A Two Center Review of Three Techniques for Posterior Vault Expansion Following Either a Staged or Expectant Approach to the treatment of Crouzon and Apert Craniosynostosis.

INTRODUCTION: Timing of posterior cranial expansion for the management of intracranial pressure can be 'staged' by age and dysmorphology or 'expectant' by pressure monitoring. We report shared outcome measures from one center performing posterior vault remodeling (PCVR) or distraction (PVDO) following a 'staged' approach and another performing spring assisted expansion (SAPVE) following an 'expectant' protocol.

METHODS: Apert or Crouzon syndrome cases who underwent posterior expansion less than two years old were included. Perioperative outcomes and subsequent cranial surgeries were recorded up to last follow-up and intracranial volume changes measured and adjusted using growth curves.

RESULTS: 38 patients were included. Following the 'expectant' protocol, Apert cases underwent SAPVE at a younger age (8 months) than Crouzon cases (16 months). The initial surgery time was shorter but total operative time, including device removal, longer for PVDO (3:52) and SAPVE (4:34) than for PCVR (3:24). Growth-adjusted volume increase was significant and comparable. 14% PCVR, 33% PVDO, and 11% SAPVE cases had complications, but without long-term deficits. Following the staged approach, 5% only underwent PVDO, 85% had a staged posterior followed by anterior surgery, and 10% required a third expansion. Following the expectant approach, 42% patients had only posterior expansion at last follow-up, 32% had a secondary cranial surgery, and 26% had a third cranial expansion.

CONCLUSIONS: Two approaches involving posterior vault expansion in young syndromic patients using three techniques resulted in comparable early volume expansion and complication profiles.