Spring-Mediated Cranial Reshaping For Craniosynostosis

Sagittal Craniosynostosis: Treatment and Outcomes According to Age at Intervention

The purpose of this study is to describe the treatment strategies and outcomes of nonsyndromic single-suture sagittal craniosynostosis based on the patient's age at intervention. Studies from MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched for patients with nonsyndromic single-suture sagittal craniosynostosis. Inclusion criteria encompassed studies with follow-up of at least 12 months, minimum of 25 patients per cohort, and first-time surgical intervention. The risk of bias in nonrandomized studies of intervention tool [Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I)] was applied. A total of 49 manuscripts with 3316 patients met criteria. Articles were categorized based on age at intervention; 0 to 6, older than 6 to 12, and older than 12 months. Fifteen of the manuscripts described interventions in more than 1 age group. From the 49 articles, 39 (n=2141) included patients 0 to 6 months old, 15 (n=669) discussed patients older than 6 to 12 months old, and 9 (n=506) evaluated patients older than 12 months old. Follow-up ranged from 12 to 144 months. Over 8 types of open surgical techniques were identified and 5 different minimally invasive procedures were described. Minimally invasive procedures were exclusively seen in the youngest patient cohort, while open cranial vault reconstructions were often seen in the 2 older cohorts. Endoscopic surgery and open conservative procedures are indicated for younger patients, while complex open cranial vault reconstructions are common in older patients. However, there is no consensus on one approach over the other. Even with the analysis of this review, we cannot factor a strong conclusion on a specific technique.

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

OBJECTIVE

To 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).

DESIGN

PRISMA-compliant systematic review.

SETTING

Not-applicable.

PATIENTS/PARTICIPANTS

Articles 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.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

The craniometric and PROM used to determine surgical outcomes.

RESULTS

Twenty-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.

CONCLUSIONS

There 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.

Endoscopic strip craniectomy with molding helmet therapy versus spring-assisted cranioplasty for nonsyndromic single-suture sagittal craniosynostosis: a systematic review

OBJECTIVE

Endoscopic strip craniectomy with postoperative molding helmet therapy (ESC-H) and spring-assisted cranioplasty (SAC) are commonly used minimally invasive techniques for correction of nonsyndromic sagittal craniosynostosis, but it is unclear which, if either, is superior. Therefore, the authors undertook a systematic review to compare ESC-H with SAC for the surgical management of nonsyndromic single-suture sagittal craniosynostosis.

METHODS

Studies were identified through a systematic and comprehensive search of four databases (Embase, MEDLINE, and two databases in the Cochrane Library). Databases were searched from inception until February 19, 2021. Pediatric patients undergoing either ESC-H or SAC for the management of nonsyndromic single-suture sagittal craniosynostosis were included. Systematic reviews and meta-analyses, single-patient case reports, mixed cohorts of nonsyndromic and syndromic patients, mixed cohorts of different craniosynostosis types, and studies in which no outcomes of interest were reported were excluded. Outcomes of interest included reoperations, blood transfusion, complications, postoperative intensive care unit (ICU) admission, operative time, estimated blood loss, length of hospital stay, and cephalic index. Pooled summary cohort characteristics were calculated for each outcome of interest. Methodological quality was assessed using the Newcastle-Ottawa Scale. The study was reported in accordance with the 2020 PRISMA statement.

RESULTS

Twenty-two studies were eligible for inclusion in the review, including 1094 patients, of whom 605 (55.3%) underwent ESC-H and 489 (44.7%) underwent SAC for nonsyndromic sagittal craniosynostosis. There was no difference between the pooled estimates of the ESC-H and SAC groups for operative time, length of stay, estimated blood loss, and cephalic index. There was no difference between the groups for reoperation rate and complication rate. However, ESC-H was associated with a higher blood transfusion rate and higher postoperative ICU admission.

CONCLUSIONS

The available literature does not demonstrate superiority of either ESC-H or SAC, and outcomes are broadly similar for the treatment of nonsyndromic sagittal craniosynostosis. However, the evidence is limited by single-center retrospective studies with low methodological quality. There is a need for international multicenter randomized controlled trials comparing both techniques to gain definitive and generalizable data.

Long-Term Neurocognitive Outcomes of Spring-Assisted Surgery versus Cranial Vault Remodeling for Sagittal Synostosis

BACKGROUND

A long-term neurocognitive comparison of patients with sagittal synostosis who underwent spring-assisted surgery or cranial vault remodeling has not been performed.

METHODS

Patients with sagittal synostosis who underwent spring-assisted surgery or cranial vault remodeling were recruited from Wake Forest School of Medicine and Yale School of Medicine, respectively. Cognitive tests administered included an abbreviated intelligence quotient, academic achievement, and visuomotor integration. An analysis of covariance model compared cohorts controlling for demographic variables.

RESULTS

Thirty-nine spring-assisted surgery and 36 cranial vault remodeling patients were included in the study. No significant differences between cohorts were found with respect to age at surgery, sex, race, birth weight, family income, or parental education. The cranial vault cohort had significantly older parental age (p < 0.001), and mean age at testing for the spring cohort was significantly higher (p = 0.001). After adjusting for covariates, the cranial vault cohort had significantly higher verbal intelligence quotient (116.5 versus 104.3; p = 0.0024), performance intelligence quotient (109.2 versus 101.5; p = 0.041), and full-scale intelligence quotient (114.3 versus 103.2; p = 0.0032). When included patients were limited to intelligence quotients from 80 to 120, the cranial vault cohort maintained higher verbal (108.0 versus 100.4; p = 0.036), performance (104.5 versus 97.7; p = 0.016), and full-scale (107.6 versus 101.5; p = 0.038) intelligence quotients. The cranial vault cohort had higher visuomotor integration scores than the surgery group (111.1 versus 98.1; p < 0.001). There were no significant differences in academic achievement.

