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Expanding the Indications for the Modified Melbourne Technique: Posterior Vault Reconstruction for Secondary
Haven Ward1, Gabriela Cendejas2, William Cobb1
1Department of Surgery, AdventHealth.
Insights
Occipital encephaloceles require complex reconstruction. A modified Melbourne technique successfully reconstructed a large posterior calvarial defect in an infant with Chiari III malformation and secondary sagittal synostosis.
Area of Science:
- Craniofacial Surgery
- Pediatric Neurosurgery
- Neural Tube Defects
Background:
- Occipital encephaloceles are rare neural tube defects involving herniation of intracranial contents.
- These defects often present with complex neurological and structural anomalies, necessitating staged craniofacial reconstruction.
- The Melbourne technique is established for posterior vault expansion in sagittal synostosis but not previously applied to large occipital encephalocele defects.
Purpose of the Study:
- To report a novel application of the modified Melbourne technique.
- To address posterior cranial vault remodeling in a patient with a large occipital encephalocele, Chiari III malformation, and secondary sagittal synostosis.
Main Methods:
- A case report of a female infant with a large occipital encephalocele (10x12 cm) and associated anomalies.
- Neonatal encephalocele resection, dural repair, and ventriculoperitoneal shunt placement.
- Posterior cranial vault remodeling at 28 months using a modified Melbourne technique with split-thickness calvarial grafting for a 9x8 cm defect.
Main Results:
- Successful posterior vault expansion and restoration of cranial integrity.
- Correction of scaphocephaly deformity.
- Demonstrated feasibility of the modified Melbourne technique for complex posterior calvarial defects.
Conclusions:
- Large occipital encephaloceles present evolving and multifactorial challenges.
- The modified Melbourne technique offers a viable reconstructive option for large posterior calvarial defects secondary to occipital encephalocele, even with associated anomalies like Chiari III malformation and sagittal synostosis.
Introduction:
Occipital encephaloceles are rare neural tube defects characterized by herniation of intracranial contents through a posterior calvarial defect and are frequently associated with complex neurological and structural anomalies. While early surgical repair is essential, children with large occipital encephaloceles remain at risk for delayed sequelae, often necessitating staged craniofacial reconstruction. Among available reconstructive strategies, the Melbourne technique and its modified variants are established methods for posterior vault expansion in severe or late-presenting sagittal synostosis. However, to our knowledge, this technique has not previously been applied in the setting of a large posterior calvarial defect associated with an occipital encephalocele.
Case Presentation:
We report the case of a female infant with a prenatally diagnosed large occipital encephalocele measuring 10×12 cm, associated with Chiari III malformation, posterior fossa hypoplasia, and mild ventriculomegaly. She underwent neonatal encephalocele resection and dural repair, followed by ventriculoperitoneal shunt placement. Over time, she developed secondary sagittal craniosynostosis and a persistent large posterior calvarial defect. At 28 months of age, she underwent posterior cranial vault remodeling using a modified Melbourne technique combined with split-thickness calvarial grafting to reconstruct an 9×8 cm occipital defect. The procedure achieved posterior vault expansion, restoration of cranial integrity, and correction of her scaphocephaly deformity.
Conclusion:
This case highlights the evolving and multifactorial challenges associated with large occipital encephaloceles, and demonstrates a novel application of the modified Melbourne technique in the setting of secondary sagittal craniosynostosis, a large posterior vault defect, and Chiari III malformation.