POSTERIOR SKULL SURGERY IN CRANIOSYNOSTOSIS

In 1984, two young infants with unusual ''clover-leaf'' patterns of sk ull deformity were treated by posterior skull-releasing surgery that d ramatically improved their overall skull shape, to the extent that fur ther operative intervention was not required. This focused our attenti on on the posterior skull and its role in craniosynostosis. In cases o f multi-suture craniosynostosis and craniofacial syndromes severely ra ised intracranial pressure is frequent, demanding early surgery. One o f the problems identified with such surgery undertaken before 6 months of age is recurrent craniosynostosis needing later re-operation. This occurred in 15 (5%) of 275 patients treated between 1978 and 1994. Si nce 1986, in the presence of significantly raised intracranial pressur e it has been our policy to do an initial posterior skull release or d ecompression. This takes the pressure of the growing brain away from t he orbits, allowing us to defer fronto-orbital advancement until the a ge of 12 months or later. Three patients managed in this way completel y avoided anterior surgery, while in another 9 patients re-operation f or recurrent anterior deformity has not been required. The exception t o this policy has been the presence of severe exorbitism posing a thre at to vision. Under these circumstances early fronto-orbital advanceme nt is mandatory, and an additional posterior skull release may be help ful later. Debate continues especially on the management of unilateral lambdoid synostosis. The recent increase in positional posterior plag iocephaly, possibly related to supine nursing of newborns, has emphasi sed the need to differentiate between a fixed deformity, which might r equire surgical correction, and positional moulding of the occiput, wh ich improves spontaneously. This paper reports our experience with 22 patients treated by posterior skull surgery, either alone or as an add itional procedure, which we believe has a definitive role in the manag ement of craniosynostosis.