A systematic review of endoscopic versus open treatment of craniosynostosis. Part 2: the nonsagittal single sutures

Craniometric and Aesthetic Outcomes in Craniosynostosis Surgery: A Systematic Review and Meta-Analysis

ObjectiveTo systematically review the published comparative aesthetic outcomes, and its determinants, for craniosynostoses surgically treated by minimally-invasive cranial procedures and open cranial vault remodeling (CVR).DesignPRISMA-compliant systematic review.SettingNot-applicable.Patients/ParticipantsArticles were included if they compared spring cranioplasty, strip minimally-invasive craniectomy or CVR for outcomes related to aesthetics or head shape. Forty-two studies were included, comprising 2402 patients.InterventionsNone.Main Outcome Measure(s)The craniometric and PROM used to determine surgical outcomes.ResultsTwenty-five studies (59%) evaluated sagittal craniosynostosis, with metopic (7;17%) and unicoronal (4;10%) the next most prevalent. Thirty-eight studies (90%) included CVR, 24 (57%) included strip craniectomy with helmeting, 9 (22%) included strip craniectomy without helmeting, 11 (26%) included spring cranioplasty, and 3 (7%) included vault distraction. A majority of studies only used 1 (43%) or 2 (14%) craniometric measures to compare techniques. In sagittal synostosis, 13 (59%) studies showed no difference in craniometric outcomes, 5 (23%) showed better results with CVR, 3 (14%) with strip craniectomy, and 1 (5%) with springs. In studies describing other synostoses, 10/14 (71%) were equivocal. Subjective outcome measures followed similar trends. Meta-analysis shows no significant difference in cranial index (CI) outcomes between CVR and less invasive procedures in patients with sagittal synostosis.ConclusionsThere is no difference in CI outcomes between CVR and less invasive procedures. The majority of literature comparing craniometric and aesthetic outcomes between CVR and less invasive procedures shows equivocal results for sagittal synostosis. However, the heterogeneity of data for other craniosynostoses did not allow meta-analysis.

A Comparison of Endoscope-Assisted and Open Frontoorbital Distraction for the Treatment of Unicoronal Craniosynostosis

BACKGROUND

Frontoorbital distraction osteogenesis (FODO) is an established surgical technique for patients with unicoronal craniosynostosis. The authors' institution has used an endoscope-assisted technique (endo-FODO) in recent years to decrease cutaneous scarring and lessen the impact on the functional growth matrix. This study compared perioperative outcomes in patients undergoing endo-FODO to those in patients undergoing the traditional coronal approach.

METHODS

Patients with unicoronal craniosynostosis undergoing FODO from 2013 to 2023 were included, and grouped by whether they underwent endo-FODO or a traditional coronal incision. Operative time, estimated blood loss, transfusion volume, and length of hospitalization were compared. Cutaneous scarring at 1 year postoperatively was assessed with the Scar Cosmesis Assessment and Rating (SCAR) scale.

RESULTS

A total of 27 patients (18 traditional and 9 endoscope-assisted) with an average age of 5.6 months (interquartile range [IQR], 5.1 to 6.3 months) at surgery were included, with no difference between groups (P = 0.999). Operative time was 114 minutes (IQR, 92 to 122 minutes) for traditional FODO and 104 minutes (IQR, 95 to 112 minutes) for endo-FODO (P = 0.607). Time under anesthesia was shorter for endo-FODO (traditional, 243 minutes [IQR, 218 to 264 minutes]; endo-FODO, 210 minutes [IQR, 191 to 224 minutes]; P = 0.029). Transfusion volume was 12.2 mL/kg lower for endo-FODO compared with traditional FODO (P = 0.001). Length of stay was similar between groups (P = 0.678). SCAR ratings were 1.83 (IQR, 1.1 to 4.47) in traditional FODO compared with 1.00 (IQR, 0.58 to 1.67) in the endo-FODO (P = 0.036).

CONCLUSIONS

Endo-FODO was associated with reduced time under anesthesia, reduced transfusion requirements, and improved SCAR scores, with no change in duration of surgery, perioperative complications, or length of stay. Future work will compare functional and aesthetic outcomes between techniques.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Open versus endoscopic surgery with helmet molding therapy in non-syndromic patients with craniosynostosis: an updated systematic review and meta-analysis of clinical outcomes and treatment-related costs

OBJECTIVE

There is an ongoing debate regarding the optimal treatment for craniosynostosis as diverse factors influence the election between endoscopic and open surgery. Previous evidence favors endoscopic procedures. However, evidence remains unfulfilled by a limited number of patients and clustered in very few centers worldwide making it difficult to define it as a replicable technique in different populations. In recent years, evidence regarding endoscopic-assisted procedures has gone through a considerable spurt showing an increased interest among surgeons globally showing optimal outcomes in different populations and centers. In this systematic review and meta-analysis, we performed an updated analysis of previous reviews, including only non-syndromic patients. We also seek to provide a summary of the tendency of treatment observed in the literature. Similarly, this is the first study to include total costs within its analysis.

MATERIAL AND METHODS

Three previous meta-analyses published in 2018 yielded 11 eligible papers. We performed a systematic review and meta-analysis of the literature in MEDLINE and EMBASE databases through PubMed, Scopus, and Ovid to fill the gap of information between 2018 and 2024. Twenty-three total articles were included in the final analysis.

RESULTS

Variables analyzed were baseline characteristics, length of stay, blood loss, transfusion rates and volume, operative time, and costs. The analysis of data concluded a younger age at surgery in patients undergoing endoscopic surgery (p ≤0.00001). Blood loss, transfusion rates, and volumes depicted favored outcomes for endoscopy with less blood loss during surgery (p ≤0.00001), operative time (p ≤0.00001), and transfusion rates (p ≤0.00001) as well as lower transfused volumes (p ≤0.00001).

CONCLUSION

Endoscopic surgery carries fewer complications than open surgery. Treatment-related costs are highly decreased in endoscopic procedures after including costs related to outpatient care. Open surgery can be considered in older children if no endoscope or experienced surgeons in endoscopic procedures are available.

