A Preliminary Investigation of Postoperative Molding to Improve the Result of Cranial Vault Remodeling

Autor: Samuel Stal, Larry H. Hollier, Stephen Higuera, Phillip M. Stevens
Rok vydání: 2005
Předmět:
Zdroj: JPO Journal of Prosthetics and Orthotics. 17:125-128
ISSN: 1040-8800
Popis: Craniosynostoses most frequently require correction by craniotomy and cranial vault remodeling to facilitate neurologic development and normal cranial shape. Although the skull can be fairly accurately contoured intraoperatively, the final shape is dependent on many factors, including bone and brain growth and bone resorption. Although molding helmets have been used for positional head molding and in the management of endoscopic suturectomy, very few studies have evaluated their use in the postoperative care of patients undergoing open cranial remodeling. The authors sought to evaluate the use of postoperative helmet therapy after surgical correction for nonsyndromic single suture craniosynostosis. A retrospective review of six patients with nonsyndromic craniosynostosis who underwent cranial remodeling by a single surgeon with postoperative helmet therapy in 2003 and 2004 was performed. The four female and two male patients ranged in age from 5 months to 13 months at the time of surgery. All the patients were seen and measured by the same orthotist, and helmet therapy was begun 2 to 4 weeks after surgery. Postoperative helmet therapy lasted for 6 months. All patients showed an improved cephalic index when compared with the initial postoperative measurements. There were no adverse consequences associated with helmet therapy. Helmet therapy after craniosynostosis surgery improves cephalic index and skull shape beyond the results obtained at surgery. The authors conclude that postoperative helmet therapy is an effective treatment adjunct to craniosynostosis surgery for patients with nonsyndromic single suture synostosis. ( J Prosthet Orthot. 2005;17:125–128.) The value of helmet therapy in the treatment of dysmorphic cranial vaults has been well established. In cranial deformities secondary to positional head molding, the use of helmets to improve the flattened areas of the skull can be quite dramatic. However, this success is dependent on the rapidly growing brain pushing out the immature cranial vault in those areas allowed by the helmet. More recently, helmets have been increasingly used after endoscopic cranial vault surgery. In this process, the fused suture is resected and a limited number of osteotomies performed. The patient is then placed immediately in a conforming helmet to help mold the surgically treated skull into the desired shape because no substantial reshaping is performed during surgery. When performed at a very early age, the results from this technique have been promising. However, very few authors have used helmets after surgery in patients who have undergone radical cranial vault remodeling, ostensibly because the addition of the helmet was deemed unnecessary once the osteotomized cranial vault had been shaped appropriately. The current article reviews a series of patients undergoing standard cranial vault remodeling for single suture synostosis via a coronal approach with frontal orbital advancement with cranial reshaping. All patients were placed into helmets immediately after surgery, with accurate documentation of skull shape recorded before and after treatment. PATIENTS AND METHODS Six patients underwent cranial remodeling with postoperative helmet therapy from 2003 to 2004. All patients had a diagnosis of nonsyndromic craniosynostosis. Two patients had metopic synostosis, two patients had left unilateral coronal synostosis, one had bilateral coronal synostosis, and one had a right unilateral coronal synostosis. The patients' ages at the time of operation ranged from 5 months to 13 months. The patients were evaluated and measured by the same orthotist, and helmet therapy was begun 2 to 4 weeks after surgery. Measurements were recorded, and the cephalic index was calculated using the formula (head width / head length X 100). The cephalic index is a proportion of the width of the head to the length of the head. The cephalic indices were compared with the normative data described by Farkas. A cephalic index of 78% was used as the ideal value. Measurements were performed using a caliper and included cranial circumference, skull base, cranial vault, orbitotragal depth, head width, and head depth ( Table 1 ). Patients had serial visits to the orthotist for measurements and adjustments at 3-week intervals, and helmet therapy lasted 4 to 6 months. Table 1. Measurements recorded by the orthotist Two to 4 weeks after surgery, a plaster mold was made by the orthotist. The plaster served as a template for the helmet ( Figure 1 ). The helmet was made of 3/8 inch co-polymer thermoplastic with an interface foam of 1/2 inch closed cell pelite ( Figure 2 ). During the orthotist follow-up visits, adjustments were made to relieve any areas of impingement. The helmet fit was closely monitored to ensure the treatment strategy was maintained. Gradual removal of the foam interface material allowed for these regular adjustments. Care was taken to ensure proper clearances of the patient's ears and allowed the patient a reasonable visual field. The orthotist verified intimate contact of the helmet in areas where growth constraint was desired and sufficient clearance where corrective growth was desired. The family was instructed how to perform daily skin checks and other pertinent caregiver instructions. The helmet was kept on the patient for a total of 23 hours a day. Figure 1. A plaster mold is made 2–4 weeks after surgery, serving as a template for the helmet. Figure 2. Two views of the helmet.
Databáze: OpenAIRE
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