Endoscopic-assisted repair of craniosynostosis

Endoscopic Strip Craniectomy and Helmet Therapy for Sagittal Craniosynostosis: An Analysis of Cranial Growth Changes in the Early Postoperative Period

OBJECTIVE

The purpose of this study is to analyze cranial width and length growth curves in the early postoperative period of patients by undergoing endoscopic sagittal strip craniectomy (ESC) to determine the timing of the maximal growth curve change. By analyzing the complex interplay of cephalic length and width measurements, we hope to better understand the cephalic index (CI) growth curve during this early period. This is the first of a multistep process to elucidate the ideal cranial remolding orthosis (CRO) treatment duration.

DESIGN

Retrospective review.

SETTING

Tertiary academic institution.

PATIENTS

Children with isolated sagittal craniosynostosis.

INTERVENTIONS

ESC and postoperative CRO treatment (2015-2019).

MAIN OUTCOME MEASURES

One cranial orthotist obtained preoperative and postoperative measurements. The maximal rate of change of width, length, and CI were compared against the postoperative week these occurred.

RESULTS

Thirteen children (mean age: 3.3 months, average preoperative CI: 73.4) underwent this intervention. CI reached its highest growth rate by 4.9 average weeks postoperatively, which correlated with the maximal width growth rate (5.2 weeks). Length curves reached their maximal growth rate by 15.5 weeks. CI peaked (81.3) by 22.7 weeks postoperatively, a significant increase from baseline.

CONCLUSIONS

Following ESC, in the early postoperative period, the CI growth curve has 4 phases: initial rapid expansion, early and late slowed expansion, and plateau, followed by possible regression phases. This highlights the importance of early postoperative CRO initiation, CRO compliance, and properly fitting CROs, especially in the first 2 phases. This data sets the stage for investigating the ideal treatment length.

Isolated Sagittal Craniosynostosis: A Comprehensive Review

Sagittal craniosynostosis, a rare but fascinating craniofacial anomaly, presents a unique challenge for both diagnosis and treatment. This condition involves premature fusion of the sagittal suture, which alters the normal growth pattern of the skull and can affect neurological development. Sagittal craniosynostosis is characterised by a pronounced head shape, often referred to as scaphocephaly. Asymmetry of the face and head, protrusion of the fontanel, and increased intracranial pressure are common clinical manifestations. Early recognition of these features is crucial for early intervention, and understanding the aetiology is, therefore, essential. Although the exact cause remains unclear, genetic factors are thought to play an important role. Mutations in genes such as FGFR2 and FGFR3, which disrupt the normal development of the skull, are suspected. Environmental factors and various insults during pregnancy can also contribute to the occurrence of the disease. An accurate diagnosis is crucial for treatment. Imaging studies such as ultrasound, computed tomography, magnetic resonance imaging, and three-dimensional reconstructions play a crucial role in visualising the prematurely fused sagittal suture. Clinicians also rely on a physical examination and medical history to confirm the diagnosis. Early detection allows for quick intervention and better treatment outcomes. The treatment of sagittal craniosynostosis requires a multidisciplinary approach that includes neurosurgery, craniofacial surgery, and paediatric care. Traditional treatment consists of an open reconstruction of the cranial vault, where the fused suture is surgically released to allow normal growth of the skull. However, advances in minimally invasive techniques, such as endoscopic strip craniectomy, are becoming increasingly popular due to their lower morbidity and shorter recovery times. This review aims to provide a comprehensive overview of sagittal craniosynostosis, highlighting the aetiology, clinical presentation, diagnostic methods, and current treatment options.

Moderne Behandlung von Kraniosynostosen

Hintergrund

Bei 13–48 % aller Lebendgeborenen treten Auffälligkeiten der Schädelform auf. Meistens ist ein lagerungsbedingter Plagiozephalus ursächlich. Bei vorzeitigem Verschluss von Schädelnähten resultieren pathognomische Deformitäten durch das kompensatorische Wachstum der umgebenden Schädelknochen. Es muss zwischen Einzelnahtsynostosen und Kraniosynostosen im Rahmen syndromaler Erkrankungen unterschieden werden.

Ziel

Diese Arbeit soll einen Überblick über Diagnostik, konservative und chirurgische Therapie von Kraniosynostosen geben.

Methoden

Narratives Review.

Ergebnis

Bei Verdacht auf eine Kraniosynostose erfolgt zunächst die klinische Beurteilung und Einschätzung durch erfahrene Untersucher. Die pathognomische Schädelform ergibt die Arbeitsdiagnose. Bestätigt wird diese durch Verfahren wie 3D-Stereofotografie und Sonographie. In komplexen Fällen können CT oder MRT notwendig sein.

Die Indikation für eine Therapie ergibt sich aus ästhetischen Gesichtspunkten und der Vorbeugung psychosozialer Folgen. Bei syndromalen Formen besteht diese insbesondere zur Vermeidung möglicher Folgen eines erhöhten Hirndrucks.

Besteht die Indikation zur Operation muss zwischen endoskopischer und offener Technik unterschieden werden. Unterschiede bestehen hier hinsichtlich Invasivität und möglichem Korrekturausmaß. Im Anschluss an die operative Behandlung schließt sich häufig eine Helmtherapie an, um das bestmögliche Ergebnis zu erreichen. Die anschließende Follow-up-Periode erstreckt sich mindestens bis zum 12. Lebensjahr. Insgesamt sollte die Behandlung im Team mit Neurochirurgen, Mund‑, Kiefer‑, Gesichtschirurgen, Kinderärzten, Augenärzten und Humangenetikern stattfinden.

