The Cleft and Craniofacial Center at Children’s of Alabama is one of the busiest in the country, with some of the most experienced physicians and support staff. From cleft palate to craniosynostosis (a condition in which the skull fuses too early) and complex tumor surgeries, the center draws patients from the entire Southeast region and beyond. It is a truly multidisciplinary group with neurologists, neurosurgeons, plastic surgeons, and a craniofacial pediatrician.
It also offers state-of-the art therapies, including a new type of endoscopic surgery for craniosynostosis in infants as young as three months that is only performed in a few centers in the U.S. “The typical procedure is an endoscopic release of the craniosynostosis followed by post-operative helmet therapy,” said neurosurgeon James M. Johnston, M.D. “Helmet therapy works well, but kids have to wear it for 23 hours a day, and that can be a lot of work for families, especially when they live far from Birmingham,” he said. In addition, the Alabama Medicaid program, which covers most of these children, does not pay for the helmets, which can cost thousands of dollars (and children often need more than one). This puts tremendous financial strain on many families.
So Dr. Johnston, joined by neurosurgeon Curtis J. Rozzelle, M.D., and plastic surgeons Rene’ P. Myers, M.D., and John Grant, M.D., brought spring-mediated cranioplasty, which was developed at Wake Forest University, to Children’s. It starts with the same endoscopic craniectomy used for children who would require helmets. Only in this procedure, the plastic surgeon steps in and inserts custom-made springs into the bony defect created by the surgery. The springs work to expand the skull over several months to correct the abnormal head shape and ensure appropriate cranial volume for brain growth. A few months later, the plastic surgeon removes the springs during a same-day surgery.
“What’s nice is that there’s no need for a helmet,” Dr. Johnston said. Plus, studies show the procedure is just as safe and effective as cranioplasties requiring helmets.1 It’s also covered by all health insurance. “So, we’re able to do it for all children,” he said.
A similar procedure using cranial distractors like those used to lengthen femurs is used for skull expansion, explained Dr. Grant. This technology is used in older children who need more intracranial volume but who are beyond the age at which the skull can form new bone to fill in surgically created soft spots. By “stretching” the bones of the skull more slowly, he said, the child’s body adjusts by making bone to fill in the growing gap.
Regardless of the procedure used, early referrals are critical for these babies, said Dr. Rozzelle. “If we can see them by 2 months of age, that gives us plenty of time to get whatever preoperative assessments we need and get them on the schedule so that either the spring or endoscopic craniectomy with subsequent molding helmet is a viable option,” he said. Older babies cannot be treated endoscopically and require standard open surgery, which may lead to more blood loss and longer hospital stays.2
Yet the craniofacial clinic still sometimes sees babies 6 months or older who never received a diagnosis or whose pediatrician didn’t refer them to Children’s. “That’s frustrating,” Dr. Rozzelle said.
Nonetheless, said Dr. Myers, “Since we are comfortable with all of the techniques, we can tailor a plan to the individual child. No one is exactly the same.”
1 Arko L, Swanson JW, Fierst TM, et al. Spring-mediated sagittal craniosynostosis treatment at the Children’s Hospital of Philadelphia: technical notes and literature review. Neurosurg Focus. 2015 May;38(5):E7
2 Hashim PW, Patel A, Yang JF, et al. The effects of whole-vault cranioplasty versus strip craniectomy on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg 134:491–501, 2014.