaping. Half of the patients underwent PVDO prior to age 1; the average age at surgery was 2.3 years (range: 0.3 to 14.1) and distraction length averaged 27.3 mm (range: 19 to 35mm). Average length of surgery was 2.9 hours (range: 1.6 to 3.8 hours), and average blood loss was 400 ml (range: 200 to 600 ml). Total treatment length was 91 days (range: 48 to 147 days). Overall linear distraction length ranged from 19-35 mm with an average of 27.3 mm. Average intracranial volume increase in all patients was 21.5% (range: 7.5 to 70.0%; p < 0.0001) and 28.4% (range: 10.8 to 66.0%; p = 0.01) in the subset of patients less than 1 year old. Posterior cranial height increased by an average of 12.2% (range: 0 to 35%, p = 0.002) and basofronal angle decreased by an average of 3.9% (range: 0 to 12%; p = 0.003) indicating a decrease in cranial height trajectory and improvement in frontal bossing.
CONCLUSION:PVDO is a safe and effective operation which may lessen the risk of intracranial hypertension and abnormal skull morphology in patients with syndromic craniosynostosis. Interestingly, our data demonstrate cranial morphological benefits both anteriorly and posteriorly; it may help to control turribrachicephaly, as well, though thorough, long-term comparison still needs to be done.


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