CONCLUSIONS

Sagittal synostosis patients who underwent cranial vault remodeling had higher intelligence quotient and visuomotor integration scores. There were no differences in academic achievement. Both cohorts had intelligence quotient scores at or above the normal range. Further studies are warranted to identify factors that may contribute to cognitive outcome differences.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Three-Dimensional Treatment Outcomes of a Virtual Helmet Design Protocol for Sagittal Strip Craniectomy

BACKGROUND

The helmet worn after sagittal strip craniectomy must be customized to the surgical procedure and the patient's anatomy to achieve optimal outcomes. This study compares three-dimensional head shape outcomes obtained from a novel virtual helmet design and from a traditional helmet design.

METHODS

Twenty-four patients underwent extended sagittal strip craniectomy performed by a single surgeon and helmet management performed by a single orthotist. Eleven patients constitute the traditional helmet group, with helmet design based on laser scans. Thirteen patients constitute the virtual helmet group, with helmet design based on an overlay of a three-dimensional volume rendering of a low-radiation protocol computed tomographic scan and three-dimensional photograph. Cephalic index and vertical height were recorded from three-dimensional photographs. Three-dimensional whole-head composite images were generated to compare global head shape outcomes to those of age-matched controls.

RESULTS

There was no significant difference in mean cephalic index between the virtual helmet group (83.70 ± 2.33) and controls (83.53 ± 2.40). The differences in mean cephalic index between the traditional helmet group (81.07 ± 3.37) and controls and in mean vertical height were each significant (p < 0.05). Three-dimensional analysis demonstrated normal biparietal and vertical dimensions in the virtual helmet group compared to controls. The traditional helmet group exhibited narrower biparietal dimension and greater vertical dimension compared to controls.

CONCLUSIONS

Traditional and virtual helmet protocols improved mean cephalic index, but the virtual helmet group yielded more consistent and greater change in cephalic index. The virtual helmet design protocol yielded three-dimensional outcomes similar to those of age-matched controls. Traditional helmet design yielded a narrower biparietal dimension and greater vertical dimension to the cranial vault compared to the virtual helmet group and controls.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparisons of Intracranial Volume and Cephalic Index After Correction of Sagittal Craniosynostosis With Either Two or Three Springs

ABSTRACT

In this retrospective study, the authors determined changes in intracranial volume (ICV) and cephalic index (CI) in patients with sagittal craniosynostosis and operated with craniotomy combined with either 2 or 3 springs. The authors included patients (n = 112) with complete follow-up that had undergone surgical correction for isolated sagittal craniosynostosis with craniotomy combined with springs between 2008 and 2017. All patients underwent computed tomography examination preoperative, at the time of spring extraction, and at 3 years of age. Intracranial volume was measured using a semiautomatic MATLAB program, and CI was calculated as the width/length of the skull. The authors found that craniotomy combined with 2 springs increased the ICV from a preoperative value of 792 ± 113 mL (mean ± standard deviation) to 1298 ± 181 mL at 3 years of age and increased the CI from 72.1 ± 4.1 to 74.6 ± 4.3, whereas craniotomy combined with 3 springs increased the ICV from 779 ± 128 mL to 1283 ± 136 mL and the CI from 70.7 ± 4.3 to 74.8 ± 3.7. The relative increase in ICV was 65 ± 21% in the two-spring group and 68 ± 34% in the three-spring group (P value = 0.559), and the relative increase in CI was 3.6 ± 3.3% in the two-spring group as compared with 6.0 ± 5.0% in the three-spring group (P = 0.004). These findings demonstrated that use of 3 springs resulted in additional absolute and relative CI-specific effects as compared with 2 springs during the time when the springs were in place, with this effect maintained at 3 years of age.

Removal of cranial springs after spring-mediated cranioplasty

Cranial spring hardware is generally removed 3 months after placement for spring-mediated cranioplasty. Spring removal is performed as an outpatient procedure under general anesthesia in approximately 15 minutes through the incision locations of the index procedure. Herein, the authors provide a multimedia demonstration of cranial spring hardware removal after spring-mediated cranioplasty for sagittal craniosynostosis.

The video can be found here: https://vimeo.com/511179695

Spring-mediated cranioplasty for sagittal craniosynostosis

Spring-mediated cranioplasty is a useful treatment modality for correcting scaphocephalic head shape in sagittal craniosynostosis because it is less invasive than whole-vault cranioplasty and offers durable morphologic outcomes. Herein, the authors provide a multimedia demonstration of alternative operative approaches for spring-mediated cranioplasty for sagittal craniosynostosis. The video can be found here: https://vimeo.com/511256259.

Planning and Osteotomy Designs in the Correction of Single-Suture Craniosynostosis

BACKGROUND

Craniosynostosis is among the abnormalities that are more commonly encountered by craniofacial surgeons. Although the overall concepts for cranial vault remodeling are relatively simple, osteotomy designs and methods for calvarial rearrangement are highly varied. In this work, we present a summary of the known designs for correction of single-suture craniosynostosis.

METHODS

A review of the literature was performed of the more frequently used osteotomy designs for single-suture craniosynostosis, as well as their reported results and outcomes. Also reviewed are some of the current available approaches for the diagnosis and surgical planning for single-suture craniosynostosis.

RESULTS

There remains a diversity of techniques available for the reconstruction of each fused cranial suture. Certain osteotomy designs are reported in the literature and are used by craniofacial surgeons more frequently. Each has its own benefits and disadvantages, and there is a growing body of outcome data available to guide surgical decision-making. Regarding diagnosis and surgical planning, computed tomography with 3-dimensional reconstruction remains the diagnostic standard of care, and efforts are ongoing to develop and implement new diagnostic modalities like Black Bone MRI to reduce radiation exposure.

CONCLUSIONS

There has been ongoing evolution of the surgical techniques available to reconstruct single-suture craniosynostosis, leading to ever-improving patient outcomes.

Perioperative Outcomes in the Treatment of Isolated Sagittal Synostosis: Cranial Vault Remodeling Versus Spring Mediated Cranioplasty

BACKGROUND

Patients undergoing cranial expansion including spring-mediated cranioplasty (SMC) and cranial vault remodeling (CVR) receive costly and high acuity post-operative intensive care (ICU) given concerns over neurologic and hemodynamic vulnerability. The authors analyzed perioperative and post-operative events for patients presenting with sagittal craniosynostosis (CS) undergoing SMC and CVR in order to compare complication profiles.