Endoscopic treatment of sagittal suture synostosis - a critical analysis of current management strategies

While many centers nowadays offer minimally invasive techniques for the treatment of single suture synostosis, surgical techniques and patient management vary significantly. We provide an overview of how scaphocephaly treated with endoscopic techniques is managed in the reported series and analyze the crucial steps that need to be dealt with during the management process. We performed a review of the published literature including all articles that examined sagittal-suture synostosis treated with endoscopic techniques as part of single- or multicenter studies. Fourteen studies reporting results of 885 patients were included. We identified 5 key steps in the management of patients. A total of 188 patients were female and 537 male (sex was only specified in 10 articles, for 725 included patients, respectively). Median age at surgery was between 2.6 and 3.9 months with a total range from 1.5 to 7.0 months. Preoperative diagnostics included clinical and ophthalmologic examinations as well as neuropsychological and genetic consultations if needed. In 5 publications, a CT scan was routinely performed. Several groups used anthropometric measurements, mostly the cephalic index. All groups analyzed equally recommended to perform endoscopically assisted craniosynostosis surgery with postoperative helmet therapy in children < 3 months of age, at least for non-syndromic cases. There exist significant variations in surgical techniques and patient management for children treated endoscopically for single suture sagittal synostosis. This heterogeneity constitutes a major problem in terms of comparability between different strategies.

The use of a single-piece bone flap for cranial reshaping in anterior craniosynostosis patients: clinical experience and a description of a novel technique

Background

Craniosynostosis is known as premature closure of one or more of the cranial sutures. Anterior craniosynostosis involves anterior plagiocephaly and trigonocephaly. One of the issues in anterior craniosynostosis skull reshaping is maintaining an aesthetically pleasing forehead curve. Therefore, in this article, we demonstrate our novel technique to use a single-piece bone flap for cranial reshaping of the anterior mold in patients diagnosed with anterior craniosynostosis. A retrospective record review of patients who underwent single piece bone flap cranial reshaping for correction of unicoronal synostosis (UCS) and metopic synostosis (MS) at an Academic Institute in Riyadh, Saudi Arabia, between 2018 and 2020, was conducted.

Results

Six non-syndromic consecutive patients were included. Three of the patients had MS. The mean age at surgery was 11.16 months (range, 6–19 months). The average OR time was 315 min (range, 263–368 min). The average intraoperative blood loss was 225 ml (range, 100–400 ml). All patients had achieved acceptable functional and aesthetic results.

Conclusion

Our novel technique is an innovative and efficient reconstructive technique to simultaneously address MS and UCS and minimize intraoperative bleeding and surgery time. However, more studies with more cases are required.

Open Repair Versus Closed Repair: A Cost-Analysis of the Two Surgical Approaches for the Treatment of Craniosynostoses

PURPOSE

The purpose of this study was to quantify the hospitalization charges of the 2 general surgical approaches in the treatment of craniosynostosis and determine if there was a significant difference between the 2. Several studies compared them side-by-side according to specific variables, such as success rates, postoperative complications, blood loss, and length of stay, but were limited by small sample sizes.

METHODS

This is a retrospective cohort study that was conducted using the Kids' Inpatient Database (KID). All patients diagnosed with craniosynostosis (Q75.0) were identified. The procedures were grouped according to the approach taken, whether it was a traditional, open approach, or a closed, minimally invasive approach. The primary predictor variable was the surgical approach (open vs closed). The outcome variables were the hospital charges (US dollars) and length of stay (days). Statistical analyses were based on the univariate and multivariate linear regression models, and P value less than .05 marked the significance level.

RESULTS

Among a sample of 2,585 cases, an open approach was employed in 2,353 cases and a closed approach in 232 cases. Race, payer information, hospital region, admission status (elective vs not elective), patient location, and surgical approach (open vs closed) were all significant predictors (P < .15) of increased hospitalization charges. Relative to white patients, being in the 'other' racial class added $10,987 in hospital charges (P < .05). Relative to the Northeast, being a patient in the West added $33,459 in hospital charges (P < .01). Not being admitted electively added $72,572 (P < .01) relative to elective admissions. Finally, open repair added $59,539 (P < .01) in charges relative to closed repair.

CONCLUSIONS

The traditional open approach added nearly $60,000 to the cost of the procedure when compared with the closed, endoscopic approach. The scope and invasiveness of the open approach demand greater surgical services, hospital services, supplies, and equipment, ultimately contributing to this increased cost.

A new approach of crenellated fronto-orbital advancement for the management of trigonocephaly: Technical note

Trigonocephaly is a craniosynostosis characterized by a premature fusion of the metopic suture associating a characteristic triangular head shape, with a frontal medial crest and hypotelorism. Various techniques have been described for its surgical treatment which is usually performed during the first year of life. However, there might be cases with a late referral, after the age of one year. One of the technical issues with a fronto-orbital advancement surgery in a child over one year of age is that there is a significant risk of persistent residual bone defects. This article describes a surgical technique of crenellated fronto-orbital advancement for correcting trigonocephaly in children over one year of age, allowing to reduce residual bone defects.

Comparison of Perioperative Outcomes and Parental Satisfaction Outcomes of Strip Craniectomy with Postoperative Helmet versus Spring-Mediated Remodeling in Sagittal Craniosynostosis

INTRODUCTION

We sought to compare outcomes and parental satisfaction between 2 approaches for sagittal craniosynostosis: strip craniectomy with spring-mediated skull remodeling (SMSR) and strip craniectomy with postoperative helmet (SCH).

METHODS

Perioperative and outcome data for SMSR or SCH patients between September 2010 and July 2019 were retrospectively reviewed. A telephone survey was administered to parents of children who underwent both procedures.

