The History and Evolution of Craniosynostosis Surgery

Early Descriptions of Cranial Morphology and Cranial Sutures

The first documented report describing the diversity of cranial morphology dates to 440 BCE in Herodotus’ work, The Histories ( Ἱστορίαι Historíai ). Herodotus (484–425 BCE), an ancient Greek historian, hypothesized through a study that environmental factors contributed to the observed variation in cranial thickness between different human populations. Hippocrates of Kos (460–370 BCE), the Greek physician who is widely praised as the “Father of Medicine,” provided one of the earliest and most comprehensive accounts of cranial anatomy and suture morphology in the treaties, On Head Wounds ( Περι των εν κεφαλη τρωματων ). Hippocrates classified four discrete skull patterns based on suture arrangement, which he likened to the shape of the Greek letters, and proposed the concept of anatomic variability. The treaties also emphasized the clinical significance of cranial thickness in the management and outcome of head injuries.

Variation in the shape of the cranium and cranial sutures were later recognized by Galen of Pergamon (130–200 BCE), a Roman physician to the gladiators. Through his anatomical studies, which were primarily on animals, he identified the cerebral aqueduct, characterized seven cranial nerves, and correlated characteristic cranial features with the condition hydrocephalus. ^{, ,} In his work, De Ossibus ad Tirones ( On the Bones for Novices ), he provided descriptions of the cranial sutures, the number of bones that form the cranium, and the shape of a normal skull. Galen also defined the term oxycephaly, introducing the notion of craniosynostosis. ^, Association of cranial deformities with craniofacial abnormalities like palatal defects was written by Oribasius (320–403), a Greek medical writer and personal physician to the Roman emperor Julian the Apostate.

One of the earliest illustrations of the cranium and cranial sutures was recorded several centuries later during the Medieval Period. Avicenna (980–1037), a Persian physician and polymath, depicted the structural framework of the cranium and the cranial sutures in his work, al-Qānūn fī al-Ṭibb ( Canon of Medicine) , the most comprehensive medical textbook of its time ( Fig. 1.1 ). He distinctly named and described the different cranial sutures, portraying the coronal suture as “an arc in whose center a perpendicular line has been set up” ; distinguishing the sagittal suture as the suture partitioning the skull into two halves, and regarding the squamosal suture as a “false” suture as they “do not penetrate the bone but overlap like fish scales.” Additionally, he accurately explained the configuration and articulation of the bones of the cranial vault, stating that the “frontal bone is located anteriorly; behind it are two parietal bones which are above the temporal bones and the occipital bone which is more compact and protects the back of the brain posteriorly.”

The knowledge of cranial anatomy and suture deformity expanded during the Renaissance through the works of key anatomists. A German physician, Johannes Dryander (1500–60) published the first detailed pictorial textbook on neuroanatomy in 1536, Anatomia Capitis Humani , which comprised of eleven elegantly engraved woodcuts. In one of his illustrations, he clearly displayed the configuration of specific cranial sutures ( Fig. 1.2A ) and alluded to the presence of the metopic suture, which “moved across the forehead to the nose.” ^, In 1543, a Flemish physician, Andreas Vesalius (1514–64), wrote and illustrated the monumental textbook of human anatomy ( Fig. 1.3A ), De Humani Corporis Fabrica Libri Septum ( On the Fabric of the Human Body ). Observations made from numerous dissections of human cadavers allowed Vesalius to appreciate anatomic variability. ^, He described a wide range of morphologic aberration of the shape of the skull and the arrangement of the sutures. He displayed one “natural” and four “unnatural” skulls, demonstrating how absence of certain sutures can lead to cranial malformations, namely craniosynostosis ( Fig. 1.3B ). ^{, ,}