Some children are born with craniofacial problems including premature closure of skull sutures and fontanelles (soft spots), delayed cranial closures and encephaloceles, bony craniofacial tumours and craniofacial trauma. A multi-disciplinary approach to these complex conditions has been proven to result in the best outcomes. At Laccon Neurosurgery, we have a close working relationship with several craniofacial / plastic surgical units and the neuroanaesthesia department of the Royal Children’s Hospital in dealing with these problems.

A common craniofacial anomaly is premature cranial suture closure – craniosynostosis. The incidence of this condition is approximately 1 in 4000 to 1 in 5000 live births. As a result of the early closure, the skull and cranium do not develop adequately for the developing brain. This results in a pressure build-up both locally and globally. There is deformation of the skull and face which may be quite disfiguring. Surgery for correction of these conditions takes the form of complex cranial vault remodeling which involves the removal of segments of the affected skull and repositioning and remodelling these fragments to create the desired skull shape and expansion of the cranial vault.

The major risks, however, are low when performed as a multi-disciplinary procedure. The outcomes when approached this way have been extremely good and the benefits certainly have outweighed the risks. Laccon Neurosurgery has been involved in this form of surgery internationally, interstate and locally for the past ten years and will continue to perform such procedures as part of a dedicated craniofacial unit.

The process of brain surgery is performed via a craniotomy. After performing an appropriately placed skin incision, a window of bone is removed using a high-speed drill. This allows access to the coverings of the brain known as dura mater. The dura mater is then incised in order to gain access to the brain, tumour or vascular anomaly.

Once the operation is completed, the dura mater is then sutured closed in most instances. From time to time, it may be necessary to patch an artificial patch in order to achieve closure of the dura mater. Once the dura mater is closed, the bone flap that was removed is repositioned into its correct location and secured with resorbable plates, titanium plates or sutures. The scalp is then closed using absorbable sutures.

In the treatment of spasticity and certain movement disorders, the delivery of baclofen directly into the CSF adjacent to the spinal cord results in improved control of the spasticity and the abnormal movements. The baclofen can be delivered via a pulsed or continuous pump system.

The procedure involved 2 incisions – one located just above the tail bone in the lower back and another over the mid-portion of the abdomen in the front. After making an incision in the lower back, a fine-bored catheter is inserted into the lumbar CSF space much like a lumbar puncture. The catheter is threaded to its correct location from this entry site. The catheter is then tunneled around the flank and into the abdominal incision “pocket”. The baclofen pump is the primed with sterile baclofen solution and the catheter is then inserted and secured onto the pump nozzle. The pump is then inserted into the abdominal pocket and secured. All wounds are washed and bathed in antibiotic fluid. The wounds are then closed suing absorbable sutures. A firm bandage is placed around the pump site to reduce postoperative swelling.

Endoscopic third ventriculostomy / ventriculoscopy is a minimally invasive key-hole neurosurgical procedure which gives access to the deepest parts of the brain. The procedure involves a small incision behind the hairline. A small opening is made in the skull. A specially designed fine bore endoscope is then inserted down this opening into the lateral ventricle (the large chambers on each side of the brain containing cerebrospinal fluid – CSF). Using this technique, access into the ventricles (chambers of the brain), deep parts of the brain and the brainstem can be achieved with relative ease. Tumours and cysts can be removed via this approach. CSF diversion / bypass can be performed. Inspection post-tumour removal can also be carried out to ensure that the tumour has been completely removed.

Ventriculoscopy can be used as an adjunct to other forms of neurosurgery in order to inspect the surgical site, remove small tumours which are located in regions with difficult access, and create openings in sites with obstruction.

Benefits:

The commonest neurosurgical condition in children, aside from trauma, is hydrocephalus (water on the brain) or CSF flow disturbances. The causes of hydrocephalus and CSF flow disturbances are not exhaustive but may include tumour, trauma, infection, vascular accidents, congenital or toxic. The end result of each is a build up of CSF within the central nervous system (including the spinal cord). This is akin to having a mountain lake, which had been draining down a small stream, suddenly having the same stream blocked or having backflow from a downstream reservoir. Fluid within the lake has to be diverted in some manner. There are several ways of diverting CSF. This may be done in the following ways:

At Laccon Neurosurgery, all these techniques may be employed to deal with hydrocephalus. Irrespective of the approach used, once surgery has been undertaken to treat hydrocephalus, the patient must be regarded as having hydrocephalus even if a permanent shunt was not inserted. Any such technique may fail and this failure will result in headaches, vomiting and drowsiness and/or cognitive decline and gait disturbance. The presence of these symptoms must be regarded as a shunt or diversion failure unless proven otherwise. In the absence of other symptoms, this clinical picture will require urgent neurosurgical review or surgery. Build-up of intracranial pressure will result in brain damage, blindness or death unless urgent neurosurgical management is obtained.