Craniostenosis. (From the Greek synostosis = closure). It is defined as the premature closure of one, several or all of the sutures and, as a result, craniostenosis (from the Greek stenosis = narrowness), always involve alterations in the volume or morphology of the skull and face and, only on some occasions , clinical and brain function disorders.
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- 1 Story
- 2 Treatment
- 3 Indications
- 4 Surgical technique
- 1 Artificial sagittal suture
- 2 Artificial coronal suture
- 5 Decompression of the orbits
- 6 Complications
- 7 Sources
The surgery skull dates back to prehistoric times, both in the Americas and in the Euro-Asian-African. The trepanned skulls of Europe , mainly in the south and in America , especially in Peru , are evidence of this activity. In Mexico we have skulls trepanned by the Zapotecs and the Aztecs . As for the face, Sutra techniques for nose reconstruction are well known in India .
The objective of surgical treatment of craniostenosis is to normalize intracranial hypertension and prevent serious complications that it can cause, such as: serious vision disorders , mental retardation , etc. As a secondary task, cosmetics are considered, when the craniostenosis is due to the ossification of a single suture , this causes an unpleasant deformation of the head without manifestations of intracranial hypertension.
The existence of intracranial hypertension, exophthalmia of progressive evolution or atrophy of the optic nerves, are precise indications for surgical treatment. Surgical behavior depends on the state of the vision and intellectual development of the child .
Incipient papilledema, decreased vision, and manifestations of mental retardation are the most common indications for surgical treatment. Lastly, it can also be indicated when there is an obvious disease of the skull, due to the early oscillation of some sutures, which allows us to suppose that in the future it will alter the development of the skull.
When there is a marked mental retardation, there is complete loss of vision and the headache disappears, it is not necessary to apply surgical treatment, because these data indicate an advanced and stable evolution of the disease .
Many operations are known for the treatment of craniostenosis with intracranial hypertension or skull deformity, but the most commonly used is a linear craniectomy of 0.5 cm to 2 cm. wide, or in other directions.
Malleable saw with meninges protector.
Artificial sagittal suture
The patient is placed on the operating table or operating room in a lateral position, with the head slightly elevated. The epicranean soft tissue incision is made exactly in the midline, starting in the frontal region at the hair insertion line and reaching 3–4 cm. behind the lamdoid suture.
The skin , subcutaneous tissue, and epicranial fascia are laterally separated up to 3 or 5 cm. from the midline. The periosteum is decorated in this area and a straight line of 2 cm is marked. Laterally and parallel to the midline from the coronal suture to the lamdoid suture.
On the path of this line are practiced 3 or 4 burr holes and the gap therebetween is resected by a clamp of gouge to obtain a linear craniectomy 1.5-2 cm. wide. It is important that the linear craniectomies exceed the coronal suture in front and the lamdoid suture behind by 1 to 2 cm. and that they penetrate the frontal bone and the occipital bone. In the end, the epicranian soft tissues are sutured.
Artificial coronal suture
The skin incision is made transverse and immediately behind the hair insertion line, parallel to the coronal suture to bring together both temporal regions. The skin, subcutaneous tissue, and epicranial fascia are separated by a distance of 3 to 4 cm. The periosteum is excised over the entire length of the exposed area and a transverse linear craniectomy is performed, the two ends of which remain in the temporal regions and widen below the temporal muscle in a circular shape, with a diameter of 3 to 4 cm.
When there is a syndrome of intracranial hypertension, linear trepanations are made in a different way, according to the methods of the different authors, by offering the skull the possibility of increasing its dimensions in different directions.
At the end of the operation, decompressive craniectomies are performed in the two temporal regions. When the operation is performed in two operative times, the same is done a few days later on the other side. To avoid deformation of the skull or the sinking of some fragments, a very thin plaster bandage is practiced for a month.
Decompression of the orbits
When the craniostenosis is associated with narrowing of the sphenoid cleft, spheno-maxillary cleft and deformity of the ceilings of the orbits, the orbital cavity decreases in volume, causing exophthalmia, making the face very unpleasant and making occlusion difficult. palpebral, which can cause keratoconjunctivitis. In such cases, decompression of the orbital cavities is indicated. It is usually performed at the same time as the artificial coronal suture is done.
A frontotemporal craniotomy is performed, the inner edge of which reaches the midline and the lower edge should be as low as possible. The posterior edge of said craniotomy corresponds to the coronal suture path, which widens up to 1.5 to 2 cm, and its edges can be covered with polyethylene . The frontal lobe separates upwards when the dura is detached from the orbital ceiling, and we continue the separation inward, approaching the lamina lamina, backwards, until the minor wing is released, then a drill hole is made that widens with the gouge until the entire roof of the orbit is removed along with the minor wing of the sphenoid, thus leaving the sphenoid cleft open.
Laterally, by separating the temporal muscle, the lateral wall of the orbit is removed, and the orbital rim is preserved. The orbital periosteum is opened and the periorbital fatty tissue comes out under tension. When there are data of marked intracranial hypertension and it is assumed that the dura mater tension is greater than in the orbits, it is advisable to perform artificial sutures at a previous operative time, and when the evidence of intracranial hypertension decreases, the decompression in the orbits.
In patients with narrowing of the optic duct causing visual disturbances and optic atrophy, decompression of the nerves is indicated. Technically, this is done through a craniotomy in the front region and an opening of the orbital roof at the back. From the same opening, the wall of the optic conduit is resected with a very fine gouge forceps or a fine electric burr until the entire nerve is well released. If this manipulation is not possible via the extradural route, it is terminated by the subdural route.
The most frequent complications during the operation are hemorrhages from the bone or injury to the dura mater, which, in many cases, is attached to the inside of the vault; On the other hand, it is irregular due to the presence of digitiform impressions. In the postoperative period, a hematoma may form below the epicranial soft tissue and its evacuation is required the day after the operation.