Craniosynostosis: Current Evaluation and Management

ABSTRACT

Craniosynostosis is characterized by the premature fusion of one or more cranial sutures, which can lead to abnormal skull shape and restricted skull growth. Although most cases are present in isolation, some are associated with genetic syndromes, such as Pfeiffer, Muenke, Couzon, Apert, and others, which increases the complexity of care. Today, a spectrum of surgical options to treat craniosynostosis are available and range from traditional open cranial vault remodeling to newer and less invasive suturectomy-based techniques. Which procedure is offered to a patient depends on not only the specific synostosis pattern but also factors such as patient age, the need for additional procedures or interventions, and evidence of elevated intracranial pressure. Thorough consultations with families to discuss achievable goals for cosmesis and function are essential in providing optimal care to each impacted child.

The Role of Helmet Therapy in Craniosynostosis: A Systematic Review

The aim of this study was to determine the impact of helmet therapy (HT) as a treatment for craniosynostosis, with a focus on the outcomes of skull morphology, reoperation rate, complications of HT, and quality of life of patients who receive it. A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review utilized the PICO format: Does HT following strip craniectomy (SC) improve outcomes (outcome) compared to SC alone (comparison) in patients undergoing craniosynostosis correction (intervention)? Searches were performed from January 1, 2000 to December 31, 2022, using PubMed, Cochrane Library, and Ovid Medline databases. Study quality was evaluated using the National Heart, Lung, and Blood Institute (NHLBI) quality assessment scale. Fourteen studies meeting the inclusion criteria were identified. Among these, 438 patients underwent SC-HT, while 104 patients underwent SC without HT. The preoperative cephalic indices for sagittal craniosynostosis in the HT and non-HT groups were 66.8 and 67.8, respectively, which improved postoperatively to 75 and 76.2, respectively. Limited long-term follow-up hindered a definitive assessment of reoperation rates. Complication rates related to HT were low at approximately 2.9%, primarily consisting of skin irritation. Parental satisfaction was high, correlating with a strong compliance rate. Existing literature does not demonstrate a clear superiority between SC with or without HT for treating nonsyndromic sagittal craniosynostosis. Outcomes appear comparable, but evidence is constrained by the predominance of single-center retrospective studies with limited methodological rigor. There is a pressing need for international multicenter trials to furnish more robust and generalizable findings.

Family Experiences with Diagnosis of Craniosynostosis: Thematic Analysis of Online Discussion Boards

OBJECTIVE

Apply thematic analysis of online discussion boards to characterize families' experiences and concerns regarding craniosynostosis diagnoses to aid physicians in tailoring care to families.

DESIGN

Grounded theory-based qualitative analysis.

SETTING

Discussion boards related to craniosynostosis identified via Google and Yahoo.

PATIENTS/PARTICIPANTS

Posts about craniosynostosis between 2017-2022.

INTERVENTIONS

Thematic analysis was performed using three rounds of coding. Post features including author type and use of technical language were examined.

MAIN OUTCOME MEASURE

Overarching themes emerging from analysis of posts, with forums analyzed until sufficient thematic repetition was observed.

RESULTS

366 posts from 4 websites by 290 unique users were included. Parents of patients with craniosynostosis wrote 59% of posts while patients wrote 4%. Five selective codes were identified: 1) Building Community, 2) Diagnosis/Evaluation, 3) Treatment, 4) Outcomes, and 5) Emotional Concerns. Building Community was the most assigned code (85% of posts). 71% of parents' posts expressing emotional concerns expressed negative emotions, commonly regarding anxiety about diagnosis (71%), frustration about doctors' responses (21%), or negative reactions to online search results (17%). 88% of patients' posts expressed positive emotions, discussing positive long-term outcomes. Concerns that may guide physicians included anxiety about delayed diagnosis, difficulty distinguishing postpartum head shape changes from craniosynostosis, and difficulty finding a care team.

CONCLUSIONS

Online discussion boards allow families of patients with craniosynostosis to share experiences and find community. Improving communication between surgeons, pediatricians, and families about timing of evaluation and revising online information about this condition may ameliorate some anxiety associated with this diagnosis.

Resorbable Patient-Specific Implants of Molybdenum for Pediatric Craniofacial Surgery-Proof of Concept in an In Vivo Pilot Study

Titanium continues to be the gold standard in the field of osteosynthesis materials. This also applies to pediatric craniofacial surgery. Various resorbable materials have already been developed in order to avoid costly and risky second operations to remove metal in children. However, none of these resorbable materials have been able to completely replace the previous gold standard, titanium, in a satisfactory manner. This has led to the need for a new resorbable osteosynthesis material that fulfills the requirements for biocompatibility, stability, and uniform resorption. In our previous in vitro and in vivo work, we were able to show that molybdenum fulfills these requirements. To further confirm these results, we conducted a proof of concept in four domestic pigs, each of which was implanted with a resorbable molybdenum implant. The animals were then examined daily for local inflammatory parameters. After 54 days, the animals were euthanized with subsequent computer tomography imaging. We also removed the implants together with the surrounding tissue and parts of the spleen, liver, and kidney for histopathological evaluation. The molybdenum implants were also analyzed metallographically and using scanning electron microscopy. A blood sample was taken pre- and post-operatively. None of the animals showed clinical signs of inflammation over the entire test period. Histopathologically, good tissue compatibility was found. Early signs of degradation were observed after 54 days, which were not sufficient for major resorption. Resorption is expected with longer in situ residence times based on results of similar earlier investigations.

Cognitive Outcomes of Children With Sagittal Craniosynostosis Treated With Either Endoscopic or Open Calvarial Vault Surgery

Importance

Several studies have reported a higher incidence of neurodevelopmental delays and cognitive deficits in patients with single-suture craniosynostosis; however, there are few studies examining the associations of repair type with cognitive outcomes.

Objective

To measure differences in neuropsychological outcomes between school-age children who were treated for sagittal craniosynostosis and unaffected controls and explore differences in cognitive function among children with sagittal craniosynostosis who were previously treated with either endoscopic strip craniectomy or open calvarial vault surgery.

