by clicking the arrows at the side of the page, or by using the toolbar.
by clicking anywhere on the page.
by dragging the page around when zoomed in.
by clicking anywhere on the page when zoomed in.
web sites or send emails by clicking on hyperlinks.
Email this page to a friend
Search this issue
Index - jump to page or section
Archive - view past issues
Chiropractic Journal of Australia : CJA December 2013
Chiropractic Journal of Australia Volume 43 Number 4 December 2013 127 RECOGNISING CRANIOSYNOSTOSIS O’NEIL • STEWART In Deformational Plagiocephaly, there is external pressure applied to one side of the skull vault. This leads to fattening of the posterior occiput on that side, ipsilateral anterior shifting of the ear, and ipsilateral frontal bossing (prominence). In true lambdoid synostosis there is occipital-mastoid bossing on the side of the synostosis, and posterior shift of the ear on that side, towards the fused suture. There is usually no frontal bossing, but if present occurs contralaterally.23 INSERT FIGURE 4: Deformational plagiocephaly (left) versus lambdoid craniosynostosis (right) - see below Palpation for ridging may not assist with lambdoid and coronal synostosis as these often present without palpable ridges. In addition to the vertex observations described above, characteristic shape changes can be seen from behind in lambdoid synostosis. This includes tilt of the skull base, inferior shift of the ear ipsilaterally, and cervical curve changes.29 In regards to management of infants with plagiocephaly, craniosynostosis is a condition which places the patient into a paradigm of co-management. The reasons for this include a decreased likelihood of improvement with chiropractic management, and more serious shape and neurological sequelae resulting from delayed medical management. Known effects of craniosynostosis include head and facial shape alterations, increased intracranial pressure, hydrocephalus, visual effects, headaches, irritability, sleep issues, neuropsychiatric disturbance, and cranial nerve abnormalities. The number and severity of these issues correlate with number of sutures involved.13,23 In addition, there is a relationship with Arnold Chiari malformation and craniosynostosis, with rates of approximately 5% in single suture craniosynostosis (sagittal and coronal types), and higher rates in syndromic and multiple suture types.30 Arnold Chiari malformation is a contraindication to upper cervical adjustments and some cranial techniques. Isolated craniosynostosis is associated with a three- to fvefold increased risk for cognitive defcits or learning/ language disabilities,31 and consistently lower mean neurodevelopmental scores in children with single-suture craniosynostosis compared with controls.32 Untreated single suture craniosynostosis is associated with a 2.2 fold increased incidence of developmental delay during early infancy, with motor skills appearing the most vulnerable to impairment during this developmental phase.33 No differences have been demonstrated in the neurodevelopmental scores when comparing different sutures involved. In contrast, it is important not to confuse positional plagiocephaly with true lambdoid synostosis, as this leads to inappropriate medical treatment (surgery).29 The clinical signs described above have been shown to clearly differentiate the true fused suture from the "functional" suture which is not anatomically fused.29 When concern is present regarding possible fusion of a suture referral for imaging is required. Radiology (x-ray) is the frst step followed by Computed Tomography (C.T.). Radiology signs confrming fusion include sclerosis, bony bridges across the suture, "beaking," or lipping along the suture, or narrowing of the suture.23 C.T. images provide a more accurate diagnosis of craniosynostosis, assists in operative planning, and rules out other brain conditions.23 Some studies have questioned the use of C.T imaging in single suture craniosynostosis due to increased dose of ionizing radiation, with ultrasound as an alternative option.34,35 Providing no contraindications exist, it is reasonable to complete the chiropractic care process whilst waiting for referral. We have identifed three studies relating to craniosynostosis and chiropractic,36-38 but were not able to locate one of these.36 In one study,38 there was reported "healing of cranosynostosis, Chiari 1 malformation and juvenile scoliosis." The diagnosis was made at 4 years of age by a paediatrician as "plagiocephaly from closed cranial sutures." The conclusion of the study was that there was early elimination of the craniosynostosis. There was no description Management A frst principle of paediatric chiropractic care involves identifying (at every visit) the correct paradigm of care the patient belongs to. This includes: a. chiropractic care, b. co- management, and c. referral. Once this is established, the primary role switches to identifcation of the neurological and kinesiological parameters of the extremity, spinal and cranial subluxation complexes, and monitoring of neurological development. Table 2 DEFORMATIONAL PLAGIOCEPHALY VERSUS LAMBDOID CRANIOSYNOSTOSIS WHEN VIEWED FROM ABOVE. Deformational plagiocephaly: (reference side of occipital fattening) Lambdoid craniosynostosis: (reference side of fused suture) Sutural Ridging Absent May be present Occipito- mastoid bulge Absent Present Occipital- parietal fattening Ipsilateral Ipsilateral Posterior bossing Contralateral occiput Contralateral parietal Ipsilateral Ear shift Forward Backwards Frontal bossing Ipsilateral Contralateral Overall head shape Parallelogram Trapezium
CJA September 2013