RESULTS

A total of 62 children were treated for sagittal craniosynostosis by either SMSR (n = 45) or SCH (n = 17). The SCH group had a lower estimated blood loss (27 vs. 47.06 mL, p = 0.021) and age at surgery (13.0 vs. 19.8 weeks) than the SMSR group. Three patients underwent early springs removal due to trauma or dislodgement, all of whom converted to helmeting. Of the 62 children initially identified, 59 were determined to have an adequate follow-up time to assess long-term outcomes. The mean follow-up time was 30.1 months (n = 16) in the SCH group and 32.0 months in the SMSR group (n = 43, p = 0.39). Two patients in the SCH group and one in the SMSR group converted to open cranial vault reconstruction. Thirty parents agreed to respond to the satisfaction survey (8 SCH, 22 SMSR) based on a Likert scale of responses (0 being most dissatisfied possible, 4 most satisfied possible). Average satisfaction was 3.86/4.0 in the SCH group and 3.45/4.0 in the SMSR group. No parents in the SCH group would change to SMSR, while 3 of the 22 SMSR survey responders would have changed to SCH.

CONCLUSIONS

Perioperative outcomes and average parental satisfaction were similar in both groups. Importance of helmet wear compliance and risk of spring dislodgement should be discussed with parents.

Operative Time as the Predominant Risk Factor for Transfusion Requirements in Nonsyndromic Craniosynostosis Repair

Background:

Despite recent advances in surgical, anesthetic, and safety protocols in the management of nonsyndromic craniosynostosis (NSC), significant rates of intraoperative blood loss continue to be reported by multiple centers. The purpose of the current study was to examine our center’s experience with the surgical correction of NSC in an effort to determine independent risk factors of transfusion requirements.

Methods:

A retrospective cohort study of patients with NSC undergoing surgical correction at the Montreal Children’s Hospital was carried out. Baseline characteristics and perioperative complications were compared between patients receiving and not receiving transfusions and between those receiving a transfusion in excess or <25 cc/kg. Logistic regression analysis was carried out to determine independent predictors of transfusion requirements.

Results:

A total of 100 patients met our inclusion criteria with a mean transfusion requirement of 29.6 cc/kg. Eighty-seven patients (87%) required a transfusion, and 45 patients (45%) required a significant (>25 cc/kg) intraoperative transfusion. Regression analysis revealed that increasing length of surgery was the main determinant for intraoperative (P = 0.008; odds ratio, 18.48; 95% CI, 2.14–159.36) and significant (>25 cc/kg) intraoperative (P = 0.004; odds ratio, 1.95; 95% CI, 1.23–3.07) transfusions.

Conclusions:

Our findings suggest increasing operative time as the predominant risk factor for intraoperative transfusion requirements. We encourage craniofacial surgeons to consider techniques to streamline the delivery of their selected procedure, in an effort to reduce operative time while minimizing the need for transfusion.

Sagittal Craniosynostosis with Uncommon Anatomical Pathologies in a 56-Year-Old Male Cadaver

Sagittal craniosynostosis (CS) is a pathologic condition that results in premature fusion of the sagittal suture, restricting the transverse growth of the skull leading in some cases to elevated intracranial pressure and neurodevelopmental delay. There is still much to be learned about the etiology of CS. Here, we report a case of 56-year-old male cadaver that we describe as sagittal CS with torus palatinus being an additional anomaly. The craniotomy was unsuccessful (cephalic index, CI = 56) and resulted in abnormal vertical outgrowth of the craniotomized bone strip. The histological analysis of the latter revealed atypical, noncompensatory massive bone overproduction. Exome sequencing of DNA extracted from the cadaveric tissue specimen performed on the Next Generation Sequencing (NGS) platform yielded 81 genetic variants identified as pathologic. Nine of those variants could be directly linked to CS with five of them targeting RhoA GTPase signaling, with a potential to make it sustained in nature. The latter could trigger upregulated calvarial osteogenesis leading to premature suture fusion, skull bone thickening, and craniotomized bone strip outgrowth observed in the present case.

Optimal duration of postoperative helmet therapy following endoscopic strip craniectomy for sagittal craniosynostosis

OBJECTIVEMany infants with sagittal craniosynostosis undergo effective surgical correction with endoscopic strip craniectomy (ESC) and postoperative helmet therapy (PHT). While PHT is essential to achieving optimal cosmesis following ESC, there has been little comprehensive analysis of the ideal PHT duration needed to attain this goal.METHODSThe authors retrospectively reviewed the charts of infants undergoing ESC and PHT for sagittal synostosis at our institution between 2008 and 2015. Data collected included age at surgery, follow-up duration, and PHT duration. Cephalic index (CI) was evaluated preoperatively (CIpre), at its peak level (CImax), at termination of helmet therapy (CIoff), and at last follow-up (CIfinal). A multivariate regression analysis was performed to determine factors influencing CIfinal.RESULTSThirty-one patients (27 male, 4 female) were treated in the studied time period. The median age at surgery was 2.7 months (range 1.6 to 3.2) and the median duration of PHT was 10.4 months (range 8.4 to 14.4). The mean CImax was 0.83 (SD 0.01), which was attained an average of 8.4 months (SD 1.2) following PHT initiation. At last follow-up, there was an average retraction of CIfinal among all patients to 0.78 (SD 0.01). Longer helmet duration after achieving CImax did not correlate with higher CIfinal values. While CImax was a significant predictor of CIfinal, neither age at surgery nor CIpre were found to be predictive of final outcome.CONCLUSIONSPatients undergoing ESC and PHT for sagittal synostosis reach a peak CI around 7 to 9 months after surgery. PHT beyond CImax does not improve final anthropometric outcomes. CIfinal is significantly dependent on CImax, but not on age, nor CIpre. These results imply that helmet removal at CImax may be appropriate for ESC patients, while helmeting beyond the peak does not change final outcome.

Endoscopic surgery for nonsyndromic craniosynostosis: a 16-year single-center experience

OBJECTIVE

In this paper the authors review their 16-year single-institution consecutive patient experience in the endoscopic treatment of nonsyndromic craniosynostosis with an emphasis on careful review of any associated treatment-related complications and methods of complication avoidance, including preoperative planning, intraoperative management, and postoperative care and follow-up.

