Multiple-revolution spiral osteotomy for cranial reconstruction. Technical note

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.

Flexible endoscope-assisted suture release and barrel stave osteotomy for the correction of sagittal synostosis

OBJECTIVE

Early suturectomy with a rigid endoscope followed by orthotic cranial helmet therapy is an accepted treatment option for single-suture craniosynostosis. To the authors' knowledge, flexible endoscope-assisted suture release (FEASR) has not been previously described. Presented herein is their experience with FEASR for the treatment of isolated sagittal craniosynostosis.

METHODS

A retrospective analysis of the health records of patients who had undergone FEASR between March 2018 and December 2020 was performed. Patients under the age of 6 months who had been diagnosed with isolated sagittal synostosis were considered eligible for FEASR. Exclusion criteria included syndromic synostosis or multiple-suture synostosis. The cephalic index, the primary measure of the cosmetic endpoint, was calculated at prespecified intervals: immediately preoperatively and 6 weeks and 12 months postoperatively. Parental satisfaction with the cosmetic outcome was determined throughout the clinical follow-up and documented according to a structured questionnaire for the first 12 months.

RESULTS

A total of 18 consecutive patients met the criteria for study inclusion. The mean patient age at the time of surgery was 3.4 months (range 2-6 months). All patients underwent a wide craniectomy with no need to convert to an open procedure. The mean craniectomy width was 3.61 cm. Estimated blood loss ranged from 5 to 30 ml. The mean operative time was 75 minutes. No intraoperative complications were observed. The average length of stay was 2.6 days. The mean cephalic index was 67.7 preoperatively, 77.1 at 6 weeks postoperatively, and 76.3 at 1 year postoperatively. The mean percentage change in the cephalic index from preoperatively to the 12-month follow-up was 10.44 (p < 0.001). The mean follow-up was 17 months (range 12-28 months). All parents were satisfied with the cosmetic outcome of the procedure. No patients developed symptoms of raised intracranial pressure (ICP) or needed invasive ICP monitoring during the follow-up period. No patients required reoperation.

CONCLUSIONS

In this modest single-hospital series, the authors demonstrated the feasibility of FEASR in treating sagittal synostosis with favorable cosmetic outcomes. The morbidity profile and resource utilization of the procedure appear similar to those of procedures conducted via traditional rigid endoscopy.

Telescoping With Multiple Revolution Cranial Osteotomies in Patients With Simple Craniosynostosis

Simple craniosynostosis is a cranial disease characterized by the premature closure of the cranial sutures, it develops during the first years of life and affects 1 in every 2000 to 2500 births worldwide (1). The cranial growth alteration occurs as parallel flattening to the compromised sutured with compensatory bulging in a perpendicular vector. Currently, The Suturectomy is the gold validated surgical treatment, that besides the dynamic Cranioplasties of multiples revolutions allows the design of bone flaps and therefore the correction of the secondary deformities caused by the synostosis. This multicenter descriptive study assessed a 20 series of cases (6 Plagiocephaly, 13 Scaphocephaly, 1 Brachycephaly) obtained in Cali, Colombia, that underwent surgery between January of 2014 and December of 2017, applying a Suturectomy surgery with additional telescoping of multiple revolution cranial osteotomies. The authors observe no clinical complications in the recruited patients regarding postoperative period of the described surgical technique (1, 90, and 180 days), thereby obtaining excellent outcomes on the maintained suture distraction focused on the assessment of the 3D reconstruction computed tomography scans.

Mini-invasive surgical technique for sagittal craniosynostosis

INTRODUCTION

Several techniques are currently available for the surgical correction of sagittal craniosynostosis. The most recently introduced ones have been specifically designed to perform a mini-invasive approach in order to reduce the postoperative morbidity. Herein, the surgical steps of a personal, mini-invasive technique used to decrease the impact of the surgical scar are described.

SURGICAL TECHNIQUE

The traditional biparietal skull expansion is realized through two to six short skin linear incisions (2-3 cm long) strategically scattered over the scalp, which allow the surgeon to perform a wide sagittal synostectomy, linear craniectomies along the coronal and lambdoid sutures, and barrel stave osteotomies on the frontal and occipital bones, if needed. No special instruments or postoperative molding therapy is required.

DISCUSSION

The main advantages of this technique are the poor visibility of the surgical scar, the reduction of the perioperative morbidity (blood transfusion, orbital edema, subcutaneous fluid collection), and the shortening of surgical times and postoperative hospitalization. The main limits are represented by the minor correction of the frontal bossing and the old age of children at surgery (no optimal results after 10-12 months of age).

Endoscopic technique for sagittal synostosis

PURPOSE

This study aimed to present a 16-year experience of treating sagittal synostosis with endoscopic-assisted techniques and postoperative cranial orthotic therapy. In 1996, we introduced the use of endoscopes for the management of sagittal synostosis in four young infants. During the subsequent years, we have treated a total of 256 patients with great success and long-term follow-up. Presented herein are the techniques and results of such clinical experience.

METHODS

A total of 256 patients with sagittal synostosis have been treated between May 1996 and April 2012. There were 187 males and 69 females. Mean age at time of surgery was 3.9 months. A wide-vertex craniectomy with bilateral barrel stave osteotomies of the temporal and parietal bones using small scalp incisions and endoscopic viewing techniques was performed. Instruments have been developed to assist with the operation. All patients were placed in postoperative molding cranial orthosis.

RESULTS

Mean estimated blood loss was 27 cc. Mean transfusion rate was 7 %. Mean surgical time was 57 min. Mean length of stay was 1.1 days. Using cephalic index (CI) as an anthropometric measurement to judge head shape, our results were classified as excellent (CI>80), good (CI 80-70), or poor (CI<70). A total of 87 % were classified as excellent, 9 % as good, and 4 % as poor.