METHODS

The authors performed a single center retrospective cohort study of patients undergoing SMC and CVR for the treatment of nonsyndromic, isolated sagittal CS from 2011 to 2018. Perioperative and post-operative factors were collected, focusing on hemodynamic instability and events necessitating ICU care. Mann-Whitney U and Fisher exact tests were used to compare data with significance defined as P < 0.05.

RESULTS

Among 106 patients, 65 (61%) underwent SMC and 41 (39%) CVR. All CVR patients received prophylactic whole blood transfusion at time of scalp incision. Acute blood loss anemia was the most common post-operative complication, prompting n = 6 (9.2%) and n = 7 (17.1%) blood transfusions in the SMC and CVR cohorts, respectively (P < 0.24). Hemodynamic instability requiring blood transfusion was rare, occurring post-operatively in n = 2 (3.1%) and n = 2 (4.9%) patients in the SMC and CVR cohorts, respectively (P < 0.64). Two patients in the CVR cohort exhibited new neurologic symptoms that self-resolved, compared to no patients in the SMC cohort (P < 0.15).

CONCLUSION

Despite differing degrees of operative invasiveness, post-operative hemodynamic and neurologic decompensation following CVR and SMC for isolated sagittal CS repair remains similarly rare. Indications necessitating post-operative intensive care are infrequent. Post-operative hemoglobin monitoring may enable early prediction for hemodynamic instability.

Comparison of 2 Sagittal Craniosynostosis Repair Techniques: Spring-Assisted Surgery Versus Endoscope-Assisted Craniectomy With Helmet Molding Therapy

INTRODUCTION

This study compares anthropometric outcomes of 2 sagittal synostosis repair techniques: spring-assisted surgery and endoscope-assisted craniectomy with molding helmet therapy.

METHODS

Patients undergoing spring-assisted surgery (n = 27) or endoscope-assisted craniectomy with helmet therapy (n = 40) at separate institutions were retrospectively reviewed. Pre- and 1-year postoperative computed tomography (CT) or laser scans were analyzed for traditional cranial index (CI), adjusted cranial index (aCI), and cranial vault volume (CVV). Nine patient-matched scans were analyzed for measurement consistency.

RESULTS

The spring-assisted group was older at both time points (P < .050) and spring-assisted group CVV was larger preoperatively and postoperatively (P < .01). However, the change in CVV did not differ between the groups (P = .210). There was no difference in preoperative CI (helmet vs spring: 70.1 vs 71.2, P = .368) between the groups. Postoperatively, helmet group CI (77.0 vs 74.3, P = .008) was greater. The helmet group also demonstrated a greater increase in CI (6.9 vs 3.1, P < .001). The proportion of patients achieving CI of 75 or greater was not significantly different between the groups (helmet vs spring: CI, 65% vs 52%, P = .370). There was no detectable bias in CI between matched CT and laser scans. Differences were identified between scan types in aCI and CVV measurements; subsequent analyses used corrected CVV and aCI measures for laser scan measures.

CONCLUSIONS

Both techniques had equivalent proportions of patients achieving normal CI, comparable effects on cranial volume, and similar operative characteristics. The study suggests that there may be greater improvement in CI in the helmet group. However, further research should be performed.

The Science Behind the Springs: Using Biomechanics and Finite Element Modeling to Predict Outcomes in Spring-Assisted Sagittal Synostosis Surgery

Spring-assisted surgery for the correction of scaphocephaly has gained popularity over the past 2 decades. Our unit utilizes standardized torsional springs with a central helix for spring-assisted surgery. This design allows a high degree of accuracy and reproducibility of the force vectors and force distance curves. In this manuscript, we expand on the biomechanical testing and properties of these springs. Standardization of design has enabled us to study the springs on bench and in vivo and a comprehensive repository of calvarial remodeling and spring dynamics has been acquired and analyzed.Finite element modeling is a technique utilized to predict the outcomes of spring-assisted surgery. We have found this to be a useful tool, in planning our surgical strategy and improving outcomes. This technique has also contributed significantly to the process of informed consent preoperatively. In this article, we expand on our spring design and dynamics as well as the finite element modeling used to predict and improve outcomes.In our unit, this practice has led to a significant improvement in patient outcomes and parental satisfaction and we hope to make our techniques available to a wider audience.

Spring-Assisted Surgery for Treatment of Sagittal Craniosynostosis

ABSTRACT

Craniosynostosis (CSS), the premature fusion of calvarial sutures, most commonly involves the sagittal suture. Cranial vault remodeling (CVR) is a traditional method of CSS correction. Minimally invasive methods are becoming widely accepted, including spring-assisted surgery (SAS). The equipment required for SAS is minimal therefore adaptable to resource challenged health systems. This paper outlines the experience of SAS in Moldova.A retrospective study was performed for patients treated with SAS for sagittal CSS from 2011 to 2018 in Moldova. Perioperative data were recorded including age, length of surgery, blood loss, volume transfused and length of stay. Four patients had pre- and post-operative computed tomography (CT) scans which were used to calculate changes in cephalic index, normative cephalic index, and intracranial volume.Thirteen patients underwent SAS. Diagnoses were made clinically and confirmed with CT. Mean age at surgery was 4.0 months, and length of surgery 62.7 minutes. All but one patient received a blood transfusion, as is standard of practice in Moldova. The mean length of post-operative recovery in ICU was 30.9 hours. No complications required surgical revision. Springs were removed after 4 to 5 months. All patients had a subjective improvement in scaphocephaly. Based on the available CT scans, an increase in cephalic index (7.3%), normative cephalic index (11.8%), and intracranial volume (38.1%) was observed. One patient underwent SAS at 11 months and required cranioplasty for asymmetry at the time of spring removal.SAS is a safe and cost-effective method of CSS correction that can be utilized in countries with limited health system resources.

Spring Cranioplasty: Incorporation Into Practice

OBJECTIVE

The aim of this paper is to discuss ways to incorporate spring-assisted cranioplasty into the surgical armamentarium for craniosynostosis.

