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  • Stereolithography for Craniofacial Sagittal Synostonsis Reconstruction with Neuronavigation and Intraoperative CT Guidance. A Technical Note.

    Final Number:

    Andrew Joshua Kobets MD; Rani Nasser MD; Adam Lance Sandler MD; Arundhati Biswas MCh MD MS FCPS; Rick Abbott MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2014 Annual Meeting

    Introduction: Sagittal synostosis affects 1 in 1000 live births and may result in increased intracranial pressure, hindrance of normal neural development, cosmetic deformity, and scaphocephaly. Historically, several approaches have used for surgical correction including the simple strip craniectomy, the pi procedure, wide synostotic suture resection with bilateral temporo-parietal decompression, and CT-guided reconstruction procedures with or without the use of stereolithographic modeling. In this report, the authors describe the first use of a CT-derived stereolithographic craniofacial model, alongside real-time intra-operative navigational assessment of bone placement in order to confirm the accuracy of surgical correction.

    Methods: 3D CT imaging was used to construct before-and-after images of our 14-month old patient's scaphocephaly in order to describe the proposed procedure to the parents, and additionally served as a basis for the printed 3D model. This model was used intraoperatively to plan the bone flaps, fashion the bone cuts, and shape the optimized peri-operative reconstruction. A lattice was constructed with a sagittal strut and the bone was placed with the conceptualized image in mind. After completion of the remodeling, the scalp was temporarily reflected and a CT scan of the remodeled skull was obtained. The images were then reconstructed three-dimensionally and merged with the optimized virtual model constructed pre-operatively. Navigation was then used to assess the reconstruction and modify any further correction in real-time, ensuring that the bones were fashioned as nearly as possible to the 3D model shown to the parents pre-operatively.

    Results: The patient experienced excellent cosmetic correction of head shape and contouring (see attached figures). Operative time was 5 hours, blood loss was 100cc, and the patient tolerated the surgery well. The parents were happy with the surgical outcome.

    Conclusions: Five key tenets are often cited for the successful application of 3D biomodels to craniofacial reconstruction and include: accuracy, diagnostic confidence, operative planning, reduction of operative times, and cost effectiveness. The addition of neuronavigation to stereolithographic modeling minimally increases operative time but ensures accuracy of correction, does not increase operative cost, and optimizes the surgical plan to provide greater confidence to both surgeons and parents.

    Patient Care: It will improve the accuracy and cosmetic outcomes for patients undergoing surgery for craniosynostosis correction.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of the integration of an updated multimodal plan for craniosynostosis correction 2) Discuss, in small groups the cost/benefit of this methodology as compared to other corrective procedures 3) Identify key points for the logistical integration of this methodology at other institutions

    References: 1. Lee SS. Intracranial compartment volume changes in sagittal craniosynostosis patients: influence of comprehensive cranioplasty. Plastic and reconstructive surgery (1963), 2010. 126(1): p. 187-96. 2. Collett BR. Laypersons' ratings of appearance in children with and without single-suture craniosynostosis. The Journal of craniofacial surgery, 2013. 24(4): p. 1331-5. 3. Christophis P, Jünger TH, Howaldt HP. Surgical correction of scaphocephaly: experiences with a new procedure and follow-up investigations. Journal of Cranio-Maxillofacial Surgery, 2001. 29(1): p. 33-38. 4. Yáñez-Vico RM, et al. A new three-dimensional analysis of asymmetry for patients with craniofacial syndromes. Oral Diseases, 2013. 19(8): p. 755-762. 5. Bell RB, Markiewicz MR. Computer-Assisted Planning, Stereolithographic Modeling, and Intraoperative Navigation for Complex Orbital Reconstruction: A Descriptive Study in a Preliminary Cohort. J Oral Maxillofac Surg 67:2559-2570, 2009 6. D'Urso PS, Atkinson RL, Lanigan MW, et al. Stereolithographie (SL) biomodelling in craniofaeial surgery British Journal of Plastic Surgery (1998), 51,522-530 7. Mardini S, et al. Three-dimensional preoperative virtual planning and template use for surgical correction of Craniosynostosis. Journal of Plastic, Reconstructive & Aesthetic Surgery (2013), 8. Khechoyan DY, Saber NR, Burge J, et al. Surgical outcomes in craniosynostosis reconstruction: The use of prefabricated templates in cranial vault remodelling. Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 9e16

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