METHODS

A retrospective chart review was conducted on all patients undergoing endoscopic, minimally invasive surgery for nonsyndromic craniosynostosis at Rady Children's Hospital from 2000 to 2015. All patients were operated on by a single neurosurgeon in collaboration with two plastic and reconstructive surgeons as part of the institution's craniofacial team.

RESULTS

Two hundred thirty-five patients underwent minimally invasive endoscopic surgery for nonsyndromic craniosynostosis from 2000 to 2015. The median age at surgery was 3.8 months. The median operative and anesthesia times were 55 and 105 minutes, respectively. The median estimated blood loss (EBL) was 25 ml (median percentage EBL 4.2%). There were no identified episodes of air embolism or operative deaths. One patient suffered an intraoperative sagittal sinus injury, 2 patients underwent intraoperative conversion of planned endoscopic to open procedures, 1 patient experienced a dural tear, and 1 patient had an immediate reexploration for a developing subgaleal hematoma. Two hundred twenty-five patients (96%) were admitted directly to the standard surgical ward where the median length of stay was 1 day. Eight patients were admitted to the intensive care unit (ICU) postoperatively, 7 of whom had preexisting medical conditions that the team had identified preoperatively as necessitating a planned ICU admission. The 30-day readmission rate was 1.7% (4 patients), only 1 of whom had a diagnosis (surgical site infection) related to their initial admission. Average length of follow-up was 2.8 years (range < 1 year to 13.4 years). Six children (< 3%) had subsequent open procedures for perceived suboptimal aesthetic results, 4 of whom (> 66%) had either coronal or metopic craniosynostosis. No patient in this series either presented with or subsequently developed signs or symptoms of intracranial hypertension.

CONCLUSIONS

In this large single-center consecutive patient series in the endoscopic treatment of nonsyndromic craniosynostosis, significant complications were avoided, allowing for postoperative care for the vast majority of infants on a standard surgical ward. No deaths, catastrophic postoperative morbidity, or evidence of the development of symptomatic intracranial hypertension was observed.

Endoscopic versus open approach in craniosynostosis repair: a systematic review and meta-analysis of perioperative outcomes

INTRODUCTION

Surgery for craniosynostosis remains a crucial element in successful management. Intervention by both endoscopic and open approaches has been proven effective. Given the differences in timing and indications for these procedures, differences in perioperative outcomes have yet to be thoroughly compared between the two approaches. The aim of the systematic review and meta-analysis was to assess the available evidence of perioperative outcomes between the two approaches in order to better influence the management paradigm of craniosynostosis.

METHODS

We followed recommended PRISMA guidelines for systematic reviews. Seven electronic databases were searched to identify all potentially relevant studies published from inception to February 2018 which were then screened against a set of selection criteria. Data were extracted and analyzed using meta-analysis of proportions.

RESULTS

Twelve studies satisfied all the selection criteria to be included, which described a pooled cohort involving 2064 craniosynostosis patients, with 965 (47%) and 1099 (53%) patients undergoing surgery by endoscopic and open approaches respectively. When compared to the open approach, it was found that the endoscopic approach conferred statistically significant reductions in blood loss (MD = 162.4 mL), operative time (MD = 112.38 min), length of stay (MD = 2.56 days), and rates of perioperative complications (OR = 0.58), reoperation (OR = 0.37) and transfusion (OR = 0.09), where all p < 0.001.

CONCLUSION

Both endoscopic and open approaches for the surgical management of craniosynostosis are viable considerations. The endoscopic approach confers a significant reduction in operative and postoperative morbidity when compared to the open approach. Given that specific indications for either approach should be considered when managing a patient, the difference in perioperative outcomes remain an important element of this paradigm. Future studies will validate the findings of this study and consider long-term outcomes, which will all contribute to rigor of craniosynostosis management.

Development of synthetic simulators for endoscope-assisted repair of metopic and sagittal craniosynostosis

OBJECTIVE Endoscope-assisted repair of craniosynostosis is a safe and efficacious alternative to open techniques. However, this procedure is challenging to learn, and there is significant variation in both its execution and outcomes. Surgical simulators may allow trainees to learn and practice this procedure prior to operating on an actual patient. The purpose of this study was to develop a realistic, relatively inexpensive simulator for endoscope-assisted repair of metopic and sagittal craniosynostosis and to evaluate the models' fidelity and teaching content. METHODS Two separate, 3D-printed, plastic powder-based replica skulls exhibiting metopic (age 1 month) and sagittal (age 2 months) craniosynostosis were developed. These models were made into consumable skull "cartridges" that insert into a reusable base resembling an infant's head. Each cartridge consists of a multilayer scalp (skin, subcutaneous fat, galea, and periosteum); cranial bones with accurate landmarks; and the dura mater. Data related to model construction, use, and cost were collected. Eleven novice surgeons (residents), 9 experienced surgeons (fellows), and 5 expert surgeons (attendings) performed a simulated metopic and sagittal craniosynostosis repair using a neuroendoscope, high-speed drill, rongeurs, lighted retractors, and suction/irrigation. All participants completed a 13-item questionnaire (using 5-point Likert scales) to rate the realism and utility of the models for teaching endoscope-assisted strip suturectomy. RESULTS The simulators are compact, robust, and relatively inexpensive. They can be rapidly reset for repeated use and contain a minimal amount of consumable material while providing a realistic simulation experience. More than 80% of participants agreed or strongly agreed that the models' anatomical features, including surface anatomy, subgaleal and subperiosteal tissue planes, anterior fontanelle, and epidural spaces, were realistic and contained appropriate detail. More than 90% of participants indicated that handling the endoscope and the instruments was realistic, and also that the steps required to perform the procedure were representative of the steps required in real life. CONCLUSIONS Both the metopic and sagittal craniosynostosis simulators were developed using low-cost methods and were successfully designed to be reusable. The simulators were found to realistically represent the surgical procedure and can be used to develop the technical skills required for performing an endoscope-assisted craniosynostosis repair.