CONCLUSIONS

Endoscopic-assisted management of sagittal synostosis is a safe, efficacious, and excellent option for treating this condition with long-lasting, superb results. It is associated with minimal morbidity and complications and improved results over traditional procedures.

Sagittal synostosis and ossified scalp hematoma: cause or consequence?

In this paper, the author presents 2 cases of sagittal synostosis with scaphocephaly that featured ossified scalp hematomas straddling the sagittal suture in the midparietal region. These ossified lesions were originally cephalohematomas. Collection of blood under the pericranium across the midline was possible in these cases because sagittal synostosis had obliterated the sagittal suture and its dense attachment to overlying periosteum. Scaphocephaly very likely exacerbated the difficulty of the deliveries and contributed to the causation of the scalp hemorrhages. The alternative hypothesis, that ossification of a scalp hematoma immobilized the suture and caused synostosis, is not tenable for reasons that are reviewed. Sagittal synostosis in these 2 instances was not a complication of birth trauma.

Effectiveness of a limited invasive scalp approach in the correction of sagittal craniosynostosis

BACKGROUND

Several surgical techniques have been proposed for the correction of sagittal craniosynostosis. Extensive procedures seem to ensure the most stable long-term results and are more indicated in the older age group. Mini-invasive approaches are particularly useful in the very young infant as they are associated with a minor surgical risk. Furthermore, they are weighted by a minor cosmetic impact related to a less extended surgical scar.

MATERIALS AND METHODS

Data of the last 94 consecutively operated on scaphocephalic patients have been reviewed to verify the effectiveness of a personal limited-invasive approach based on four to six short linear scalp incisions vs the traditional bicoronal skin flap. The patients have been divided in two groups: (1) the control group (2000-2002): 45 children, operated on by means of a traditional bicoronal skin incision, and (2) the study group (2002-2004): 49 children, treated through four to six linear scalp incisions. The patients' variables were comparable. The results were evaluated in terms of duration of the surgical procedure, estimated blood loss (EBL), transfusion risk, postoperative complication rate, length of hospital stay, and postoperative cephalic index and cosmetic outcome as perceived by the patients' families.

RESULTS

No significant differences between the two groups were found about the early and the long-term surgical results; however, about one third of the subjects of the control group complained about the visibility of the surgical scar. In the study group, a significant reduction in the duration of the operation (p < 0.0001), postoperative hospital stay (p < 0.0001), EBL (p = 0.011), transfusion risk (p = 0.018), and complication rate (p = 0.016) was observed.

CONCLUSION

The current trend in the management of scaphocephaly is to favor simplified surgical procedures to be performed in the younger ages prevalently. The technique here presented allows achieving a stable long-term cranial reshaping, even when performed in the very young patient. The technique can be utilized also in older subjects with results comparable to those of more extensive surgical procedures. This less invasive technique is weighted by minor complication rates and minor impact of the surgical scar.

The "clamshell" craniotomy technique in treating sagittal craniosynostosis in older children

OBJECT

Although most patients with sagittal craniosynostosis are recognized and treated in infancy, some children are not referred to craniofacial centers until later in childhood. In this paper the authors describe a novel operative technique for calvarial reconstruction in older children with previously untreated sagittal craniosynostosis.

METHODS

The authors report a clinical series of eight patients who were treated using novel single-stage calvarial reconstruction, and they assess the complications and outcomes. The patient is placed supine for the procedure, which consists of a coronal incision, bifrontal craniotomy without orbital osteotomy, and multiple interlocking midline parietooccipital osteotomies and recontouring. Fixation is achieved using a bioabsorbable plate system. Cranial indices were calculated from measurements obtained before and after the reconstructive procedures. Preoperative, intraoperative, and postoperative photographs and three-dimensional computed tomography scans are presented for review. Between November 2003 and April 2005, the authors treated seven boys (age range approximately 1-10 years, mean age 4.2 years) with uncorrected sagittal craniosynostosis and one with bicoronal and sagittal synostosis. The mean operating time was 5.13 hours (range 4.3-8 hours), with a mean blood loss of 425 ml (range 200-800 ml). As a percentage of the estimated circulating blood volume, the mean operative blood loss was 33.5% (range 17-57%). The mean hospital stay was 4.9 days. The cranial index significantly improved from a mean of 65.6 to 71.3% (p = 0.001). No acute or delayed complications have been noted. Follow-up examinations performed at an average of 12 months (range 1-17 months) have confirmed early patient and family satisfaction.

CONCLUSIONS

An approach of aggressive calvarial reconstruction with multiple interleaving osteotomies crossing the midline achieves improvements in biparietal narrowing. Combined with a bifrontal reconstruction, early outcomes are excellent, with an acceptable amount of intraoperative blood loss and no significant complications.

Blood sparing in craniosynostosis surgery

One of the main risks of craniosynostosis surgery is the possible need for an allogenic blood transfusion (ABT). Most patients are operated on in the first months of life, when physiological conditions are particularly sensitive to even limited blood losses. Furthermore, most surgical techniques proposed in the past were based on extensive craniectomies and cranial remodeling. Because of the known infective and immunologic risks of ABT, in recent years more attention has been dedicated to factors that might help reduce the risk of ABT. We review recent preoperative (ie, erythropoietin administration), intraoperative (ie, acute normovolemic hemodilution, intraoperative blood salvage), and postoperative (ie, clinical monitoring, postoperative blood salvage) anesthesiologic procedures developed with this aim in mind. We also consider operative techniques and technical apparatus that reduce surgical invasiveness, particularly preoperative planning, age selection, and the role of endoscopic assistance and gradual distraction devices.