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Nota : Estas mediciones se obtienen generalmente mediante el accesorio de la banda o casco orthotist. A difference of asymmetry greater than 6 mm between anthropometric measurements see diagram above in any of the anthropometric data in the first column of the following table warrants coverage of a trial of orthotic banding to correct the craniofacial deformity:.

Note : These measurements are generally obtained by the orthotist fitting the band or helmet. Cephalic index equal to head width eu minus eu multiplied by divided by head length g minus op. Note : remodeling bands or helmets are contraindicated and considered not medically necessary after 2 years of age.

Aetna considers the use of sleep positioning wrap for the treatment of infants with positional head shape deformities experimental and investigational because its effectiveness has not been established.

Aetna considers intra-operative indocyanine green angiography to evaluate scalp perfusion during cranial vault remodeling in infants experimental and investigational because the effectiveness of this approach has not been established.

Plagiocephaly an asymmetrical head shape is most often the result of an infant spending extended periods of time on their back, typically during sleep. Plagiocephaly can also occur as a feature of other disorders e. Although 1 in infants exhibit variable degrees of plagiocephaly, true sutural synostosis, which interferes with cranium development and may cause increased intra-cranial pressure, occurs in only 0.

Positional plagiocephaly is treated conservatively and many cases do not require any treatment as the condition may resolve spontaneously when the infant begins to sit up. When the deformity is moderate or severe and a trial of re-positioning the infant has failed, a pediatric neurologist, neurosurgeon or other appropriate specialist in craniofacial deformities may prescribe a cranial remodeling band to remodel the misshapen head.

Cranial orthotics are designed to improve plagiocephaly without synostosis or deformational plagiocephaly, which is a condition found in infants whose heads show an asymmetrical flattening caused by uneven external pressures on the skull.

Orthotic management of plagiocephaly without synostosis is usually initiated between three and 18 months of age and continues for an average of four to six months. Both helmets and cranial bands are recommended to be worn 23 hours per day with an hour off for exercises and skin care. Average treatment time with the cranial remodeling band or helmet is 4.

A systematic evidence review of cranial orthosis treatment for infant deformational plagiocephaly prepared for the UK National Health Services NHS QIS, found no randomized controlled trials assessing the effectiveness of cranial orthoses for the treatment of deformational plagiocephaly were identified. The assessment stated that no evidence-based conclusions can be reached on the effectiveness of cranial orthoses due to the limited methodological quality of the available trials.

There is some evidence suggesting that a cranial remodeling band or helmet may improve outcomes following surgery to treat synostotic plagiocephaly.

The investigators reported that correction toward a normal cephalic index was seen in the banded group throughout the course of treatment, while this trend was not present in the non-banded group.

Cranial rmodeling bands and helmets are contraindicated in infants older than 24 months. The skulls of these children have finished growing and no longer have the pliability and plasticity necessary to create a change in shape. In a randomized controlled trial, Hutchison et al examined the effectiveness of the Safe T Sleep positioning wrap in infants with positional head shape deformities. Head shape was measured using a digital photographic technique, and neck function was assessed.

They were followed-up at home 3, 6 and 12 months later. Those that had poor improvement were more likely to have both plagiocephaly and brachycephaly and to have presented later to clinic. The authors concluded that most infants improved over the month study period, although the use of a sleep positioning wrap did not increase the rate of improvement. The author noted that criteria for determining a second orthosis include the following:. The American Academy of Orthotists and Prosthetists' draft consensus statement on "Orthotic management of deformational plagiocephaly AAOP, stated that "very young infants who have not developed midline head control, rolling, or sitting, may require a second orthosis to prevent regression of the head shape".

The guideline also noted that termination of the orthotic treatment program is recommended, without weaning, when head shape falls within normal limits. If unresolved torticollis exists or if sleeping patterns are poor same side as flatness , use is continued for an additional 2 to 4 weeks. Furthermore, unshunted or uncontrolled hydrocephalus as well as craniosynostosis are contraindications for cranial remolding orthosis.

Chan and colleagues noted that craniosynostosis results in characteristic skull deformations. Correction of craniosynostosis has traditionally involved an open cranial vault remodeling CVR procedure. A technique recently developed endoscope-assisted craniectomy EAC repair in conjunction with a post-operative molding helmet to guide cranial growth. Few studies compared these 2 approaches to the treatment of the various forms of craniosynostosis.

This study was a retrospective review of 57 patients who underwent craniosynostosis repair by either the endoscope-assisted or open techniques; and compared operating room times, blood loss, volume of transfused blood, length of hospital stay, and overall costs. The endoscopic technique was performed on younger children 4. The authors concluded that issues with the endoscope-assisted procedure primarily concerned the post-operative helmet regimen, specifically patient compliance The endoscope-assisted repair with post-operative helmet molding therapy was a cost-effective procedure with less operative risk and minimal post-operative morbidity.

This was a valuable treatment option in younger patients with compliant care-givers. Eligibility criteria included an age less than 1 year and at least 1 year of clinical follow-up data. Financial and clinical records were reviewed for data related to length of hospital stay and transfusion rates as well as costs associated with physician, hospital, and outpatient clinic visits. The average age of patients who underwent CVR was 6. Endoscope-assisted craniectomy plus HT was associated with shorter hospital stays mean of 1.

Hinchcliff et al stated that the current treatment of craniosynostosis is open surgical excision of the prematurely fused suture and CVR. Due to the change in skull morphology and the increase in volume, some tension on the skin flaps is noted with closure. Although complete wound breakdown is rare, it can be a devastating complication.