Less is more: does the addition of barrel staves improve results in endoscopic strip craniectomy for sagittal craniosynostosis?

OBJECTIVE Endoscopic strip craniectomy (ESC) with postoperative helmet orthosis is a well-established treatment option for sagittal craniosynostosis. There are many technical variations to the surgery ranging from simple strip craniectomy to methods that employ multiple cranial osteotomies. The purpose of this study was to determine whether the addition of lateral barrel-stave osteotomies during ESC improved morphological outcomes. METHODS An IRB-approved retrospective review was conducted on a consecutive series of cases involving ESC for sagittal craniosynostosis at 2 different institutions from March 2008 to August 2014. The patients in Group A underwent ESC and those in Group B had ESC with lateral barrel-stave osteotomies. Demographic and perioperative data were recorded; postoperative morphological outcomes were analyzed using 3D laser scan data acquired from a single orthotic manufacturer who managed patients from both institutions. RESULTS A total of 73 patients were included (34 in Group A and 39 in Group B). Compared with Group B patients, Group A patients had a shorter mean anesthetic time (161.7 vs 195 minutes; p < 0.01) and operative time (71.6 vs 111 minutes; p < 0.01). The mean hospital stay was similar for the 2 groups (1.2 days for Group A vs 1.4 days for Group B; p = 0.1). Adequate postoperative data on morphological outcomes were reported by the orthotic manufacturer for 65 patients (29 in Group A and 36 in Group B). The 2 groups had similar improvement in the cephalic index (CI): Group A, mean change 10.5% (mean preoperative CI 72.6, final 80.4) at a mean follow-up of 13.2 months; Group B, mean change 12.2% (mean preoperative CI 71.0, final 79.6) at a mean follow-up of 19.4 months. The difference was not statistically significant (p = 0.15). CONCLUSIONS Both ESC alone and ESC with barrel staving produced excellent outcomes. However, the addition of barrel staves did not improve the results and, therefore, may not be warranted in the endoscopic treatment of sagittal craniosynostosis.

Endoscopic Strip Craniectomy for Craniosynostosis: Do We Really Understand the Indications, Outcomes, and Risks?

Endoscopic strip craniectomy with postoperative helmet therapy has been introduced as a means to correct various forms of craniosynostosis. Although some authors have deemed the procedure safe and effective, many questions remain regarding this promising yet developing approach. The authors discuss 4 cases where patients were inadequately treated with endoscopic strip craniectomy resulting in a recommendation of complete secondary open cranial vault reconstruction. In addition, the authors present the findings from an informal survey of craniofacial colleagues to highlight an important discrepancy between published and anecdotal reports of complications. Finally, the authors highlight the need for further investigation into the proper indications and clinical outcomes of endoscopic strip craniectomy to better understand the role of this technique in the treatment of craniosynostosis.

Safety of Open Cranial Vault Surgery for Single-Suture Craniosynostosis: A Case for the Multidisciplinary Team

INTRODUCTION

Single Suture Craniosynostosis (SSC) occurs in 1 in 2,500 live births and is the most common type of craniosynostosis treated in most centers. Surgical treatment has evolved over the past century and open techniques are tailored to the specific suture type. Additionally, the concept of multi-disciplinary team care has proliferated and is becoming the standard of care for SSC. The combination of these evolutions, we believe, has improved the safety of cranial vault surgery for SSC.

METHODS

A retrospective review of patients participating in the Infant Learning Project at Seattle Children's Hospital who underwent cranial vault surgery for treatment of SSC between 2002 and 2006 was performed. Pre-operative assessment, surgical techniques, anesthetic and intraoperative events and both intra-operative and post-operative adverse events were analyzed.

RESULTS

Eighty eight patients fulfilled the inclusion criteria (42 sagittal, 23 metopic, 19 unicoronal, 4 lambdoid). Length of procedure varied (FOA 5.2 hrs, modified pi 2.5 hrs, total vault 4.9 hrs and switch cranioplasty 4.6 hrs), as did transfusion amount (FOA 385 mL, modified pi 216 mL, total vault 600 mL, switch cranioplasty 207 mL) although 99% of patients received a transfusion of some sort. There were no deaths and no major intraoperative complications. Minor events include; ET tube malposition (1), desaturation (1), acidosis (1), hypothermia (9), coagulopathy (2), Hct < 25 (55). Average hospital stay was 3.4 days with no major post-operative complications. One patient was readmitted to the ICU and 1 had a scalp hematoma, but no patients returned to the operating room within 6 months after surgery.

DISCUSSION

The surgical treatment of SSC has evolved from lengthy, risky procedures to become almost routine at most craniofacial centers. Additionally, the care for patients with SSC has evolved from a single provider to a multidisciplinary team concept based around protocols for workup, delivery of anesthesia, streamlined surgical procedures and post-operative care and assessment. This evolution has given open cranial vault surgery for SSC an acceptable safety profile.

Minimally Invasive Suturectomy and Postoperative Helmet Therapy : Advantages and Limitations

Various operative techniques are available for the treatment of craniosynostosis. The patient's age at presentation is one of the most important factors in the determination of the surgical modality. Minimally invasive suturectomy and postoperative helmet therapy may be performed for relatively young infants, whose age is younger than 6 months. It relies upon the potential for rapid brain growth in this age group. Its minimal invasiveness is also advantageous. In this article, we review the advantages and limitations of minimally invasive suturectomy followed by helmet therapy for the treatment of craniosynostosis.

Use of tranexamic acid in craniosynostosis surgery

Background

Intraoperative tranexamic acid (TXA) administration has been used to abate blood loss in a variety of surgical procedures. Several recent studies have supported its efficacy in reducing transfusion requirements in pediatric cranial vault reconstruction (CVR).