BACKGROUND

Spring-assisted cranioplasty after cranial suturectomy for craniosynostosis was popularized in the literature by Dr Lauritzen in 2008 after reporting the results of the first 100 cases. Since that time, more craniofacial surgeons and neurological surgeons have incorporated this surgical technique for treatment of patients presenting with craniosynostosis. This paper will discuss how the team at Nationwide Children's Hospital has incorporated spring-assisted cranioplasty into the care of patients presenting with sagittal synostosis.

METHODS

In this article, the authors review our previous protocol for the treatment of children with sagittal synostosis prior to the introduction of spring cranioplasty. The authors then describe the impetus for incorporating spring-assisted cranioplasty for sagittal synostosis into our practice, and barriers we encountered during this implementation. The authors then discuss their current, comprehensive protocol for treating children with sagittal craniosynostosis. Finally, the authors review the expected and unexpected advantages that our craniofacial program has experienced as they implemented spring-assisted cranioplasty.

CONCLUSION

Incorporation of spring-assisted cranioplasty for sagittal synostosis offers an additional minimally invasive technique, which presents great advantages for many families, and is rewarding for both craniofacial and neurological surgeons.

The History of Spring-Assisted Surgery Implementation into the Treatment Algorithm for Craniofacial Deformities

Spring-assisted surgery has been a part of the craniofacial surgeon's armamentarium for more than 2 decades now. The development and implementation of this technique will be reviewed as well as the evolution of spring surgery at Wake Forest University.

A Comparison of Subgaleal Versus Subperiosteal Dissection in Open Cranial Vault Expansion for Sagittal Craniosynostosis

BACKGROUND

The aim of this study was to evaluate surgical outcomes for patients with sagittal craniosynostosis undergoing open cranial vault remodeling with a modified pi procedure comparing subgaleal versus subperiosteal dissection.

METHODS

A retrospective chart review was performed for children between the ages of 3 and 7 months with sagittal craniosynostosis undergoing open cranial vault expansion at Seattle Children's Hospital. Patient demographics, operative variables, and postoperative outcomes including the surface area of bony cranial defects at 2-year follow-up were evaluated.

RESULTS

Over a 3-year period, 35 patients between the ages of 3 and 7 months underwent surgical correction of sagittal craniosynostosis using our institutional adaptation of the modified pi technique. Twenty-five patients underwent exposure via a subgaleal (SG) approach, 10 patients had a subpericranial (SP) exposure. Compared with the SP group, the SG group had significant lower estimated blood loss and a shorter operating time (P < 0.05). There were no significant differences with regard to hospital length of stay or postoperative complications (P ≥ 0.48). At 2 years postoperatively, there were no significant differences in the size of the largest cranial defects (SG: 1.1 ± 0.1 cm² versus 3.7 ± 0.1 cm², P = 0.40); no patients required a secondary cranioplasty.

CONCLUSIONS

Open posterior and middle cranial vault expansion is a safe and efficient method of open cranial vault expansion in sagittal craniosynostosis regardless of the plane of dissection. Elevation of the scalp flaps in the SG plane is a minor technical modification that can reduce blood loss and operative times.

Outcomes of Endoscopic Versus Open Spring Assisted Surgery for Sagittal Craniosynostosis

Spring-assisted surgery (SAS) has been shown to be an effective technique for correction of isolated sagittal craniosynostosis in patients less than 6 months of age. At their institution, the authors adopted a minimally invasive technique in 2010, using a shorter incision and an endoscope. A retrospective chart review of 101 patients with isolated, nonsyndromic, sagittal craniosynostosis, who underwent SAS, was performed in order to compare perioperative and clinical outcomes of the open (n = 51) and minimally-invasive (n = 50) approaches. Surgeries were performed by 2 neurosurgeons and 3 plastic surgeons, between 2005 and 2018. The pre and postoperative cephalic indices were not significantly different in both groups. Minimally-invasive spring placement required a longer operative time than the open approach, with the mean minimally-invasive operative time at 65 minutes, compared to 53 minutes (P < 0.0001). Spring removal operative time was not significantly different, with the minimally-invasive operative time at 31 minutes versus 29 minutes (P = 0.48). There were no significant differences in major or minor complications when comparing the open and minimally-invasive approaches. In conclusion, both the open and the minimally-invasive SAS techniques are effective for early correction of isolated sagittal craniosynostosis, although the minimally-invasive approach requires a longer operative time for spring placement.

Ventricular shunt complications in patients undergoing posterior vault distraction osteogenesis

PURPOSE

The primary objective of this study is to investigate post-operative morbidity and shunt revision rates of patients with shunt-dependent hydrocephalus (SDH) undergoing posterior vault distraction osteogenesis (PVDO) compared to patients undergoing conventional posterior vault reconstruction (PVR).

METHODS

A retrospective case-controlled cohort analysis of all patients with SDH undergoing PVDO and PVR for syndromic or complex craniosynostosis was performed. Demographic information, perioperative variables, distraction protocols, and shunt-related complications-infection, surgical revision of shunt, increased length of stay (LOS), and readmission within 90 days of surgery-were compared using the appropriate statistical tests.

RESULTS

Fourteen patients with ventricular shunts who underwent PVDO and eight patients with shunts who underwent PVR were identified. Shunt-related complication rates were significantly higher with PVDO (n = 5) compared to PVR (n = 0), p = 0.0093. Among the five patients who suffered complications, the most common were shunt infection (n = 4), shunt malfunction (n = 4), and wound infections (n = 3). All patients with complications required additional operations for shunt revision and/or replacement; four patients required multiple takebacks for such procedures, with an average of three additional procedures per patient.

CONCLUSIONS

In complex or syndromic craniosynostosis patients who have previously undergone ventricular shunting, PVDO is associated with higher shunt-related complications and need for additional procedures when compared to traditional PVR. While the benefits of PVDO in the treatment of syndromic craniosynostosis are well documented, the risks of PVDO in the face of a VP shunt must be considered. Further investigation into patient-specific risk factors and risk reduction strategies is warranted.

A comparison of endoscopic strip craniectomy and pi craniectomy for treatment of sagittal craniosynostosis

OBJECTIVE

Sagittal craniosynostosis is managed with a wide variety of operative strategies. The current investigation compares the clinical outcomes of two widely performed techniques: pi craniectomy and minimally invasive endoscopic strip craniectomy (ESC) followed by helmet therapy.