Design, Setting, and Participants

This cohort study was performed between 2018 and 2022. Eligible participants included patients aged 5 to 17 years who had previously been seen as infants or toddlers (<3 years) at 1 of 3 surgical centers for craniosynostosis repair with either endoscopic surgery or open calvarial vault surgery. A separate cohort of unaffected controls were included for comparison. Data analysis was conducted from November 2023 to February 2024.

Exposures

Open calvarial vault surgery or endoscopic repair for single-suture craniosynostosis.

Main Outcomes and Measures

The primary outcome was the Differential Ability Scales-II (DAS-II) General Conceptual Ability (GCA) score, an index for overall intellectual ability. Secondary outcomes included DAS-II subscale scores (Verbal Ability, Nonverbal Reasoning, Spatial Ability, Working Memory, and Processing Speed), and Patient-Reported Outcomes Measurement Information System (PROMIS) cognitive function scores.

Results

A total of 81 patients with sagittal craniosynostosis (59 male [73%]; 22 female [27%]) and 141 controls (81 male [57%]; 60 female [43%]) were included. Of the 81 participants with sagittal craniosynostosis, 46 underwent endoscopic repair and 35 underwent open repair. Median (range) age at time of follow-up assessment was 7.7 (5.0-14.8) years for children with sagittal craniosynostosis and median age at assessment was 8.5 (7.7-10.5) years for controls. After controlling for age at assessment, sex, and socioeconomic status, there was no statistically significant or clinically meaningful difference in GCA scores between children who underwent endoscopic repair (adjusted mean score, 100; 95% CI, 96-104) and open repair (adjusted mean score, 103; 95% CI, 98-108) (P > .99). We found no significant difference in PROMIS scores between repair types (median [range] for endoscopic repair 54 [31-68] vs median [range] for open repair 50 [32-63]; P = .14). When comparing the treatment groups with the unaffected controls, differences in subscale scores for GCA and working memory were observed but were within normal range.

Conclusions and Relevance

In this cohort study, there were no statistically or clinically significant differences in cognitive outcomes among school-age children by and type of surgical procedure used to repair nonsyndromic sagittal craniosynostosis. These findings suggest primary care clinicians should be educated about different options for craniosynostosis surgery to ensure early referral of these patients so that all treatment options remain viable.

Cognitive Development in Lambdoid Craniosynostosis: A Systematic Review and Meta-Analysis

OBJECTIVE

Lambdoid craniosynostosis affects approximately 1 in 33 000 live births per year, and surgical correction is often sought in order to achieve normocephaly and allow for adequate brain growth. However, the effects of lambdoid synostosis and its treatment on cognitive development are unknown.

DESIGN

Systematic review and meta-analysis.

PATIENTS, PARTICIPANTS

A systematic review of Ovid Medline, Embase, Web of Science, Scopus, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov was conducted in January 2022. Included studies assessed cognitive development of patients with nonsyndromic unilateral lambdoid craniosynostosis.

MAIN OUTCOME MEASURES

Results of developmental tests were compared to normative data or controls to generate Hedges' g for meta-analysis.

RESULTS

Nine studies met the inclusion criteria. Meta-analysis of 3 studies describing general cognition showed that cases scored significantly lower than their peers, but within 1 standard deviation (g = 0.37, 95% CI [-0.64, -0.10], P = .01). Meta-analysis of verbal and psychomotor development showed no significant differences in children with lambdoid synostosis. Studies were of fair quality and had moderate-to-high heterogeneity.

CONCLUSIONS

Patients with lambdoid craniosynostosis may score slightly below average on tests of general cognition in comparison to normal controls, but results in other domains are variable. Analyses were limited by small sample sizes. Multidisciplinary care and involvement of a child psychologist may be helpful in identifying areas of concern and providing adequate scholastic support. Further research recruiting larger cohorts will be necessary to confirm these findings and extend them to other developmental domains such as attention and executive function.

Prospective Evaluation of Health-Related Quality-of-Life in Children with Craniosynostosis

OBJECTIVE

To investigate health-related quality of life (HRQL) in children aged 2 to 7 years, who have undergone surgery for craniosynostosis.

DESIGN

Cross-sectional survey.

SETTING

A tertiary pediatric academic medical center.

PARTICIPANTS

Children with craniosynostosis who underwent surgical correction, and who were 2-7 years old at the time of the study. Children from families that did not speak English were excluded.

INTERVENTIONS

Caregivers were asked to fill out the Pediatric Quality of Life Inventory (PedsQL) Core Parent Report and the PedsQL Cognitive Functioning Scale.

MAIN OUTCOME MEASURES

PedsQL: Psychosocial Health Summary Score, Physical Health Summary Score, Total Core Score, Cognitive Functioning Scale Score. Scores range from 0 to 100, with higher scores reflecting greater QoLSubject factors: comorbidities, syndromic status, type of craniosynostosis, type of surgery.

RESULTS

The study included 53 subjects, of whom 13.2% had a syndrome. Core and cognitive scores did not depend on presence of a syndrome or suture involved. Subjects who underwent posterior cranial distraction achieved higher Total Core Scores than subjects who underwent open vault remodeling. Among subjects with sagittal craniosynostosis, there was a tendency for higher scores among children who underwent minimally-invasive surgery compared to those who underwent open vault remodeling.

CONCLUSIONS

This study demonstrates similar HRQL among children with and without a syndrome, higher HRQL among children undergoing posterior cranial distraction than those undergoing open vault remodeling, and trends towards higher HRQL in children with sagittal craniosynostosis who underwent minimally-invasive surgery compared to those who underwent open vault remodeling.

