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Diagnosis and management of posterior plagiocephaly
I F Pollack1, H W Losken, P Fasick
1Department of Neurosurgery, Children's Hospital of Pittsburgh, PA 15213, USA.
Insights
Most infants with posterior plagiocephaly have deformational plagiocephaly, not true synostosis. Nonsurgical treatments like positional therapy and molding helmets are effective for correcting head shape in these infants.
Area of Science:
- Pediatric Neurosurgery
- Craniofacial Surgery
- Developmental Pediatrics
Background:
- Posterior plagiocephaly management is debated due to conflicting data on true lambdoidal synostosis versus positional molding.
- Divergent institutional approaches exist for treating infant posterior plagiocephaly.
Purpose of the Study:
- To test the hypothesis that most posterior plagiocephaly cases are due to positional molding, not true synostosis.
- To evaluate the efficacy of nonsurgical treatments for cosmetic improvement in infants with posterior plagiocephaly.
Main Methods:
- Prospective study of 71 infants (1992-1995) with a consistent management philosophy.
- Radiographic and CT evaluations to differentiate true synostosis from deformational plagiocephaly.
- Treatment involved positional therapy, with custom molding helmets for non-responders.
Main Results:
- Deformational plagiocephaly diagnosed in 69 infants; only 2 had true lambdoidal synostosis.
- Positional preference was a key factor in 67 cases.
- Positional therapy alone improved 35 infants; helmets were used for 34, with successful outcomes in most by 6 months.
Conclusions:
- The majority of infants with posterior plagiocephaly do not have true synostosis.
- Nonsurgical interventions are highly effective for managing deformational plagiocephaly.
- Positional preference significantly impacts the development of this condition.
Objective:
The management of infants with posterior plagiocephaly has been controversial both because of widely differing estimates in the literature of the relative frequencies of true lambdoidal synostosis vs positional molding and because of divergent approaches to treating this problem in different institutions. Based on our experience, we hypothesized that the vast majority of children with posterior plagiocephaly did not have true synostosis and that the cosmetic impairment in such patients could be effectively treated with nonsurgical modalities.
Methods:
Between 1992 and 1995, we prospectively applied in 71 infants a consistent management philosophy for these malformations that has incorporated a detailed evaluation of sutural anatomy as the basis for a physiologic approach to treatment. This approach has been directed at distinguishing true synostosis from deformational plagiocephaly and at avoiding surgery for patients with deformational abnormalities by using a combination of nonsurgical modalities to restore normal cranial growth dynamics. All children first underwent skull radiographs to determine whether the lambdoidal sutures were patent. In equivocal cases, computed tomography was also performed. Patients without true synostosis were enrolled on a course of positional therapy. In patients that did not improve after 2 to 3 months, a custom-fitted orthoplastic molding helmet was applied to facilitate passive skull recontouring.
Results:
Forty children had patent sutures based on skull radiographs, and 29 others, in whom the radiographs were equivocal, had open sutures based on computed tomography, thus establishing the diagnosis of deformational plagiocephaly in 69. Predisposing factors for this deformity included a strong positioning preference during early infancy (n = 67), torticollis (n = 10), prematurity (n = 6), and developmental delay (n = 2). Only two patients had true lambdoidal synostosis; in each case, this was associated with synostosis of the posterior sagittal suture and was managed effectively with cranial reconstructive surgery. Thirty-five patients with deformational plagiocephaly had a dramatic improvement in their cranial contour with positional therapy alone; 34 patients failed to improve and were treated with molding helmets. All but five children, each of whom was more than 6 months old at initial intervention (P < .025), developed a normal or nearly normal head shape with these measures.
Conclusion:
The vast majority of children with posterior plagiocephaly do not have true synostosis and can be effectively managed by nonsurgical means. The impact of positional preference on the development of this process is discussed.