Anaesthetic care during minimally invasive neurosurgical procedures in infants and children

Management of Unicoronal and Metopic Synostoses: Minimally Invasive Approaches

Early endoscopic-assisted correction of unicoronal and metopic synostosis is an excellent, safe, cost-effective, and highly effective option for affected patients. Although open calvarial remodeling has a place in the armamentarium of the craniofacial team, the skull base changes seen in endoscopic-assisted techniques are unparalleled. The procedures are associated with low morbidity and no mortality. There is minimal blood loss, decreased operating time, significantly reduced blood transfusion rates, decreased hospitalization length, decreased cost, and less pain and swelling. Early diagnosis and referral for surgical evaluation are critical to obtaining these results.

Anesthesia for Endoscopic Third Ventriculostomy in Children

Neuroendoscopy has established itself as a routine neurosurgical procedure in pediatric population. To have an uneventful smooth perioperative course, it is important for anesthesiologist to know about the key steps, possible complications, and specific anesthetic requirements. Among neuroendoscopies, endoscopic third ventriculostomy is the commonly performed one.

Endoscopic pediatric neurosurgery: implications for anesthesia

Endoscopic surgery is increasingly utilized in neurosurgery for all pediatric age groups. Endoscopic intraventricular neurosurgery represents a unique approach to intracranial pathology but may cause a unique set of limitations and potential complications. Important endoscopic neurosurgical techniques and their indications, perioperative anesthesia management, complications, and success rates are reviewed with special emphasis on endoscopic third ventriculostomy and endoscopic-assisted strip craniectomy in early infancy. Despite encouraging short- and long-term results of early pediatric endoscopic neurosurgery, multicenter randomized studies will be needed to further determine safety and the effect on cognitive development and quality of life.

Endoscopically assisted correction of sagittal craniosynostosis

Craniosynostosis is premature fusion of one or more of the cranial sutures of an infant's skull. Several sutures may be fused, alone or in combination. The endoscopically assisted approach to correcting craniosynostosis is an alternative to more traditional techniques, such as open-strip craniectomy and the Pi procedure for infants younger than four months of age and the cranial vault remodeling procedure for older children. The endoscopic procedure is less invasive and decreases the time patients spend under anesthesia, the need for transfusions, and lengths of hospital stay. The endoscopic approach relies on early diagnosis and surgery because the bones of very young infants are thin and pliable, which makes it easier to cut and remove the fused suture via a minimally invasive approach. After surgery, a cranial remolding helmet is used to direct skull growth.

Endoscopic strip craniectomy in early infancy: the initial five years of anesthesia experience

BACKGROUND

Minimally invasive endoscopic strip craniectomy (ESC) is a relatively new surgical technique for treating craniosynostosis in early infancy. In this study we reviewed our anesthesia experience with ESC. The hypothesis was that infants with low body weight and syndromes would have a higher risk of perioperative blood transfusion and that those with respiratory complications are more likely to be admitted to the intensive care unit (ICU).

METHODS

We retrospectively reviewed patient charts and anesthesia records of the first 100 consecutive infants who underwent ESC between May 2004 and December 2008 and follow-up evaluations until December 2009. Outcomes included (a) perioperative blood transfusion, (b) venous air embolism (VAE), (c) ICU admission, and (d) reoperation with craniofacial reconstruction procedures. Multivariable logistic regression was used to determine significant factors of patient outcomes.

RESULTS

Infants ranging from 4 to 34 weeks of age (weight: 3.2 to 10.1 kg), presented for 87 single and 13 multiple ESC. Four infants had a craniofacial syndrome. The mean surgical time was 48 minutes (range: 26 to 86 minutes). Ninety-two infants had a median estimated blood loss of 23 mL (interquartile ranges [IQR]: 15 to 30 mL). Eight infants who required blood transfusion received a median amount of 17.2 mL/kg (IQR: 10.1 to 21.2 mL/kg). Body weight ≤5 kg (P = 0.04), sagittal ESC (P < 0.01), syndromic craniosynostosis (P < 0.01), and earlier date of surgery in the series (P < 0.01) were factors associated with blood transfusion. VAE was detected in 2 infants with no changes in clinical outcome. Eight infants were admitted to the ICU. Factors associated with ICU admission were blood transfusion (P < 0.001) and respiratory complications (P < 0.001). Eighty-two infants were discharged on postoperative day 1 (range: 1 to 3 days). Six infants underwent subsequent fronto-orbital advancement and 1 cranial vault reconstruction. Multiple-suture craniosynostosis (P < 0.01), associated syndromes (P = 0.03), and ICU admission after ESC (P = 0.04) were predictive of reoperation.

CONCLUSIONS

Twenty percent of infants undergoing ESC had 1 or more of the following: need for blood transfusion, VAE, respiratory complications, and ICU admission. Multivariable analysis confirmed that patients with lower body weight, those with earlier date of surgery in the series, those undergoing sagittal ESC, and those with syndromic craniosynostosis had a higher rate of blood transfusion. ICU admissions often occurred in infants requiring transfusion and those with respiratory complications. Infants with multiple-suture craniosynostosis were more likely to require subsequent craniofacial reconstruction procedures.

Multiple-suture nonsyndromic craniosynostosis: early and effective management using endoscopic techniques

OBJECT

The authors present the results of treating infants with multiple-suture nonsyndromic craniosynostosis in whom the authors used minimally invasive endoscopy-assisted techniques and postoperative cranial molding over an 11-year period.

METHODS

A total of 21 patients who presented with multiple-suture (nonsyndromic) craniosynostosis were treated using minimally invasive endoscopy-assisted craniectomies. Surgery was followed by treatment with custommade cranial orthoses for up to 12 months. A total of 48 sutures were treated. The most common was the coronal suture (38 cases) and this was followed by the sagittal (11 cases), metopic (6 cases), and lambdoid (3 cases) sutures. There were 13 male and 8 female pediatric patients. Their ages ranged between 3 weeks and 9 months (mean 3.2 months, median 2.5 months). The sagittal suture was treated with a wide vertex craniotomy via 2 incisions located behind the anterior fontanel and in front of the lambda. The metopic suture underwent a suturectomy as did the coronal and lambdoid sutures.

RESULTS

The mean follow-up duration was 61 months (range 3-135 months). There were no deaths. In patients with bicoronal synostosis, brachycephaly was corrected. Patients presenting with vertical dystopia or nasal deviation had these deformities corrected as well. The mean blood loss was 42 ml (range 10-120 ml). The mean hospital length of stay was 1 day. The intraoperative transfusion rate was 0%. The results indicate that nonsyndromic multiple-suture synostosis can be safely and effectively treated using endoscopic techniques.

CONCLUSIONS

Early treatment of complex multiple-suture synostosis with endoscopic techniques provides an excellent surgical alternative. The results of the present study indicate marked correction of skull base and craniofacial deformities. Endoscopy provides a safe and effective way to treat these patients.