Part II: Blood Transfusion and Donor Exposure in the Surgical Management of Trigonocephaly Patients: A Protocol From Alder Hey Craniofacial Unit

Trigonocephaly is a craniofacial malformation caused by premature fusion of the metopic suture. Surgical correction frequently results in the need for blood transfusion. Transfusion complications include transfusion-transmitted infections (TTIs), immune-mediated reactions, and volume overload. Donor exposure (DE) describes the number of blood products from unique donors with increasing DE equating to an increased risk of TTI. We evaluate data on 204 trigonocephaly patients covering 20 years of practice with respect to blood transfusions and DE. This represents the largest series from a single unit to date. A protocol based on our experiences has been devised that summarizes the key interventions we recommend to minimize blood transfusions and DE in craniofacial surgery. Patients operated on between 2000 and 2020 were included. DE and a range of values were calculated including estimated red cell loss (ERCL) and estimated red cell volume transfused (ERCVT). Groups were established by relevant interventions and compared using the Mann-Whitney U test. Mean DE fell from 1.46 at baseline to 0.85 ( P <0.05). Median allogenic transfusion volume fell from 350 mL at baseline to 250 mL ( P <0.05). Median ERCL fell from 15.05 mL/kg at baseline to 12.39 mL/kg and median ERCVT fell from 20.85 to 15.98 mL/kg. Changes in ERCL and ERCVT did not reach statistical significance. DE can be minimized with the introduction of key interventions such as a restrictive transfusion policy, preoperative iron, cell saver, tranexamic acid, and use of a matchstick burr for osteotomies.

Shared Decision-Making: Process for Design and Implementation of a Decision Aid for Patients With Craniosynostosis

To describe the process of developing a craniosynostosis decision aid.

We conducted a mixed-methods exploratory study between August 2019 and March 2020 to develop a decision aid about surgical treatment for single suture craniosynostosis.

A single tertiary care academic children's hospital.

The decision aid development team consisted of surgeons, research fellows, a clinical nurse practitioner, clinical researchers with expertise in decision science, and a university-affiliated design school. Qualitative interviews (N = 5) were performed with families, clinicians (N = 2), and a helmeting orthotist to provide feedback on decision aid content, format, and usability.

After cycles of revisions and iterations, 3 related decision aids were designed and approved by the marketing arm of our institution. Distinct booklets were created to enable focused discussion of treatment options for the 3 major types of single suture craniosynostosis (sagittal, metopic, unicoronal).

Three decision aids representing the 3 most common forms of single suture craniosynostosis were developed. Clinicians found the decision aids could help facilitate discussions about families' treatment preferences, goals, and concerns.

We developed a customizable decision aid for single suture craniosynostosis treatment options. This tool lays the foundation for shared decision-making by assessing family preferences and providing clear, concise, and credible information regarding surgical treatment. Future research can evaluate this tool's impact on patient-clinician discussions about families' goals and preferences for treatment.

Correction of trigonocephaly after endoscopic strip craniectomy with postoperative helmet orthosis therapy: a 3D stereophotogrammetric study

OBJECTIVE

Endoscopic strip craniectomy with postoperative helmet orthosis therapy (ESCH) has emerged as a less invasive alternative to fronto-orbital remodeling for correction of trigonocephaly. However, there is no standardized objective method for monitoring morphological changes following ESCH. Such a method should be reproducible and avoid the use of ionizing radiation and general anesthesia for diagnostic imaging. The authors analyzed a number of metrics measured using 3D stereophotogrammetry (3DSPG) following ESCH, an imaging alternative that is free of ionizing radiation and can be performed on awake children.

METHODS

3DSPG images obtained at two time points (perisurgical and 1-year follow-up [FU]) of children with metopic synostosis who had undergone ESCH were analyzed and compared to 3DSPG images of age-matched control children without craniofacial anomalies. In total, 9 parameters were measured, the frontal angle and anteroposterior volume in addition to 7 novel parameters: anteroposterior area ratio, anteroposterior width ratios 1 and 2, and right and left anteroposterior diagonal ratios 30 and 60.

RESULTS

Six eligible patients were identified in the operated group, and 15 children were in the control group. All 9 parameters differed significantly between perisurgical and age-matched controls, as well as from perisurgical to FU scans. Comparison of FU scans of metopic synostosis patients who underwent surgery to scans of age-matched controls without metopic synostosis revealed that all parameters were statistically identical, with the exception of the right anteroposterior diagonal ratio 30, which was not fully corrected in the treated patients. The left anterior part of the head showed the most change in surface area maps.

CONCLUSIONS

In this pilot study, ESCH showed satisfactory results at 1 year, with improvements in all measured parameters compared to perisurgical results and normalization of 8 of 9 parameters compared to an age-matched control group. The results indicate that these parameters may be useful for craniofacial units for monitoring changes in head shape after ESCH for trigonocephaly and that 3DSPG, which avoids the use of anesthesia and ionizing radiation, is a satisfactory monitoring method.

Open Versus Minimally Invasive Approach for Craniosynostosis: Analysis of the National Surgical Quality Improvement Program-Pediatric

OBJECTIVE

This multicenter study aimed to compare demographic, operative, and short-term outcomes data between open and minimally invasive surgical approaches for craniosynostosis repair utilizing the American College of Surgeon's National Surgical Quality Improvement Program Pediatric (NSQIP-P) database and highlight surgical disparities among races and ethnicities.

DESIGN

Retrospective review of large multicenter database.

SETTING

Freestanding general acute care children's hospitals, children's hospitals within a larger hospital, specialty children's hospitals, or general acute care hospitals with a pediatric wing.

PATIENTS AND PARTICIPANTS

A total of 4931 pediatric patients underwent craniosynostosis correction within the NSQIP-P database from 2013 to 2019.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Demographic information included age at surgery, sex, race, and ethnicity. Operative and outcomes measures included operative time, anesthesia time, days until discharge, postoperative complications, blood transfusions, 30-day readmission, and 30-day unplanned return to operating room.

RESULTS

Patients who underwent minimally invasive surgery had significantly shorter operative and anesthesia times (p < .001; p < .001), fewer days until discharge (p < .001), fewer postoperative complications (p < .05), and less blood transfusions (p < .001). The proportion of White patients was significantly higher in the minimally invasive surgery group (p < .01), whereas Black and Hispanic patients had a significantly higher proportion in the open surgery group (p < .001; p < .001). Additionally, the percentage of patients undergoing minimally invasive surgery increased from 3.8% in 2014 to over 13% in 2019.

