108. Posterior Cranial Vault Distraction Osteogenesis: Surgical Technique to Maximize Safety and Optimize Outcomes

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Authors: Amy Katherine Bruzek, MD; Amy Bruzek, MD, MS; Raquel Ulma; Gina Sacks, MD; Kevin Chen, MD; Cormac Maher, MD; Hugh Garton; Steven Buchman, MD; Karin Muraszko, MD (Ann Arbor, MI)

Introduction:

Posterior cranial vault distraction osteogenesis is an established alternative to traditional posterior vault osteotomy for multi-suture craniosynostosis. The benefits of distraction osteogenesis over traditional osteotomy include scalp tension relief while allowing for maximal bone remodeling. Most described posterior vault distraction techniques place the inferior osteotomy above the torcula. We describe low occipital craniotomy extending to the foramen magnum for improved cosmesis and volume expansion of the narrow skull base that frequently accompanies multi-suture craniosynostosis.

Methods:

We performed a retrospective chart review of pediatric patients with multi-suture craniosynostosis who underwent posterior distraction osteogenesis surgery at the University of Michigan between 2012-2019. Fourteen children were included and all patients underwent preoperative evaluation by neurosurgery, plastic surgery, ophthalmology, and neuropsychiatry. CT scans and MRI brain and cervical spine with CSF flow were obtained preoperatively to evaluate bony morphometry, venous sinus position, and potential chiari malformation.

Results:

Average age at time of posterior vault distraction was 14.21 months (range 5 to 93 months). All patients had multi-suture craniosynostosis; six patients had Apert syndrome, three had Crouzon, and one had Saethre-Chotzen. Three patients had chiari malformation prior to posterior distraction; two improved and one remained stable postoperatively. Blood loss averaged 86mL (range 20mL to 200mL), with 7 patients requiring transfusion. Complications included distractor device failure requiring reoperation (1 patient), shunt exposure requiring operation (1 patient), and mild scalp wound infection requiring superficial wound care (1 patient). All patients underwent fronto-orbital advancement 8 to 14 months after posterior distraction osteogenesis.

Conclusion:

We describe posterior distraction osteogenesis with suboccipital craniotomy and step-wise distraction with improved cosmetic outcome, relief of the scalp closure with slow distraction, and decompression of the foramen magnum. We further describe the importance of preoperative imaging in determining optimal distraction vector and safe surgical technique.

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