METHODS

This IRB-approved retrospective study examined patients diagnosed with nonsyndromic, single-suture sagittal craniosynostosis treated with either pi craniectomy or ESC. Included patients had a minimum postoperative follow-up of 5 months.

RESULTS

Fifty-one patients met the inclusion criteria (pi 21 patients, ESC 30 patients). Compared to patients who underwent ESC, the pi patients were older at the time of surgery (mean age 5.06 vs 3.11 months). The mean follow-up time was 23.2 months for ESC patients and 31.4 months for pi patients. Initial cranial index (CI) was similar between the groups, but postoperatively the ESC patients experienced a 12.3% mean increase in CI (from 0.685 to 0.767) compared to a 5.34% increase for the pi patients (from 0.684 to 0.719), and this difference was statistically significant (p < 0.001). Median hospital length of stay (1 vs 2 days) and operative duration (69.5 vs 93.3 minutes) were significantly less for ESC (p < 0.001 for both). The ESC patients showed a trend toward better results when surgery was done at younger ages. Craniectomy width in ESC cases was positively associated with CI improvement (slope of linear regression = 0.69, p = 0.026).

CONCLUSIONS

While both techniques effectively treated sagittal craniosynostosis, ESC showed superior results compared to pi craniectomy. ESC showed a trend for better outcomes when done at younger ages, although the trend did not reach statistical significance. A wider craniectomy width (up to 2 cm) was associated with better outcomes than smaller craniectomy widths among the ESC patients.

Current Trends in Management of Nonsyndromic Unilateral Coronal Craniosynostosis: A Cross-sectional Survey

Background

Although the natural history of nonsyndromic unilateral coronal craniosynostosis has been extensively described, optimal management remains controversial due to lack of Level 1 evidence. This study aims to assess the current state of practice among craniofacial surgeons.

Methods

Ninety-four craniofacial surgeons were approached to complete a survey consisting of 15 questions. Data were collected assessing surgeons' primary surgical indication, timing of intervention, preoperative imaging, and choice of technique for patients presenting with nonsyndromic unilateral coronal craniosynostosis. Choice of technique and timing of intervention in case of recurrence were also investigated.

Results

After 5 mailings, the response rate was 61%. The combination of both appearance and raised intracranial pressure was the primary indication for treatment for 73.2% of surgeons. Preoperative CT scan of the skull was "always" performed by 70.1% of respondents. Open surgical management was most commonly performed at 8-10 months of age (38.6%). Bilateral frontal craniectomy with remodeling of the supraorbital bandeau and frontal bone was the most common choice of procedure (84.2%). In case of mild to moderate and moderate to severe recurrences at 1 year of age, 89.5% and 47.4% of surgeons opted for conservative management, respectively. Optimal timing for repeat cranioplasty was after 4 years of age (65.5%). Overall, 43.4% quoted lack of evidence as the greatest obstacle to clinical decision-making when dealing with unilateral synostosis.

Conclusion

This survey exposes the lack of consensus and the disparity of opinion among craniofacial surgeons regarding the management of nonsyndromic coronal synostosis, particularly in the setting of recurrence.

Short- and Long-Term Outcomes by Procedure Type for Nonsagittal Single-Suture Craniosynostosis

BACKGROUND

Minimally invasive approaches for the treatment of single-suture craniosynostosis are sometimes touted as equivalent to cranial vault reconstruction. While techniques for sagittal synostosis have been reviewed previously, evidence regarding open and less invasive surgical techniques for metopic, coronal, and lambdoid synostosis has yet to be reviewed.

METHODS

Systematic searches were performed using Embase.com and PubMed. Included studies reported short- or long-term outcomes, compared at least 2 standard techniques, discussed single-suture coronal, metopic, or lambdoid craniosynostosis, and enrolled at least 20 study participants. Two authors screened titles and abstracts, and also performed full text review and data extraction. Given heterogeneous outcomes, qualitative synthesis was performed after data extraction.

RESULTS

The search strategy yielded 2348 articles. Of these, 313 were removed as duplicates, and 1935 were excluded during title/abstract review. After full text review of 100 articles, 19 were selected for data extraction. The heterogeneity of outcomes precluded meta-analysis and required qualitative synthesis. While short-term outcomes indicated decreased morbidity of minimally invasive techniques, only 2 articles presented long-term reoperation rates. One study reported higher reoperation rates in the less invasive technique, and the second reported no reoperations in the median follow-up period of 33 months.

CONCLUSION

Studies comparing long-term outcomes between different surgical techniques for single-suture craniosynostosis remain deficient. The development of standardized outcome measures is essential, and prospective, multicenter studies are necessary to assess the long-term efficacy of these procedures.

Is Postoperative Intensive Care Unit Care Necessary following Cranial Vault Remodeling for Sagittal Synostosis?

BACKGROUND

Of U.S. craniofacial and neurosurgeons, 94 percent routinely admit patients to the intensive care unit following cranial vault remodeling for correction of sagittal synostosis. This study aims to examine the outcomes and cost of direct ward admission following primary cranial vault remodeling for sagittal synostosis.

METHODS

An institutional review board-approved retrospective review was undertaken of the records of all patients who underwent primary cranial vault remodeling for isolated sagittal craniosynostosis from 2009 to 2015 at a single pediatric hospital. Patient demographics, perioperative course, and outcomes were recorded.

RESULTS

One hundred ten patients met inclusion criteria with absence of other major medical problems. Average age at operation was 6.7 months, with a mean follow-up of 19.8 months. Ninety-eight patients (89 percent) were admitted to a general ward for postoperative care, whereas the remaining 12 (11 percent) were admitted to the intensive care unit for preoperative or perioperative concerns. Among ward-admitted patients, there were four (3.6 percent) minor complications; however, there were no major adverse events, with none necessitating intensive care unit transfers from the ward and no mortalities. Average hospital stay was 3.7 days. The institution's financial difference in cost of intensive care unit stay versus ward bed was $5520 on average per bed per day. Omitting just one intensive care unit postoperative day stay for this patient cohort would reduce projected health care costs by a total of $540,960 for the study period.