CONCLUSIONS

This study adds to a growing consensus that minimally invasive surgery has significantly decreased operative time, anesthesia time, transfusion rates, length of hospital stay, and postoperative complications compared to open surgery. Racial and ethnic surgical disparities showed larger proportions of Black and Hispanic populations undergoing open procedures.

Superior Long-term Appearance of Strip Craniectomy Compared with Cranial Vault Reconstruction in Metopic Craniosynostosis

Background:

Strip craniectomy with orthotic helmet therapy (SCOT) is an increasingly supported treatment for metopic craniosynostosis, although the long-term efficacy of deformity correction remains poorly defined. We compared the longterm outcomes of SCOT versus open cranial vault reconstruction (OCVR).

Methods:

Patients who underwent OCVR or SCOT for isolated metopic synostosis with at least 3 years of follow-up were identified at our institution. Anthropometric measurements were used to assess baseline severity and postoperative skull morphology. Independent laypersons and craniofacial surgeons rated the appearance of each patient’s 3D photographs, compared to normal controls.

Results:

Thirty-five patients were included (15 SCOT and 20 OCVR), with similar follow-up between groups (SCOT 7.9 ± 3.2 years, OCVR 9.2 ± 4.1 years). Baseline severity and postoperative anthropometric measurements were equivalent. Independent adolescent raters reported that the forehead, eye, and overall appearance of SCOT patients was better than OCVR patients (P < 0.05, all comparisons). Craniofacial surgeons assigned Whitaker class I to a greater proportion of SCOT patients with moderate-to-severe synostosis (72.2 ± 5.6%) compared with OCVR patients with the same severity (33.3 ± 9.2%, P = 0.02). Parents of children who underwent SCOT reported equivalent satisfaction with the results of surgery (100% versus 95%, P > 0.99), and were no more likely to report bullying (7% versus 15%, P = 0.82).

Conclusions:

SCOT was associated with superior long-term appearance and perioperative outcomes compared with OCVR. These findings suggest that SCOT should be the treatment of choice for patients with a timely diagnosis of metopic craniosynostosis.

Predictors of Blood Transfusion for Endoscopic Assisted Craniosynostosis Surgery

ABSTRACT

Blood loss is a main cause of morbidity after craniofacial procedures. The purpose of this study is to identify the incidence and predictors for transfusion of blood products in the endoscopic assisted strip craniectomy population. Data was prospectively collected from a single-center multi-surgeon cohort of 78 consecutive patients who underwent endoscopic assisted strip craniectomy for craniosynostosis between July 2013 and December 2020. The authors reviewed patient and treatment characteristics and outcomes. Of the 78 patients, 26 patients were transfused yielding an overall rate of transfusion of 33%. The most common fused suture was sagittal (n = 42, 54%) followed by metopic (n = 15, 19%), multiple (n = 10, 13%), coronal (n = 7, 9%) and finally lambdoid (n = 4, 5%). On univariate analysis, patients' weight in the transfusion cohort were significantly lower than those who did not receive a transfusion (5.6 ± 1.1 versus 6.5 ± 1.1 kg, P = 0.0008). The transfusion group also had significantly lower preoperative hemoglobin compared to the non-transfusion group (10.6 versus 11.1, P = .049). Eleven percent patients admitted to step-down received a transfusion, whereas 39% of patients admitted to the pediatric intensive care unit received a transfusion (P = 0.042). On multivariate analysis, only higher patient weight (operating room [OR] 0.305 [0.134, 0.693], P = 0.005) was protective against a transfusion, whereas colloid volume (OR 1.018 [1.003, 1.033], P = 0.019) predicted the need for a transfusion. Our results demonstrate that endoscopic craniosynostosis cases carry a moderate risk of transfusion. Individuals with lower weight and those that receive colloid volume are also at elevated risk.

Antifibrinolytics Are Not Associated With Reduced Blood Loss in Minimally-Invasive Endoscopic-Assisted Craniectomy for Repair of Single-Suture Craniosynostosis

ABSTRACT

Minimally-invasive endoscopic-assisted craniectomy (EAC) achieves similar functional and cosmetic outcomes, whereas reducing morbidity risk that is often associated with complex cranial vault reconstruction. Antifibrinolytics (AF) usage to limit blood loss and transfusion requirements during complex cranial vault reconstruction has been studied extensively; however, studies are limited for AF therapy in EAC. The aim of this single-center retrospective observational cohort pilot study was to evaluate whether the use of AF was associated with reduced blood loss in infants undergoing EAC. The authors hypothesized that there would be no difference in blood loss between patients who received AF and those that did not receive AF during EAC. Non-syndromic patients who underwent single-suture EAC were retrospectively evaluated. Primary outcome measure was intraoperative calculated blood loss (mL/kg). Secondary outcome measures included perioperative red blood cells transfusion volumes, number of blood donor exposures, and pediatric intensive care unit and total hospital length of stay. Study cohort demographic and outcome data were analyzed; Fisher exact test was used for categorical data, Student t test was used for continuous data. A P value of < 0.05 was considered statistically significant. Forty-nine EAC patients were included in the study with 34 patients in the AF cohort and 15 patients in the non-AF cohort. There were no significant differences in demographics between the 2 groups. Additionally, there was no significant difference in intraoperative calculated blood loss or any secondary outcome measure. In our single-suture EAC study cohorts, AF administration was not associated with a decrease in blood loss when compared to those that did not receive AF therapy.

Suturectomies Assisted by Cranial Orthosis Remodeling for the Treatment of Craniosynostosis Can Be Performed Without an Endoscope

BACKGROUND

Minimally-invasive endoscopic strip-craniectomy (or suturectomy) for the repair of craniosynostosis combined with postoperative cranial orthotic molding has been widely adopted in the past 2 decades, proving itself as a safe and effective procedure. Over time the authors transitioned from performing an endoscopic strip-craniectomy, to performing the same surgery without the endoscope. The authors here describe our technique and compare its results to those published in the literature for endoscopic suturectomies.

