Summary

Cranioplasty is performed with various materials and autogenous bone. Since 1956 the Author has adopted the cranioplasty with acrilic resin in 149 consecutive cases and is satisfied with this technique in adult patients, less so in children where, due to the growing of the head and growing of the bone around the skull defect the acrilic cranioplasty can be displaced with bad cosmetic results so much that often it requires redoing. For this reasons the Author has adopted recently the cranioplasty with inner table of bone flap as described by KAZUHIKO et all in 1985. This technique has been used to repair the skull defect in two children with very satisfactory results. It is worth reporting this method of grafting applicable in various situations. particularly in children and especially in Africa where acrilic resin may not be available.

Resume

Les cranioplasties sont effectuees avec differents materiaux et avec de 1’os autogenique. Depuis 1956. I’auteur a utilise dans 149 cas la resine acrylique avec satisfaction chez les adultcs. Chez les enfants, par contre, en raison de la croissane du crane, la cranioplastie acrylique peut se deplacer, de telle sorte qu’il faut souvent la refaire. C’est pourquoi l’auteur a recemment utilise la table interne de 1’os comme lambeau, selon la technique decrite par KAZUHIKO et al en 1985. Elle a ete utilisee chez deux enfants avec d’excellents resultats. En outre, ce type de greffe peut etre utilise dans differents cas chez les enfants, tout particulierement en Afrique ou la resine acrylique n’est pas toujours disponible.

Keywords : Cranioplasty, autogenous bone, children, Africa

The cranioplasty is performed with autogenous bone and other materials. Whilst the autogenous bone graft is more physiological, it has various inconveniences mainly in the repair of large skull defects, the donor place (tibia, ribs, scapula and iliac bone) that results at the end cause of more problems that the actual cranioplasty, is more traumatizing, time consuming, prolonged hospitalization. In the last decades the preference has been given to the cranioplasty with acrilic resin that has the following advantages: is a simple technique not requiring long time to perform, possibility of modelling perfectly and insert directly the cranioplasty using as mould the skull defect, good tissue tolerance. The material is insulating, avoid the inconveniences of heating, is radiotransluccnt, docs not modify the EEG. low cost compared with other materials, possibility to perform in any moment without any special preparation, a cranioplasty with good cosmetic results of any skull defect, large or small or irregular. These are the reasons why since 1956 the cranioplasty with acrilic resin has been performed by the Author in 149 consecutive cases.
While this technique is satisfactory in the adults. is less so in children where due to the growing of the head and of the bone around the skull defect. the cranioplasty may be displaced with bad cosmetic results so much that often it requires redoing. For this reason it has been recently adopted the cranioplasty with inner table of bone flap as described by KAZUHIKO et al in 1985, in two children 6 and 8 years old with very satisfactory results.

CASE 1

This 6 year old female was hit on the head in Rwanda in May. 1994. Had a depressed skull fracture and the depressed bone was removed by a local surgeon. She had a circular bone defect of the diameter of 5 cm in the right occipital region, well pulsating. No neurological deficits. On the 22nd November. 1995 a large bone dowel was taken in the parietal area and the bone was splitted with a chisel. Replacement of the cortical bone at the donor site and placement of the inner table at the level of the skull defect. Both bone flaps were Fixed with chromic catgut. Closure in layers over suction drain. The post operative course was uneventful. Cosmetic results excellent. The postoperative x-rays some months later showed good results of grafting.

CASE 2

This 8 year old male was hit in the right parietal region in May, 1994 in Rwanda. Had a depressed skull fracture with a mild left hemiparesis. On the 29th November, 1995 the depressed skull was removed. A bone flap was performed in the right occipital area and the inner table ciseled out to repair the bone defect. Replacement of the cortical bone flap in the donor place and fixing of both bone flaps with chromic catgut. Closure in layers over suction drain. The post operative course was uneventful. The post operative x-rays six months later showed a good result of the grafting.

DISCUSSION

Despite the autogenous bone is the most suitable material for cranioplasty because of its anatomical similarity to the skull, the use of the standard acrilic cranioplasty remains at present the procedure used by most neurosurgeons. This is mainly due to the fact that the bone is rigid and it can be difficult to contour the graft with respect to skull defect, surgery and possibility of infection and pain at the door site, time consuming and other reasons that have made the autogenous bone for cranioplasty less and less popular. On the other hand, in children the use of standard acrilic cranioplasty has some disadvantages due to the growing of the child’s head with possibility of displacement of the cranioplasty with bad cosmetic results. This was the reason while in this two children we have used the technique described by KAZUHIKO et all in 1985 with satisfactory results.
As reported by KAZUHIKO et all the advantages of the use of the inner table are the following: no additional skin incision are necessary, nor is the need for bone to be taken from other parts of the body: physiological fusion can be expected; foreign body reaction avoided. This technique had some disadvantages however: is difficult in large sized bone defect, and in elderly patients, here splitting the two tables of the skull may be difficult because of the sclerotic changes of the skull.
In conclusion, we agree with KAZUHIKO et all that this method provides intraoperative one-stage cranioplasty using autogenous bone taken from the same operative field. This method of grafting can be used in various situations, but is particularly useful in young patients and in Africa where the acrilic material may not be available.