Objective

To conduct a retrospective chart review to determine whether a significant reduction in packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusions exists when TXA is used.

Methods

A retrospective cohort study of 28 patients who underwent CVR for sagittal craniosynostosis was performed. Transfusion requirements for 14 patients who did not receive TXA were compared with 14 patients who did. Predictors of increased blood product transfusion were also studied.

Results

Total volume of PRBC transfusion was reduced by 50% with the use of TXA (P=0.004) with a 34% reduction in intraoperative PRBC transfusion (P=0.017) and a 67% reduction in postoperative PRBC transfusion (P<0.001). Total volume of FFP transfusion was reduced by 46% (P=0.002) and postoperative FFP transfusion was reduced by 100% (P=0.001). The use of TXA was associated with a lower total volume of PRBC (P=0.003) and FFP (P=0.003) transfusions. Older patient age was associated with lower total volume of PRBC transfused (P=0.046 and P=0.002), but not with FFP (P=0.183 and P=0.099) transfusion volumes. Increasing patient weight was associated with lower PRBC (P=0.010 and P=0.020) and FFP (P=0.045 and P=0.016) transfusion volumes.

Conclusion

TXA decreased blood product transfusion requirements in patients undergoing CVR for sagittal craniosynostosis, and should be a routine part of the strategy to reduce blood loss in these procedures.

[The clinical picture of nonsyndromic craniosynostosis in children]

OBJECTIVE

to study clinical presentations of nonsyndromic craniosynostosis (NCS) in children.

MATERIAL AND METHODS

Authors analyzed 56 cases of different forms of NCS. To verify the diagnosis, all children underwent computed tomography with 3D cranial reconstruction.

RESULTS AND CONCLUSION

The distribution of diagnoses was as follows: scaphocephaly - 28 (50%) patients, trigonocephaly - 21 (38%), different forms of plagiocephaly - 7 (12%). On admission to the hospital, 25 (43%) patients were diagnosed with perinatal CNS damage, 10 (18%) were born premature, 33 (59%) had neurological deviations. The clinical picture of NCS was polymorphic that might explain an increase in the number of children with late-diagnosed craniosynostosis. The early diagnosis of NCS which is the basis for using less invasive surgical methods is particularly important for prognosis.

Use of tranexamic acid in craniosynostosis surgery

BACKGROUND

Intraoperative tranexamic acid (TXA) administration has been used to abate blood loss in a variety of surgical procedures. Several recent studies have supported its efficacy in reducing transfusion requirements in pediatric cranial vault reconstruction (CVR).

OBJECTIVE

To conduct a retrospective chart review to determine whether a significant reduction in packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusions exists when TXA is used.

METHODS

A retrospective cohort study of 28 patients who underwent CVR for sagittal craniosynostosis was performed. Transfusion requirements for 14 patients who did not receive TXA were compared with 14 patients who did. Predictors of increased blood product transfusion were also studied.

RESULTS

Total volume of PRBC transfusion was reduced by 50% with the use of TXA (P=0.004) with a 34% reduction in intraoperative PRBC transfusion (P=0.017) and a 67% reduction in postoperative PRBC transfusion (P<0.001). Total volume of FFP transfusion was reduced by 46% (P=0.002) and postoperative FFP transfusion was reduced by 100% (P=0.001). The use of TXA was associated with a lower total volume of PRBC (P=0.003) and FFP (P=0.003) transfusions. Older patient age was associated with lower total volume of PRBC transfused (P=0.046 and P=0.002), but not with FFP (P=0.183 and P=0.099) transfusion volumes. Increasing patient weight was associated with lower PRBC (P=0.010 and P=0.020) and FFP (P=0.045 and P=0.016) transfusion volumes.

CONCLUSION

TXA decreased blood product transfusion requirements in patients undergoing CVR for sagittal craniosynostosis, and should be a routine part of the strategy to reduce blood loss in these procedures.

Trigonocephaly: A simple modified technique

Trigonocephaly is the premature fusion of the metopic suture leading to deformation of anterior calvarium causing keel shaped deformity of forehead. In most cases, surgical correction is for aesthetic and psychosocial reasons. Various techniques have been described. Here we describe a technique, which is simple to perform with good postoperative results. Metopic suture is excised, one side is reconstructed in finger clasping manner to fit in an expanded area, and the other side is transected and simply molded, and all these fixed with nonabsorbable suture. Supraorbital horizontal bar is mobilized on either side anteriorly and fixed with titanium plate and screws.

Endoscopic-assisted craniosynostosis surgery

Over the last decade, endoscopy has been increasingly utilized in craniosynostosis surgery. In 2006, the author added endoscopy followed by helmet therapy to the treatment of young craniosynostosis patients. Since then, 73 children have been successfully treated utilizing endoscopic techniques with a transfusion rate of 23%. Most children are discharged on the first postoperative day; helmet therapy begins one week later. A helmet is worn for 4 to 6 months with one helmet replacement. Complications were limited to three reoperations to address suboptimal results, and one reoperation for a persisting skull defect. One sagittal sinus injury was addressed successfully, with resolution of a small intrasinus thrombus and no adverse brain sequelae. Although not applicable to every craniosynostosis patient, properly applied endoscopic-assisted craniosynostosis surgery is safe and effective, adding another option to the treatment armamentarium for craniosynostosis.

Evidence-based medicine: Craniosynostosis

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Make the appropriate diagnosis for each of the single-sutural synostoses, based on the physical examination. (2) Explain the functional concerns associated with these synostoses and why surgical correction is indicated. (3) Distinguish between the different types of surgical corrections available, the timing for these various interventions, and in what ways these treatments achieve overall management objectives. (4) Identify the basic goals involved in caring for the syndromic synostoses.