CONCLUSION

Despite the common practice of postoperative admission to the intensive care unit following cranial vault remodeling for sagittal craniosynostosis, the authors suggest that postoperative care be considered on an individual basis, with only a small percentage requiring a higher level of care.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Three-dimensional changes in head shape after extended sagittal strip craniectomy with wedge ostectomies and helmet therapy

OBJECTIVE Outcome studies for sagittal strip craniectomy have largely relied on the 2D measure of the cephalic index (CI) as the primary indicator of head shape. The goal of this study was to measure the 2D and 3D changes in head shape that occur after sagittal strip craniectomy and postoperative helmet therapy. METHODS The authors performed a retrospective review of patients treated with sagittal strip craniectomy at their institution between January 2012 and October 2015. Inclusion criteria were as follows: 1) isolated sagittal synostosis; 2) age at surgery < 200 days; and 3) helmet management by a single orthotist. The CI was calculated from 3D images. Color maps and dot maps were generated from 3D images to demonstrate the regional differences in the magnitude of change in head shape over time. RESULTS Twenty-one patients met the study inclusion criteria. The mean CI was 71.9 (range 63.0-77.9) preoperatively and 81.1 (range 73.0-89.8) at the end of treatment. The mean time to stabilization of the CI after surgery was 57.2 ± 32.7 days. The mean maximum distances between the surfaces of the preoperative and 1-week postoperative and between the surfaces of the preoperative and end-of-treatment 3D images were 13.0 ± 4.1 mm and 24.71 ± 6.83 mm, respectively. The zone of maximum change was distributed equally in the transverse and vertical dimensions of the posterior vault. CONCLUSIONS The CI normalizes rapidly after sagittal strip craniectomy (57.2 days), with equal distribution of the change in CI occurring before and during helmet therapy. Three-dimensional analysis revealed significant vertical and transverse expansion of the posterior cranial vault. Further studies are needed to assess the 3D changes that occur after other sagittal strip craniectomy techniques.

A Systematic Approach to Predicting Spring Force for Sagittal Craniosynostosis Surgery

Spring-assisted surgery (SAS) can effectively treat scaphocephaly by reshaping crania with the appropriate spring force. However, it is difficult to accurately estimate spring force without considering biomechanical properties of tissues. This study presents and validates a reliable system to accurately predict the spring force for sagittal craniosynostosis surgery. The authors randomly chose 23 patients who underwent SAS and had been followed for at least 2 years. An elastic model was designed to characterize the biomechanical behavior of calvarial bone tissue for each individual. After simulating the contact force on accurate position of the skull strip with the springs, the finite element method was applied to calculating the stress of each tissue node based on the elastic model. A support vector regression approach was then used to model the relationships between biomechanical properties generated from spring force, bone thickness, and the change of cephalic index after surgery. Therefore, for a new patient, the optimal spring force can be predicted based on the learned model with virtual spring simulation and dynamic programming approach prior to SAS. Leave-one-out cross-validation was implemented to assess the accuracy of our prediction. As a result, the mean prediction accuracy of this model was 93.35%, demonstrating the great potential of this model as a useful adjunct for preoperative planning tool.

Management options of non-syndromic sagittal craniosynostosis

There have been various effective surgical procedures for the treatment of non-syndromic sagittal craniosynostosis, but no definitive guidelines for management have been established. We conducted a study to elucidate the current state of practice and establish a warranted standard of care. An Internet-based study was sent to 180 pediatric neurosurgeons across the country and 102 craniofacial plastic surgeons in fourteen different countries, to collect data for primary indication for surgical management, preference for timing and choice of surgery, and pre-, peri-, and post-operative management options. The overall response rate from both groups was 32% (n=90/284). Skull deformity was the primary indication for surgical treatment in patients without signs of hydrocephalus for both neurosurgeons and craniofacial surgeons (80% and 63%, respectively). Open surgical management was most commonly performed at six months of age by neurosurgeons (46%) and also by craniofacial surgeons (35%). Open surgical approach was favored for patients younger than four months of age by neurosurgeons (50%), but endoscopic approach was favored by craniofacial surgeons (35%). When performing an open surgical intervention, most neurosurgeons preferred pi or reversed pi procedure (27%), whereas total cranial vault remodeling was the most commonly performed procedure by craniofacial surgeons (37%). The data demonstrated a discrepancy in the treatment options for non-syndromic sagittal craniosynostosis. By conducting/comparing a wide survey to collect consolidative data from both groups of pediatric neurosurgeons and craniofacial plastic surgeons, we can attempt to facilitate the establishment of standard of care.

[Guide to clinical practice for the diagnosis, treatment and rehabilitation of non-syndromic craniosynostosis on 3 levels of care]

INTRODUCTION

Craniosynostosis is a congenital anomaly resulting from the premature fusion of the cranial sutures changing growth patterns of the skull.

METHODOLOGY

Focus, scope, target population and clinical questions to be solved were defined. A systematic search for evidence in different databases (Medline, Embase, KoreaMed, Cochrane Library and the website of the World Health Organization) in stages was performed: clinical practice guidelines; systematic reviews, and clinical trials and observational studies; using MeSH, Decs and corresponding free terms, unrestricted language or temporality. Risk of bias was evaluated using appropriate tools (AMSTAR, Risk of Bias or STROBE). The quality of evidence was graduated using the GRADE system. Modified Delphi Panel technique was used to assign the recommendation's strength and direction, as well as the degree of agreement with it, taking into account the quality of evidence, balance between risks and benefits of interventions, values and preferences of patients and availability of resources.

RESULTS

There were 3,712 documents obtained by search algorithms; selecting 29 documents for inclusion in the qualitative synthesis. Due to heterogeneity between studies, it was not possible to perform meta-analysis.

CONCLUSIONS

We issued 7 recommendations and 8 good practice points, which will serve as support for decision-making in the comprehensive care of patients with craniosynostosis.