METHODS

A retrospective chart review was performed for patients with nonsyndromic craniosynostosis who underwent minimally-invasive nonendoscopic suturectomy between 2019 and 2020 at our institution.

RESULTS

Thirteen patients (11 males; 2 females) were operated including 5 Metopic, 5 Sagittal, 2 coronal, and 1 lambdoid craniosynostosis. The average age at surgery was 4.35 months. The average length of surgery was 71 minutes. Averaged intraoperative estimated blood loss was 31.54 mL. Eleven patients received a blood transfusion (most before performing the skin incision) with a mean amount of 94.62 mL of blood transfused during surgery. The mean hemoglobin at discharge was 10.38 mg/dL. There was only 1 intraoperative mild complication. The mean intrahospital length of stay was 1.77 days with no postoperative complications noted. All patients initiated remodeling orthotic treatment following surgery. Long-term follow-up scans were available for 8 patients (5 metopic, 2 sagittal, and 1 lambdoid) with an average follow-up of 9 months. In all cases, there was a significant improvement in the skull width at the synostosis location as well as in the skull proportions and symmetry. The above outcomes are similar to those published in the literature for endoscope-assisted strip-craniectomies.

CONCLUSIONS

Suturectomies assisted with cranial orthosis remodeling for the treatment of all types of nonsyndromic craniosynostosis can be performed without an endoscope while maintaining minimal-invasiveness, good surgical results, and low complication rates.

Treatment of Osteomyelitic Bone Following Cranial Vault Reconstruction With Delayed Reimplantation of Sterilized Autologous Bone: A Novel Technique for Cranial Reconstruction in the Pediatric Patient

ABSTRACT

Craniosynostosis, a deformity of the skull caused by premature fusion of ≥1 cranial sutures, is treated surgically via endoscopic approaches or cranial vault remodeling. Postoperative infection is rare. Management of postoperative surgical site infections often involves culture-directed intravenous antibiotics and debridement, with removal of osteomyelitic bone and hardware in refractory cases. Removal of autologous bone in a pediatric patient presents a reconstructive challenge, as alloplastic options are not optimal in a growing child, especially in the setting of infection. Moreover, infants and small children have limited autologous bone options for reconstruction. We present our case of a young child who developed an infectious complication following cranial vault remodeling. The patient's demographic information, clinical presentation and postoperative course, radiologic features, surgical interventions, and treatment outcomes were reviewed. In our case, autologous osteomyelitic bone underwent tissue processing to eradicate the infection and complete skull reconstruction using the patient's own processed autologous bone was performed in a delayed fashion. The patient is now 1 year postoperative with no recurrence of infection. We present this case as a novel technique to eradicate infection in autologous bone, allowing for delayed autologous cranial reconstruction.

Minimally invasive strip craniectomy for metopic craniosynostosis using a lighted retractor

Surgical options for metopic craniosynostosis include the traditional open approach or a minimally invasive approach that typically involves an endoscopy-assisted strip craniectomy. The minimally invasive approach has been associated with less blood loss and operative time, a lower transfusion rate, and a shorter length of stay. Additionally, it is more cost-effective than open reconstruction, despite the need for a postoperative cranial orthosis and multiple follow-up visits. The authors describe a variation of the minimally invasive approach using a lighted retractor to perform a strip craniectomy of the metopic suture in a 2-month-old patient with metopic craniosynostosis.

The video can be found here: https://vimeo.com/511237503.

Quantitative and qualitative comparison of morphometric outcomes after endoscopic and conventional correction of sagittal and metopic craniosynostosis versus control groups

OBJECTIVE

Surgical correction for sagittal and metopic craniosynostosis (SCS and MCS) aims to alter the abnormal cranial shape to resemble that of the normal population. The achieved correction can be assessed by morphometric parameters. The purpose of the presented study was to compare craniometric parameters of control groups to those same parameters after endoscopic and conventional (open) correction.

METHODS

The authors identified 4 groups of children undergoing surgical treatment for either SCS or MCS, with either endoscopic (SCS, n = 17; MCS, n = 16) or conventional (SCS, n = 29; MCS, n = 18) correction. In addition, normal control groups of nonaffected children who were 6 (n = 30) and 24 (n = 18) months old were evaluated. For all groups, several craniometric indices calculated from 3D photographs were compared for quantitative analysis. For qualitative comparison, averages of all 3D photographs were generated for all groups and superimposed to visualize relative changes.

RESULTS

For children with SCS, the cephalic index and coronal circumference index significantly differed preoperatively from those of the 6-month normal controls. The respective postoperative values were similar to those of the 24-month normal controls after both endoscopic and conventional correction. Similarly, for children with MCS, indices for circumference and diagonal dimension that were significantly different preoperatively became nonsignificantly different from those of 24-month normal controls after both endoscopic and conventional correction. The qualitative evaluation of superimposed average 3D head shapes confirmed changes toward normal controls after both treatment modalities for SCS and MCS. However, in SCS, the volume gain, especially in the biparietal area, was more noticeable after endoscopic correction, while in MCS, relative volume gain of the bilateral forehead was more pronounced after conventional correction. The average 3D head shapes matched more homogeneously with the average of normal controls after endoscopic correction for SCS and after conventional correction for MCS.

CONCLUSIONS

This quantitative analysis confirms that the performed surgical techniques of endoscopic and conventional correction of SCS and MCS alter the head shape toward those of normal controls. However, in a qualitative evaluation, the average head shape after endoscopic technique for SCS and conventional correction for MCS appears to be closer to that of normal controls than after the alternative technique. This study reports on morphometric outcomes after craniosynostosis correction. Only an assessment of the whole multiplicity of outcome parameters based on multicenter data acquisition will allow conclusions of superiority of one surgical technique.

Combined unilateral coronal-lambdoid suture synostosis: surgical outcome of suturectomy and postoperative helmet therapy

INTRODUCTION

Nonsyndromic, multi-suture craniosynostosis is not common, especially those involving unilateral coronal and lambdoid sutures. Based on the experience on 6 cases, we analyzed the skull morphology of combined unilateral coronal-lambdoid suture synostosis and evaluated the surgical outcome of suturectomy.