SUMMARY

This article provides an overview of the diagnosis and management of infants with craniosynostosis. This review also incorporates some of the treatment philosophies followed at The Craniofacial Center in Dallas, but is not intended to be an exhaustive treatise on the subject. It is designed to serve as a reference point for further in-depth study by review of the reference articles presented. This information base is then used for self-assessment and benchmarking in parts of the Maintenance of Certification process of the American Board of Plastic Surgery.

Odilon Marc Lannelongue (1840–1911) and strip craniectomy for craniosynostosis

In the 19th century, Dr. Odilon Marc Lannelongue was a pioneering French surgeon who introduced a surgical technique for the treatment of craniosynostosis. In 1890, Dr. Lannelongue performed correction of sagittal synostosis by strip craniectomy. From his procedure, multiple techniques have been developed and endorsed for this condition, ranging from simple suturectomies to extensive calvarial vault remodeling. In addition, even today, endoscopically aided strip craniectomy is performed as a surgical treatment of craniosynostosis. This article describes the life and works of the surgeon who revolutionized the management of craniosynostosis.

Endoscope-assisted repair of metopic synostosis

PURPOSE

Endoscopic treatment of nonsyndromic craniosynostosis has been used in recent decades. The aim of this study is to present the results of endoscope-assisted surgery of the patients with metopic synostosis.

METHODS

Nineteen patients with metopic synostosis underwent endoscope-assisted surgery between 2005 and 2012. The frontal angle was measured on CT scans pre- and postoperatively. A midline strip craniectomy was made, making sure that the removal extended inferiorly to the nasofrontal suture. Postoperatively, all patients wear a custom molding helmet. The helmet was then worn for 23 h daily and worn for the next 10-12 months.

RESULTS

There were 15 boys and 4 girls, ranging in age from 4 to 24 weeks. Mean operative time and transfused blood volume were 43.42 min and 76.31 ml, respectively. Mean follow-up was 59.3 weeks. Good esthetic results, judged by radiological examination and photograph comparison, were obtained in all patients.

CONCLUSIONS

Endoscope-assisted repair of metopic synostosis is safe and offers promising results in infants before the age of 6 months. Molding helmet therapy following surgery is very important in obtaining the good results. Early diagnosis and referral for surgery are crucial.

Pancraniosynostosis following endoscope-assisted strip craniectomy and helmet orthosis for sagittal suture craniosynostosis in a nonsyndromic patient

A variety of surgical strategies are used to correct sagittal craniosynostosis. There is increasing experience with the use of endoscope-assisted techniques, although there is no consensus regarding the optimal technique. Pancraniosynostosis occurring after the surgical repair of single-suture craniosynostosis is an unusual complication. The authors describe the case of a nonsyndromic patient who underwent an endoscope-assisted strip craniectomy with the subsequent use of a helmet orthosis for correction of an isolated sagittal suture craniosynostosis. The patient's early postoperative course was uneventful. Pancraniosynostosis subsequently developed, requiring much more extensive surgical correction. Awareness of this potential complication is necessary to ensure its recognition and appropriate management.

Cranial sutures: a multidisciplinary review

INTRODUCTION

Progress in cranial suture research is shaping our current understanding of the topic; however, emphasis has been placed on individual contributing components rather than the cranial sutural system as a whole. Improving our holistic view helps further guide clinicians who treat cranial sutural abnormalities as well as researchers who study them.

MATERIALS AND METHODS

Information from anatomy, anthropology, surgery, and computed modeling was integrated to provide a perspective to interpret suture formation and variability within the cranial functional and structural system.

RESULTS

Evidence from experimental settings, simulations, and evolution suggest a multifactorial morphogenetic process associated with functions and morphology of the sutures. Despite molecular influences, the biomechanical cranial environment has a main role in both the ontogenetic and phylogenetic suture dynamics.

CONCLUSIONS

Furthering our holistic understanding of the intricate cranial sutural system promises to expand our knowledge and enhance our ability to treat associated anomalies.

Endoscopic-assisted treatment of trigonocephaly

Minimally invasive, endoscopic repair of metopic craniosynostosis has emerged as a potentially efficacious, safe, and aesthetically acceptable alternative to open procedures. Potential advantages of an early endoscopic approach to repair metopic craniosynostosis include a reduction in blood loss and consequent decreases in transfusion volumes, decreased hospital costs, shorter operative times, and limited duration of hospitalization. Other benefits of minimally invasive techniques would be avoidance of anaesthetic surgical scarring, decrease in postoperative swelling and discomfort, and lower rate of complications such as duramater tears, postoperative hyperthermia, or infection. However, a concern is usually raised about the achievements of the "endoscopic" techniques when compared to "standard" open approaches. The indications for endoscopic-assisted surgery in the treatment of trigonocephaly remain controversial and further series and follow-up of these patients are necessary to set up the role of these approaches.

Nonendoscopic, minimally invasive calvarial vault remodeling without postoperative helmeting for sagittal synostosis

OBJECT

Multiple surgical procedures have been described for the management of isolated nonsyndromic sagittal synostosis. Minimally invasive techniques have been recently emphasized, but these techniques necessitate the use of an endoscope and postoperative helmeting. The authors assert that a safe and effective, more "minimalistic" approach is possible, avoiding the use of endoscopic visualization and routine postoperative application of a cranial orthosis.

METHODS

A single-institution cohort analysis was performed on 18 cases involving infants treated for isolated nonsyndromic sagittal synostosis between 2008 and 2010 using a nonendoscopic, minimally invasive calvarial vault remodeling (CVR) procedure without postoperative helmeting. The surgical technique is described. Variables analyzed were: age at time of surgery, sex, estimated blood loss (EBL), operative time, intraoperative complications, postoperative complications, length of stay, pre- and postoperative cephalic index (CI), clinical impressions, and results of a 5-question nonstandardized questionnaire administered to patient caregivers regarding outcome.