Distraction Osteogenesis Update: Introduction of Multidirectional Cranial Distraction Osteogenesis

In this review, we discuss in detail our current procedure for treating craniosynostosis using multidirectional cranial distraction osteogenesis (MCDO). The MCDO method allows all phenotypes of skull deformity to be reshaped by distraction osteogenesis, except in patients who are 5 months of age or younger and patients with posterior cranial vault problems. We report the results of clinical data of 36 children with craniosynostosis who underwent MCDO between 2005 and 2014 in our institute. This method has the following benefits, such as a high flexibility of reshaping, shorter treatment period and less invasive secondary intervention. We also discuss the other distraction osteogenesis techniques that are used to treat craniosynostosis and compare them with MCDO. The preferred procedure for correction of craniosynostosis may depend on the patient's age, the extent of deformity, and the extent of correction achievable by surgery. We can arrange the combinations of various methods according to the advantage and disadvantage of each technique.

Transsutural distraction osteogenesis for 285 children with craniosynostosis: a single-institution experience

OBJECT Although distraction osteogenesis (DO) requires a secondary procedure in the surgical correction of craniosynostosis, it is relatively simple, requires less transfusion, results in a shorter intensive care unit stay, and is quite safe. Because of these positive factors, various DO techniques have been developed. However, there is disagreement regarding the superiority of DO. The authors reported on a new DO technique, transsutural DO (TSDO), 6 years ago that was performed in 23 patients over a period of 6 months, and it continues to be used at the present time. In this paper the authors report the results of TSDO performed in 285 patients with craniosynostosis over a period of 6 years at a single institution. METHODS TSDO consists of a simple suturectomy of the pathological suture followed by direct distraction of the suturectomy site only. Types of TSDO conducted included sagittal TSDO in 95 patients, bicoronal in 14, unilateral coronal in 57, lambdoid in 26, metopic in 13, multiple in 19, syndromic in 33, and secondary in 28. The mean age (± SD) of the patients was 19.4 ± 23.0 months, and mean follow-up was 39.5 ± 21.0 months. RESULTS The mean operating time was 115 ± 43 minutes, and mean anesthesia time was 218 ± 56 minutes. The mean transfusion volume of red blood cell components was 48 ± 58 ml, and mean transfusion volume of fresh-frozen plasma was 19 ± 35 ml. Total transfusion volume was significantly less in infants younger than 12 months of age and in children with lower lumbar puncture pressures (p < 0.05). Complications included 1 (0.4%) death from postoperative acute pneumonia after a distractor removal operation and 23 (8%) surgical morbidities comprising 10 revisions (3.5%) and 13 early removals of distracters (4.6%). CONCLUSIONS TSDO is a simple, effective, and safe method to use for treating all types of craniosynostosis. Some morbidity was experienced in this study, but it may be attributed to the learning curve of the technique.

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.

Management of sagittal synostosis: a solution to equipoise

BACKGROUND

In the craniofacial surgery literature, there is a wide disparity of opinions regarding the appropriate treatment of nonsyndromic sagittal synostosis. With the lack of level 1 evidence to support a particular regimen, our study aims to elucidate the current state of practice among craniofacial surgeons with the hope of establishing a standard of care.

METHODS

An internet-based survey was sent to 102 craniofacial surgeons in 14 countries on 4 continents. Data were collected regarding the following parameters: primary indication for surgery, preference of timing, and choice of operative intervention for patients presenting with nonsyndromic isolated sagittal synostosis with normative intracranial pressure values. Surgeons were also queried regarding preoperative, intraoperative, and postoperative protocols.

RESULTS

After 2 mailings, the response rate was 58% (59/102). For 63% of respondents, skull deformity was the primary indication for treatment of craniosynostosis. Open surgical management of sagittal craniosynostosis was most commonly performed at 6 months (35%) of age. Total cranial vault remodeling was the most commonly performed procedure (37%). Thirty-five percent of craniofacial surgeons chose an endoscopic surgical approach for patients presenting at younger than 4 months. Only 10% of craniofacial surgeons selected spring-assisted strip craniectomy. Seventy-one percent of polled surgeons performed computed tomographic scans of the skull in all cases, irrespective of presentation.

CONCLUSION

Our survey demonstrates that there exists a wide disparity of opinion regarding diagnosis and treatment of nonsyndromic sagittal synostosis. When current practice is compared to findings in the literature, significant discrepancies exist.

Spring-mediated sagittal craniosynostosis treatment at the Children’s Hospital of Philadelphia: technical notes and literature review

OBJECT

Sagittal craniosynostosis has been treated using both cranial remodeling techniques and modification of the sagittal strip craniectomy. A more recent technique is to implant springs in conjunction with a suturectomy to transversely expand the parietal bones to accommodate the growing brain. In this paper the authors describe and evaluate several modifications to the spring-mediated cranioplasty (SMC) technique, most notably use of an ultrasonic scalpel to limit dural dissection and maximize opening of the stenosed suture by placement of multiple spring devices. In addition, the literature is reviewed comparing SMC to other surgical treatments of sagittal synostosis.

METHODS

The authors retrospectively reviewed patients who presented to the Children’s Hospital of Philadelphia with a diagnosis of sagittal synostosis from August 2011 to November 2014. A pooled data set was created to compare our institutional data to previously published work. A comprehensive literature review was performed of all previous studies describing the SMC technique, as well as other techniques for sagittal synostosis correction.

RESULTS

Twenty-two patients underwent SMC at our institution during the study period. Patients were 4.2 months of age on average, had a mean blood loss of 56.3 ml, and average intensive care unit and total hospital stays of 29.5 hours and 2.2 days, respectively. The cranial index was corrected to an average of 73.7 (SD 5.2) for patients who received long-term radiological follow-up. When comparing the authors’ institutional data to pooled SMC data, blood loss and length of stay were both significantly less (p = 0.005 and p < 0.001, respectively), but the preoperative cranial index was significantly larger (p = 0.01). A review of the SMC technique compared with other techniques to actively expand the skull of patients with sagittal synostosis demonstrated that SMC can be performed at a significantly earlier age compared with cranial vault reconstruction (CVR).

CONCLUSIONS

The authors found that their institutional modifications of the SMC technique were safe and effective in correcting the cranial index. In addition, this technique can be performed at a younger age than CVRs. SMC, therefore, has the potential to maximize the cognitive benefits of early intervention, with lower morbidity than the traditional CVR.

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.