METHODS

Patients who underwent an operation for craniosynostosis in Seoul National University Children's Hospital from 2010 to 2018 were reviewed. For qualitative analysis of the surgical outcome, five typical morphologic characteristics (ipsilateral superior orbital rim deviation, deviation of the nasal ridge, ipsilateral frontal flattening, contralateral parietal bulging, ipsilateral occipitomastoid bulging) in unilateral coronal-lambdoid suture synostosis were evaluated based on medical photos, plain skull radiographs, and CT scans. For quantitative analysis, three parameters (nasal root deviation, orbital asymmetry, posterior skull base deviation) were measured.

RESULTS

Among 316 patients with craniosynostosis, 41 patients had nonsyndromic, multi-suture synostosis. There were 6 unilateral coronal-lambdoid suture synostosis patients who were all treated with suturectomy. Qualitative evaluation of the postoperative outcome revealed that the nasal root and orbital rim deviations and the contralateral occipitomastoid bulging showed satisfactory improvements. However, ipsilateral frontal flattening and contralateral parietal bulging were improved but still present in most cases. Quantitative, craniometric analysis supported the qualitative outcomes. The nasal ridge deviation angle was corrected from 7.04 to 1.79 degrees. The posterior skull base deviation angle improved from 6.29 to 3.55 degrees.

CONCLUSION

Unilateral coronal-lambdoid suture synostosis suturectomy followed by helmet therapy resulted in favorable outcomes, although the correction of frontal flattening was less satisfactory than the other measures. Considering the minimal invasiveness of the treatment, suturectomy may be a viable option for these patients.

Extended experience in parieto-occipital expansion surgery by meander technique-clinical and radiological evaluation

INTRODUCTION

Brachycephaly and anterior and posterior plagiocephaly appear as an isolated entity or manifest in syndromic conditions. In severe cases, possible treatment options currently comprise either cranioplasty or osteogenetic distraction. The aim of this paper is to retrospectively review the perioperative course of a series of children treated by posterior meander expansion technique at our institution with focus on the course of postoperative intracranial volume and eventual tonsillar descent evolution.

METHODS

Forty-two children received a posterior cranial vault remodeling by means of a posterior meander technique during a 7-year period. Hospital records were reviewed, and pre- and postoperative MRIs were analyzed for intracranial volume, cephalic and asymmetry index, and tonsillar position over time.

RESULTS

Median age at surgery was 11.5 months (range 17 days-10 years). Nineteen children had a symmetrical cranial deformity, twenty-three an asymmetrical synostosis. Half of the cohort showed a syndromic condition. Transfusions were administered in the majority (92.2%) of the cases. A significant postoperative increase of intracranial volume was present from 1188.9 ± 370.4 cm³ to 1324.8 ± 352.9 cm³ (p < 0.001). The asymmetry index showed a significant improvement postoperatively: 0.86 ± 0.06 versus 0.91 ± 0.05 (p < 0.001), while the cephalic index showed a non-statistical change (0.91 ± 0.11 versus 0.88 ± 0.08). Tonsillar herniation, bilateral or homolateral, showed no significant changes at early control, while a nonsignificant amelioration of tonsillar descent was seen among children older than 12 months at late imaging follow-up.

CONCLUSION

Among the osteoplastic techniques, the posterior meander technique offers several advantages, such as early mobilization of the child, less bony defects, absence of implants, and a small complication rate. However, further comparative studies among different surgical techniques are needed.

Endoscopic Versus Open Total Vault Reconstruction of Sagittal Craniosynostosis

: Sagittal craniosynostosis is the most common form of congenital cranial deformity. Surgical interventions are performed either open or endoscopic. Advancements in minimally invasive surgery have enabled the development of the endoscopic suturectomy technique. This is contrasted to the traditional open cranial vault reconstruction. There is a paucity of data comparing the head shape changes from both techniques. This study aims to compare the morphological outcome of endoscopic suturectomy versus total cranial vault reconstruction.

METHODS

This is a retrospective comparative study involving 55 cases of sagittal craniosynostosis, 37 of which has open total cranial vault reconstruction and 18 had endoscopic suturectomy procedure. Preoperative and postoperative 3D photographs of both groups were analyzed and compared. The change in correction between preoperative and postoperative state was measured against a crowd-driven standard for acceptable head shape.

RESULTS

Total cranial vault had higher percentage change between pre and postoperative cranial index than endoscopic suturectomy (14.7% versus 7.7%, P = 0.003). However, both techniques were able to achieve the minimum standard of 70% correction (TCV 107.5%, ES 100.4%, P = 0.02).

CONCLUSION

Total cranial vault and endoscopic suturectomy are effective in correcting scaphocephaly among children with sagittal craniosynostosis. Additionally, both techniques are able to achieve a percentage correction that exceeds the 70% benchmark established by the lay public.

School-Aged Anthropometric Outcomes After Endoscopic or Open Repair of Metopic Synostosis

BACKGROUND AND OBJECTIVES

Metopic craniosynostosis can be treated by fronto-orbital advancement or endoscopic strip craniectomy with postoperative helmeting. Infants younger than 6 months of age are eligible for the endoscopic repair. One-year postoperative anthropometric outcomes have been shown to be equivalent, with significantly less morbidity after endoscopic treatment. The authors hypothesized that both repairs would yield equivalent anthropometric outcomes at 5-years postoperative.

METHODS

This study was a retrospective chart review of 31 consecutive nonsyndromic patients with isolated metopic craniosynostosis treated with either endoscopic or open correction. The primary anthropometric outcomes were frontal width, interfrontal divergence angle, the Whitaker classification, and the presence of lateral frontal retrusion. Peri-operative variables included estimated blood loss, rates of blood transfusion, length of stay, and operating time.

RESULTS

There was a significantly lower rate of lateral frontal retrusion in the endoscopic group. No statistically significant differences were found in the other 3 anthropometric outcomes at 5-years postoperative. The endoscopic group was younger at the time of surgery and had improved peri-operative outcomes related to operating time, hospital stay and blood loss. Both groups had low complication and reoperation rates.

