The Use of Intraoperative Radiography for Osteotomy Planning in Craniosynostosis Posterior Cranial Vault Distractor Application, Technique Description

Taghreed Alhumsi, MD, SB-plast, EBOPRAS; Abdulaziz Alshenaifi, MD; Mohammed Almarghoub, MD


ePlasty. 2020;20(e8) 

In This Article


The patient is anesthetized and placed in a prone position with a mild neck extension and with careful attention paid to head support and ventilation tubes. After positioning the head, the hair is shaved completely. An initial lateral radiograph is then taken of the skull using a C-arm machine. A towel clip or any radiopaque instrument is used to locate the future placement of the superior osteotomy and the corresponding bicoronal incision under x-ray guidance (Figure 1). A bicoronal incision is designed in a zigzag fashion in accordance with the chosen site of the osteotomy earlier confirmed by a radiograph. The patient is then prepped and draped in a sterile fashion. A local anesthetic solution is used and injected subcutaneously, and locking hemostatic sutures are stitched on both edges of the anticipated bicoronal flaps to minimize bleeding. The flaps are elevated. After the elevation of the flaps, the superior and inferior osteotomy lines are marked using straight radio-opaque instruments, such as Kirschner wires or any straight instrument from the operative set, under x-ray guidance. The inferior osteotomy line is placed as inferior as possible to help expand the posterior vault and minimize step-off. Radiography helps make both right-sided and left-sided cuts parallel (Figure 2). We usually use 2 distractors, one on each side of the skull. The distractor positions, orientation, and vectors are also confirmed before cutting the osteotomy. It is essential to make sure that both right- and left-sided distractors are parallel in vector and share the same direction (Figure 3). Burr holes in preparation of the osteotomy are designed away from the distractor footplates. Distractors are then fixed accordingly, and a single drain is inserted in the posterior flap. The flaps are closed in a layered fashion with planned puncture-like openings that are created for each distractor arm on each side. Finally, a single x-ray shot is taken to confirm proper placement of distractors at the end of the surgery. The patient is extubated at the end of the procedure. X-ray protection garments and shields are used throughout the procedure.

Figure 1.

A towel clip is used to locate the future placement of the superior (left) and inferior (right) osteotomies at the beginning of the surgery to properly locate the bicoronal incision.

Figure 2.

The superior and inferior osteotomy lines are marked using straight elevators under x-ray guidance. Elevators are adjusted (left) until they are parallel (right) before the osteotomy is done.

Figure 3.

Right- and left-sided distractors (left) are adjusted to be parallel (right) in vector and share the same direction.