These researchers presented their experience with the use of the SPY imaging system Lifecell Corporation, Branchburg, NJ to visualize and record blood flow within the flaps of a 1-year old patient with anterior plagiocephaly. The authors concluded that intra-operative indocyanine green angiography has the potential to be a significant advantage in such cases, providing a safe and objective method to assess intra-operative scalp perfusion, allowing the surgeon to take additional measures to ameliorate any ischemic problems.

Xia et al reported on a systematic evidence review to compare molding helmet therapy with head repositioning therapy for infants with deformational plagiocephaly. Journals Ovid and conference proceedings were screened. Studies that compared molding helmet therapy with head repositioning therapy for otherwise healthy infants with deformational plagiocephaly with or without torticollis were eligible for inclusion.

Infants had to have received no prior treatment. Reasons for exclusion of identified studies included insufficient information about recruitment of samples and methods used to measure outcomes. The review assessed treatment success.

Included studies compared molding with repositioning with and without physiotherapy or neck stretching. In most studies, the duration of treatment ranged from three to five months. All infants were under 12 months when treatment started; in most studies treatment started at five to eight months. Two reviewers independently selected studies. The number of children in each treatment group ranged from 10 to Five prospective, one retrospective and one study with a prospective repositioning group and a retrospective molding group were included.

All studies included consecutive infants. Flaws included allocation based on physician or patient preference, cross-over from repositioning to molding, inadequate details of co-interventions, lack of reporting of masked outcome assessment, molding offered to older or more severely affected infants and a high drop-out rate. Five studies with comparable data reported that success rates were higher in infants treated with molding compared to repositioning therapy. Of the other two studies, the average treatment time for reposition was much greater than the duration of molding time and the other did not use the same anatomical landmarks to assess outcomes in both groups.

Reasons for exclusion of other studies included inadequate data or information about treatments, significant measurement bias and recruitment only of children who failed repositioning.

The authors concluded that there was considerable evidence that molding therapy may be more effective at reducing skull asymmetry than repositioning therapy in infants with deformational plagiocephaly. However, studies were potentially biased and more research was required. Taylor et al reported long-term aesthetic outcomes with fronto-orbital advancement and CVR in treating unicoronal synostosis over a year period.

These investigators performed a retrospective review on patients with isolated unicoronal synostosis from to Demographic, pre-operative phenotypic, and long-term aesthetic outcomes data were analyzed with chi-squared and Fisher's exact test for categorical data and Wilcoxon rank-sum and Kruskal-Wallis rank for continuous data.

A total of patients were treated; met inclusion criteria. None underwent secondary intervention for intracranial pressure. Over-correction resulted in decreased risk of temporal hollowing [OR, 0. Patients with 5 years or more of follow-up were more likely to develop supraorbital retrusion [OR, 7. The authors concluded that traditional fronto-orbital advancement and CVR appears to mitigate risk of intracranial pressure but may lead to aesthetic shortcomings as patients mature, namely fronto-orbital retrusion and temporal hollowing.

Base de mediciones se realizaron en los lactantes de edades comprendidas entre 5 y 6 meses, con mediciones de seguimiento a las 8, 12, y 24 meses. A custom-fitted helmet designed to relieve pressure on the flattened side is often used in severe cases which are rare. However, a single-blind trial has found no difference in outcomes, including change in skull shape plagiocephaly or brachycephaly and full recovery, at two years of age in 84 infants with moderate to severe positional skull deformation who were randomly assigned to helmet therapy or to no therapy natural course of the condition.

In addition, a number of adverse effects were reported with helmet use, including skin irritation and parental difficulty in cuddling the infant. The trial had several limitations, including the 21 percent participation rate and exclusion of the most severe cases of positional flattening. Utria and colleagues noted that due to the changing properties of the infant skull, there is still no clear consensus on the ideal time to surgically intervene in cases of non-syndromic craniosynostosis NSC.

These investigators shed light on how patient age at the time of surgery may affect surgical outcomes and the subsequent need for reoperation. They performed a retrospective cohort review for patients with NSC who underwent primary cranial vault remodeling between and Patients' demographic and clinical characteristics and surgical interventions were recorded.

Post-operative outcomes were assessed by assigning each procedure to a Whitaker category. Multi-variate logistic regression analysis was performed to determine the relationship between age at surgery and need for minor Whitaker I or II versus major Whitaker III or IV re-operation.

Odds ratios for Whitaker category by age at surgery were assigned. A total of unique patients underwent cranial vault remodeling procedures for NSC during the study period. Multi-variate logistic regression demonstrated increased odds of requiring major surgical revisions Whitaker III or IV in patients younger than 6 months of age OR 2. The authors concluded that timing, as a proxy for the changing properties of the infant skull, is an important factor to consider when planning vault reconstruction in NSC.

They stated that the data presented in this study demonstrated that patients operated on before 6 months of age had increased odds of requiring major surgical revisions. Tong and associates stated that there is no published data addressing the use of post-operative subgaleal drains in patients undergoing primary cranioplasty for craniosynostosis.

These investigators conducted a retrospective chart review in this population of patients, comparing outcomes of those who received post-operative drains with those who did not. They hypothesized that the subgaleal drains can significantly reduce post-operative facial edema and decrease the length of hospital stay.

These researchers conducted a retrospective chart review of all patients undergoing primary cranioplasty for craniosynostosis with subgaleal drain placement May to March A comparison group without drain placement was matched appropriately to establish a comparison of outcomes.

The authors examined if subgaleal drainage led to improvement in post-operative facial edema, reduced length of hospital stay, post-operative changes in hematocrit Hct , and complication rates.


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