CONCLUSIONS

In our cohort of school-aged children with isolated metopic craniosynostosis, patients who underwent endoscopic repair had superior or equivalent outcomes on all 4 primary anthropometric measures compared with those who underwent open repair. Endoscopic repair was associated with significantly faster recovery and decreased morbidity. Endoscopic repair should be considered in patients diagnosed with metopic craniosynostosis before 6 months of age.

Endoscopic Spring-Mediated Distraction for Unilambdoid Craniosynostosis

BACKGROUND

Craniosynostosis treatment modalities have changed over time. These have included open calvarial remodeling, suturectomy with helmet molding, hand-powered distraction devices, and spring-mediated distraction. Implantable springs were first described for their use in treatment of craniosynostosis in 1998 (Lauritzen et al, Plast Reconstr Surg 121;2008:545-554). They have been used for the correction of craniosynostosis involving single and multiple sutures and have been placed through both endoscopic and open approaches. Their use for correction of lambdoid synostosis has been previously only described using an open approach (Arnaud et al, Child Nerv Syst 28;2012:1545-1549). The senior author has performed spring-mediated distraction for treating unilambdoid craniosynostosis using an endoscopic approach, which is described below and has not previously been reported by other authors.

METHODS

A retrospective analysis of our series of endoscopic unilambdoid synostosis repairs is included in this article. Patients were analyzed based on patient characteristics, operative details, and outcomes. The operation commences by approaching the lambdoid suture endoscopically through a 2- to 3-cm incision lateral to the lambdoid suture. Burr holes are placed on either side of the suture and a suturectomy is performed. Springs are bent preoperatively to a predetermined force. Two springs are placed across the suturectomy defect and the skin is closed. The patient is monitored for improvement in head shape and cranial X-rays are performed to measure the degree of distraction.

RESULTS

Seven patients underwent endoscopic spring-mediated distraction for unilambdoid craniosynostosis. The average age at the time of operation was 9.4 months. The median force of each spring placed was 7.0 N. The median length of hospital stay after spring placement was 2 days. Springs were removed at 5.6 months on average. Five patients had X-rays immediately after placement and prior to removal. Each spring expanded an average distance of 15.3 mm. There were no surgical complications. Three patients had both preoperative and postoperative computed tomography scans available. The angle of the cranial base, calculated by comparing foramen magnum to cribriform plate angles, improved 5.8° (12.3 preoperatively to 6.6 postoperatively).

CONCLUSION

Endoscopic spring-mediated distraction is a safe and effective method of treatment for unilambdoid craniosynostosis. The series represents the largest experience with this technique. The approach can be considered in all patients with unilambdoid synostosis given the efficacious improvement in vault remodeling, low patient morbidity, short operating time, and minimal inpatient stay.

A Novel Sand Dollar and Staves Technique for Unilateral Lambdoid Craniosynostosis

BACKGROUND

Unilateral lambdoid synostosis (ULS) is the rarest form of craniosynostosis. Due to the associated cranio-caudal shift seen in ULS, surgical correction is technically challenging from a morphological standpoint. Herein, the authors present a novel "Sand-Dollar and Staves" technique for the repair of ULS.

METHODS

A zigzag coronal incision is performed, and an anteriorly-based pericranial flaps are elevated. Prefabricated cutting guides are placed and the calvarium is marked. To treat the flattening on the ipsilateral side, a wedged suturectomy is performed with additional barrel staves. A large circle centered over the bulging on the contralateral side is cut out above the open lambdoid suture. This piece is barrel staved in a radial fashion, leaving the center intact and creating a Sand-Dollar appearance. This disk is then flattened and trimmed. The modified Sand-Dollar is fixed using an absorbable plating system. While gentle pressure is applied to the Sand-Dollar piece as it is being secured, the ipsilateral side demonstrates compensatory filling. Results are evaluated using the Whitaker Classification.

RESULTS

Four patients underwent surgical correction with this technique. The procedure was performed at mean age of 11.7 months. The mean operative time was 2.5 hours. Intraoperative blood loss was 50 to 100 ml. Total hospitalization time was 2 to 3 days. No post-operative complications were encountered. Whitaker scores ranged from 1 to 1.5. The mean follow-up was 10 months.

CONCLUSION

The Sand-Dollar and Staves procedure is a novel, single-stage approach for the management of ULS with decreased operative time, blood loss, and hospital stay with satisfactory aesthetic outcomes.

Minimally Invasive Endoscopic Surgery for Infantile Craniosynostosis: A Longitudinal Cohort Study

OBJECTIVE

To evaluate patient outcomes of minimally invasive endoscopic strip craniectomy (ESC) for craniosynostosis.

STUDY DESIGN

This is a retrospective cohort analysis (2004-2018) of 500 consecutive infants with craniosynostosis treated by ESC with orthotic therapy at a single center. Operative outcomes included transfusions, complications, and reoperations as well as head circumference change based on World Health Organization percentiles. Multivariable logistic regression was used to identify risk factors associated with blood transfusion. Paired t tests were used for within-patient comparisons and Fisher exact test to compare syndromic and nonsyndromic subgroups.

RESULTS

ESC was associated with low rates of blood transfusion (6.6%), complications (1.4%), and reoperations (3.0%). Risk factors for transfusion included syndromic craniosynostosis (P = .01) and multiple fused sutures (P = .02). Median surgical time was 47 minutes, and hospital length of stay 1 day. Transfusion and reoperation rates were higher among syndromic patients (both P < .001). Head circumference normalized by 12 months of age relative to World Health Organization criteria in infants with sagittal, coronal, and multisuture craniosynostosis (all P < .001).

CONCLUSIONS

ESC is a safe, effective, and durable correction of infantile craniosynostosis. ESC can achieve head growth normalization with low risks of blood transfusion, complications, or reoperation. Early identification of craniosynostosis in the newborn period and prompt referral by pediatricians allows families the option of ESC vs larger and riskier open reconstruction procedures.