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Consensus Topics

The Use of Postoperative Cranial Orthoses in the Management of Craniosynostosis

Barringer, William J. MS, CO

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JPO Journal of Prosthetics and Orthotics: October 2004 - Volume 16 - Issue 4 - p S56-S58
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Craniosynostosis is a cranial deformity that can be directly related to the premature closure of cranial sutures. It affects one in 2100 children,1 and of those, 40 to 60 are sagittal, 20 to 30 are coronal, and 10 are metopic.1,2 Lambdoid synostosis is the rarest.3 Researchers do not have a clear understanding of the genetic influences or developmental pathology that predisposes cranial sutures to premature closure.

Treatment for craniosynostosis is reserved for surgical intervention. Many different types of surgical procedures have been described, including cranial vault reconstruction and endoscopic techniques. Although cranial orthoses are contraindicated for primary treatment of any variation of craniosynostosis, they can be a valuable adjunct to the postoperative management of many cases. The purpose of this discussion is to provide a review of pertinent literature concerning the use and role of postoperative orthoses. In addition, the results of a survey regarding postoperative orthotic treatment protocols are provided.

LITERATURE REVIEW

The different manifestations of craniosynostosis are commonly studied and reported; however, few authors have attempted to investigate the use of cranial orthoses after surgery. Many authors recommend the use of orthoses postsurgery to further enhance surgical correction, yet studies concerning the benefit of postoperative management are rare. A retrospective study at the University of Texas–Houston Medical School reviewed 21 children with sagittal craniosynostosis between 1994 and 2001.4 Six of these children were in the nonorthotic group and 15 were managed with orthoses postoperatively. The investigators used the dynamic orthotic cranioplasty (DOC) band (Cranial Technologies, Inc., Phoenix, AZ) postoperatively and recorded anthropomorphic measurements presurgery and postsurgery, or postorthotic treatment. They found that the preoperative cephalic indices, when compared with postoperative cephalic indices, of both groups were significantly different and documented a statistically significant improvement. Although surgical improvement was seen in both groups, the orthotic group demonstrated a trend toward normal that the nonorthotic group did not. Statistical analysis concluded that the use of an orthosis maintains surgical correction while promoting new growth patterns. Therefore, the authors recommend the use of cranial orthoses as an adjunct to surgery for sagittal synostosis.

Jimenez and Barone,5 in a prospective study, investigated 100 patients with a distribution of 61 sagittal sutures, 23 coronal sutures, 18 metopic sutures, and four lambdoid sutures involved. Although their study was primarily aimed at surgical techniques, all patients were fit with postoperative cranial orthoses. The authors presented no statistical evidence; however, they believe that the use of cranial orthoses postoperatively further promotes normal growth and counteracts the tendency of the cranial vault to resume a presurgical shape. Patients treated with surgery had a mean age of 3.1 months and were fit with two to three orthoses worn until at least 12 months of age. These authors also advocated the use of postoperative cranial orthoses to enhance the surgical result.

In a study of nine patients by Pomatto et al.,6 the authors suggest that postoperative orthoses assist in improving the cephalic index after endoscopic procedures. Using the DOC band, measurements were documented at the beginning of treatment and every 2 weeks until the completion of treatment. They, too, concluded that orthotic treatment produced more normal head shapes.

In a similar study by Joganic et al.,7 the DOC band was used for postoperative treatment in 62 cases. Their data suggest that osteotomy of the calvarium in craniofacial reconstruction renders the skull base susceptible to change when the DOC band is used. They also stated that the DOC band was effective in reversing early relapse of deformity when certain forces were present.

Persing et al.8 at the University of Virginia in 1986 reported on a “skull molding cap” that was fabricated with Orthoplast and used as a follow up to surgery. Although no statistical data were included, the authors suggested that the primary use of this orthosis was to prevent relapse of the calvarium to presurgical shape and provide additional correction when needed. The orthoses were worn 6 to 9 months postsurgery or until bony stability had been realized.

Figures 1 and 2 show just two of the many orthotic designs used in the postoperative management of craniosynostosis.

Figure 1.
Figure 1.:
Two views of the postoperative orthosis used by the University of Michigan.
Figure 2.
Figure 2.:
Cranial Technologies orthosis using tension bands to assist with correction.

SURVEY RESULTS

In an attempt to gather current trends in postoperative orthotic management of infants with craniosynostosis, 12 institutions were surveyed either by phone or mail: The Cleveland Clinic, St. Louis Children’s Hospital, Atlanta Children’s Hospital, The University of Oklahoma, The University of Missouri, Gillette Children’s Hospital, Mary Freebed Rehabilitation Hospital, The University of Michigan, Cranial Technologies, Pongratz Orthotics and Prosthetics, Restorative Health Service, and Eastern Cranial Affiliates. The results of the survey are outlined in Table 1.

Table 1
Table 1:
The use of postoperative cranial orthoses in the management of craniosynostosis

DISCUSSION

The goal of this survey was to investigate the use of postoperative cranial orthoses after surgery for craniosynostosis. Although the survey was limited in size (only 12 centers) and the questions were not scientifically designed, the information gathered might prove useful to those who are not familiar with the techniques of postoperative orthotic management.

Although much has been written on the surgical care of these patients, little has been said about the postoperative care. Most authors reserve little time for discussion of postoperative treatment and dedicate no time to orthoses as an adjunct to surgical management. However, there are a few studies that document the use of postoperative cranial orthoses and their efficacy as an adjunct to surgery. These authors believe that postoperative cranial orthoses are a valuable tool in enhancing the surgical outcomes for craniosynostosis.4–8 It appears that orthoses can be used to extend the correction gained in surgery or to protect against regression to the presurgical deformity. It is also apparent that age, severity of deformity, type of deformity, surgical procedure, physician preference, and bone healing play important roles in determining the overall outcome and decision-making.

REFERENCES

1. Lajeunie E, Le Merren M, Bonaiti-Pellie C, et al. Genetic study of nonsyndromic coronal craniosynostosis. Am J Med Genet 1995;55:500–504.
2. Hunter AG, Rudd NL. Craniosynostosis I. Sagittal synostosis: its genetics and associated clinical findings in 214 patients who lacked involvement of the coronal suture. Tetralogy 1984;14:185–194.
3. Sun P, Pershing J. Craniosynostosis. In: Albright AL, Pollack IF, Adelson PD, eds. Principles and Practice of Pediatric Neurosurgery. New York: Thieme Medical Publishers; 1999:219–242.
4. Seymour-Dempsey K, Baumgartner J, Teichgraeber J. Molding helmet therapy in the management of sagittal synostosis. J Craniofac Surg 2002;13:631–635.
5. Jimenez D, Barone C. Early management of craniosynostosis using endoscopic-assisted strip craniectomies and cranial orthotic molding therapy. Pediatrics 2002;110:97–104.
6. Pomatto J, Beals S, Joganic E. Preliminary results and new treatment protocol for cranial banding following endoscopic-assisted craniectomy for sagittal synostosis. J Craniofac Surg 2001;9:47–49.
7. Joganic EF, Beals SP, Ripley CE, et al. Enhancement of craniofacial reconstruction by dynamic orthotic cranioplasty. In: Marchac D, ed. Craniofacial Surgery. Bologna, Italy: Monduzzi Editore; 1995:151–153.
8. Persing JA, Nichter LS, Jane JA, et al. External cranial vault molding after craniofacial surgery. Ann Plast Surg 1986;17:274–283.
© 2004 American Academy of Orthotists & Prosthetists