RESULTS

Eleven male and 7 female infants (mean age 2.3 months) were included in the study. The mean duration of follow-up was 16.4 months (range 6-38 months). The mean procedural time was 111 minutes (range 44-161 minutes). The mean length of stay was 2.3 days (range 2-3 days). The mean EBL in all 18 patients was 101.4 ml (range 30-475 ml). One patient had significant bone bleeding resulting in an EBL of 475 ml. Excluding this patient, the mean EBL was 79.4 ml (range 30-150 ml). There were no deaths or intraoperative complications; one patient had a superficial wound infection. The mean CI was 69 preoperatively versus 79 postoperatively, a statistically significant difference (p < 0.0001). Two patients were offered helmeting for suboptimal surgical outcome; one family declined and the single helmeted patient showed improvement at 2 months. No patient has undergone further surgery for correction of primary deformity, secondary deformities, or bony irregularities. Complete questionnaire data were available for 14 (78%) of the 18 patients; 86% of the respondents were pleased with the cosmetic outcome, 92% were happy to have avoided helmeting, 72% were doubtful that helmeting would have provided more significant correction, and 86% were doubtful that further surgery would be necessary. Small, palpable, aesthetically insignificant skull irregularities were reported by family members in 6 cases (43%).

CONCLUSIONS

The authors present a nonendoscopic, minimally invasive CVR procedure without postoperative helmeting. Their small series demonstrates this to be a safe and efficacious procedure for isolated nonsyndromic sagittal synostosis, with improvements in CI at a mean follow-up of 16.1 months, commensurate with other techniques, and with overall high family satisfaction. Use of a CVR cranial orthosis in a delayed fashion can be effective for the infrequent patient in whom this approach results in suboptimal correction.

Metopic synostosis

Premature closure of the metopic suture results in a growth restriction of the frontal bones, which leads to a skull malformation known as trigonocephaly. Over the course of recent decades, its incidence has been rising, currently making it the second most common type of craniosynostosis. Treatment consists of a cranioplasty, usually preformed before the age of 1 year. Metopic synostosis is linked with an increased level of neurodevelopmental delays. Theories on the etiology of these delays range from a reduced volume of the anterior cranial fossa to intrinsic malformations of the brain. This paper aims to provide an overview of this entity by giving an update on the epidemiology, etiology, evolution of treatment, follow-up, and neurodevelopment of metopic synostosis.

Endoscope-assisted strip craniectomy and postoperative helmet therapy for treatment of craniosynostosis

Object

The primary goals of treatment in the infant with craniosynostosis are to correct the deformity and allow for adequate brain growth in as safe and effective a manner as possible. Herein, the authors present the results of treating craniosynostosis using an endoscope-assisted strip craniectomy and postoperative helmet therapy (EASC + PHT) in the hopes of providing further evidence of its role in the treatment of multiple different forms of craniosynostosis. This is a retrospective review of the patients treated with this technique at Children's Hospital Boston.

Methods

The electronic medical records of all children with craniosynostosis treated using this technique were reviewed retrospectively. A priori, data were collected for deformity type, patient age at surgery, number of transfusions, operative time, length of hospital stay, and anthropometric measurements.

Results

One hundred seventy-three patients (61 females and 112 males) were treated at our institution between July 2004 and March 2011 with EASC + PHT. The mean operative time was 46.30 minutes. Eight (4.6%) of the 173 patients received blood transfusions. The average length of hospital stay was 1.35 days, with the majority of patients being discharged the day after surgery. All complications and any patient who required additional craniofacial reconstructions are discussed. In addition, a subgroup analysis was done for patients who had undergone surgery and had longer than 1 year of follow-up.

Conclusions

The authors' growing database of patients supports the experiences described by others that early treatment of craniosynostosis with an EASC + PHT is a safe and efficacious technique. In addition, cost reduction due to decreased hospital stay and limitation of blood transfusions are demonstrable benefits associated with the use of this technique.

Endoscopically assisted versus open repair of sagittal craniosynostosis: the St. Louis Children's Hospital experience

OBJECT

This study investigated the differences in effectiveness and morbidity between endoscopically assisted wide-vertex strip craniectomy with barrel-stave osteotomies and postoperative helmet therapy versus open calvarial vault reconstruction without helmet therapy for sagittal craniosynostosis.

METHODS

Between 2003 and 2010, the authors prospectively observed 89 children less than 12 months old who were surgically treated for a diagnosis of isolated sagittal synostosis. The endoscopic procedure was offered starting in 2006. The data associated with length of stay, blood loss, transfusion rates, operating times, and cephalic indices were reviewed.

RESULTS

There were 47 endoscopically treated patients with a mean age at surgery of 3.6 months and 42 patients with open-vault reconstruction whose mean age at surgery was 6.8 months. The mean follow-up time was 13 months for endoscopic versus 25 months for open procedures. The mean operating time for the endoscopic procedure was 88 minutes, versus 179 minutes for the open surgery. The mean blood loss was 29 ml for endoscopic versus 218 ml for open procedures. Three endoscopically treated cases (6.4%) underwent transfusion, whereas all patients with open procedures underwent transfusion, with a mean of 1.6 transfusions per patient. The mean length of stay was 1.2 days for endoscopic and 3.9 days for open procedures. Of endoscopically treated patients completing helmet therapy, the mean duration for helmet therapy was 8.7 months. The mean pre- and postoperative cephalic indices for endoscopic procedures were 68% and 76% at 13 months postoperatively, versus 68% and 77% at 25 months postoperatively for open surgery.

CONCLUSIONS

Endoscopically assisted strip craniectomy offers a safe and effective treatment for sagittal craniosynostosis that is comparable in outcome to calvarial vault reconstruction, with no increase in morbidity and a shorter length of stay.