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Chiropractic Journal of Australia : CJA December 2013
128 Chiropractic Journal of Australia Volume 43 Number 4 December 2013 RECOGNISING CRANIOSYNOSTOSIS O’NEIL • STEWART Table 3 ADVANTAGES AND DISADVANTAGES WITH THE DIFFERENT TECHNIQUES FOR GRADUAL EXPANSION OF THE POSTERIOR CRANIAL VAULT48 TECHNIQUE ADVANTAGES DISADVANTAGES Free-foating bone fap Hardware independent - possible in the very young infants with thin calvarial bone Relapse Brain compression Craniotomy required Trans-sutural springs No craniotomy required May be combined with simultaneous advancement of the frontal cranium Lack of control over expansion distance and vector Expansion dependant on Lambdoid suture position Removal in second procedure Distractors Control over distraction distance and vector Potential for large volume gain Percutaneous hardware -- risk for infections Removal in second procedure Craniotomy required of the actual suture involved, or any other examination of the head shape, sutures or any imaging conducted. There was no description of the actual clinical signs regarding craniosynostosis which improved. In the second study37 there was a medical diagnosis (paediatrician and obstetrician) of craniosynostosis (not defned) in a three week old female. The clinical examination revealed round and symmetrical head shape. The posterior fontanel was fused, and the anterior fontanel was reported as small and diamond shaped, with a slight bulge, but was later described as 1cm in diameter. After chiropractic care the head circumference had increased from 34.5 at birth to 39.2 at 10 weeks, with the anterior fontanel remaining open. The mother had described the head as little and the practitioner, on clinical examination, had reported the head to appear small for other patients of similar age. The conclusion was that the craniosacral work had infuenced the craniosynostosis. In both studies there are issues relating to diagnosis, examination and outcomes. The diagnosis in both studies was vague, with no mention of the specifc suture involved. In addition, the examination in each study did not indicate any of the typical signs expected with true craniosynostosis. Given the frequency of functional sutural issues being misdiagnosed as true craniosynostosis29,39 and the lack of typical craniosynostosis examination fndings in both studies, it is possible, even likely, that both patients were incorrectly diagnosed by the medical practitioners with craniosynostosis, when in fact each patient had functional sutural issues/ deformational plagiocephaly. Regarding outcomes, one study37 reported improvements in cranial development in an infant with medically diagnosed craniosynostosis seen between the ages of 3 and 10 weeks. The main outcome measure appeared to be the improvements in head circumference (from 34.5 cm at birth to 39.2 cm at 10 weeks) and the fact that the anterior fontanel remained open at 10 weeks. Using head circumference as a measure of improvement in this baby would actually indicate a slight decrease in relative cranial growth (70.0 percentile at birth to 66.9 percentile at 10 weeks) when using WHO head circumference charts. A closed posterior fontanel at 3 weeks, 1cm anterior fontanel at 3 weeks, and open fontanel at 10 weeks are normal fndings at those ages and thus are poor indicators of improvement of craniosynostosis at later times. The usual method of anterior fontanel measurement is to take the A-P and transverse diameters, add them together, and divide by two.40 Nethertheless, there is a role for chiropractic, including cranial and spinal techniques, in the general health management of patients with craniosynostosis, and there may be many benefts to wellbeing and function in doing so. It could be postulated that neonatal chiropractic care and its effects on dural tension may allow for normal cranial development, thus preventing the early changes which lead to craniosynostosis. However, it should be noted it is unlikely to release anatomically fused sutures. The diffcult question in each case is the determination of the diagnosis of a fused suture versus a functional suture. It is hoped that the processes outlined above make the ability to distinguish the two easier, with imaging modalities providing differentiation when clinical examination fndings are in doubt. We welcome the publication of any studies indicating improvements with chiropractic management in true craniosynostosis. Until there is more evidence in this area, we feel it is prudent to refer all patients with possible craniosynostosis for medical evaluation. Chiropractic management should continue whilst waiting for medical evaluation, provided no contraindications exist. Medical Management: The medical management for true craniosynostosis is surgery, followed by strict helmet therapy for approximately 12 months.41 The goal of surgical management of craniosynostosis is to release the affected suture and reconstruct any dysmorphic cranial components, to allow unrestricted development of the brain, as well as an anatomically normal skull shape. Surgery is recommended in the frst 3-9 months of age, due to a better remodeling ability and to avoid neurological sequalae.13 Signs of raised intracranial pressure are indicators for immediate urgent referral.23 When detected early, and in combination with 3D CT assessment, surgical repair is generally performed endoscopically. The following table differentiates the most common surgeries. Endoscopy-assisted surgery for correction of craniosynostosis in children under 4 months represents a valid and relatively safe management option. Absorbable springs
CJA September 2013