Development and characterization of elastic nanocomposites for craniofacial contraction osteogenesis

Development of resorbable elastic composites as an alternative means to apply contractive forces for manipulating craniofacial bones is described herein. Composites made from the biodegradable elastomer, poly (1,8-octanediol co-citric acid) (POC), and hydroxyapatite (nHA) with a 200 nm diameter (0-20% loadings) were created to develop a material capable of applying continuous contractive forces. The composites were evaluated for variation in their mechanical properties, rate of degradation, and interaction of the hydroxyapatite nanoparticles with the polymer chains. First, an ex vivo porcine model of cleft palate was used to determine the rate of cleft closure with applied force. The closure rate was found to be 0.505 mm N(-1) . From this approximation, the ideal maximum load was calculated to be 19.82 N, and the elastic modulus calculated to be 1.98 MPa. The addition of nHA strengthens POC, but also reduces the degradation time by 45%, for 3% nHA loading, compared to POC without nHA. X-ray diffraction data indicates that the addition of nHA to amorphous POC results in the formation of a semicrystalline phase of the POC adjacent to the nHA crystals. Based on the data, we conclude that amongst the 0-20% nHA loadings, a 3% loading of nHA in POC may be an ideal material (1.21 MPa elastic modulus and 13.17 N maximum load) to induce contraction forces capable of facilitating osteogenesis and craniofacial bone repair.

Surgical treatment of sagittal synostosis by extended strip craniectomy: cranial index, nasofrontal angle, reoperation rate, and a review of the literature

BACKGROUND

Sagittal synostosis is the most common non-syndromic single suture craniosynostosis. Different techniques of surgical correction, including extended strip craniectomy (ESC), have been used to treat this condition. The aim of this study is to evaluate radiologic changes and rate of symptomatic restenosis after ESC in a large group of patients less than 12 months of age with non-syndromic sagittal synostosis.

METHODS

A retrospective study of patients from 1990 to 2012 was performed comparing cranial index (CI) and nasofrontal angle (NFA) before and after surgical correction by ESC. Also, the frequency of subsequent reoperations for symptomatic restricted head growth was determined.

RESULTS

A total of 238 patients underwent ESC. Follow-up information was available for 182 patients. The average age at the time of the operation was 4.5 months and the mean duration of follow-up was 49.6 months. The average post procedure radiologic follow-up (22 patients) was 40.7 months.

CONCLUSIONS

The mean CI increased from 0.68 to 0.75 (p < 0.001) after ESC. Also, mean NFA increased from 127 to 133° (p < 0.001). Five patients (2.7%) required a second operation due to symptomatic cranial growth restriction. Reoperation occurred at an average of 26.5 months after the initial procedure. The most common symptom reported was headache. ESC is effective in treating non-syndromic sagittal synostosis. It significantly improved NFA without the need for direct frontal bone resection or frontal orbital osteotomy and significantly increased CI without adjunctive helmet treatment. Patients should be followed for at least 5 years after surgical correction as symptomatic restenosis, although rare, can occur.

Results of early surgery for sagittal suture synostosis: long-term follow-up and the occurrence of raised intracranial pressure

PURPOSE

Numerous techniques are used to correct sagittal synostosis. Although cosmetic results and operative complications are well documented, little is known about functional outcome. In our institution, the technique for extended strip craniectomy evolved over time. This study compares cosmetic results, complications, and signs of raised intracranial pressure (ICP) between the variants of the extended strip craniectomy.

METHODS

Seventy-nine consecutive patients undergoing early extended strip craniectomy for scaphocephaly (2002-2008) were included. Four techniques were used: A, a simple bilateral parietal flap with out-fracturing of the bone flap; B, C, and D included remodeling of the parietal flap by adding triangular cuts and bending or suturing the resulting fingers. In technique D, the sagittal strip was rotated and fixed between the parietal flaps. Data on head circumference (HC), skull X-ray, and fundoscopy were collected prospectively.

RESULTS

For all patients, the average cranial index (CI) was 74 after 3 months and 72 after 2 years. Although technique D resulted in the best initial improvement, there was no significant percentage increase in CI after 24 months between the four techniques. Postoperatively, 9 % of the patients developed papilledema, 42 % developed a fontanel bulge, and 57 % had diminished HC. Four patients were reoperated on because of raised ICP.

CONCLUSIONS

Postoperative CI is mainly determined by preoperative CI and hardly affected by type of extended strip craniectomy. Signs of raised ICP occurred more frequently than expected, therefore structural follow-up is required to detect such signs. Technique and timing of surgery should aim at creating sufficient intracranial volume.

Comparison of spring-mediated cranioplasty to minimally invasive strip craniectomy and barrel staving for early treatment of sagittal craniosynostosis

The treatment of sagittal craniosynostosis has evolved from early strip craniectomy to total cranial vault remodeling and now back to attempts at minimally invasive correction. To optimize outcomes while minimizing morbidity, we currently use 2 methods of reconstruction in patients younger than 9 months: spring-mediated cranioplasty (SMC) and minimally invasive strip craniectomy with parietal barrel staving (SCPB). The purpose of this study was to compare the safety and efficacy of the 2 methods. Hospital records of our first 7 SMCs and our last 7 SCPBs were analyzed for demographics, the type of operation performed, estimated blood loss, transfusion requirements, operative time, length of stay in the intensive care unit, length of hospital stay, preoperative cephalic index, postoperative cephalic index, and complications. The techniques were then compared using analysis of variance.All 14 patients successfully underwent cranial vault remodeling with significant improvement in cephalic index. Demographics, length of stay in the intensive care unit (P = 0.15), preoperative cephalic index (P = 0.86), and postoperative cephalic index (P = 0.64) were similar between SMC and SCPB. Spring-mediated cranioplasty had statistically significantly shorter operative time (P = 0.002), less estimated blood loss (P < 0.001), and shorter length of hospital stay (P = 0.009) as compared with SCPB. Complications included 1 spring dislodgment in an SMC that did not require additional management and 1 undercorrection in the SCPB group. Both SMC and SCPB are safe, effective means of treating sagittal craniosynostosis. Spring-mediated cranioplasty has become our predominant means of treatment of scaphocephaly in patients younger than 9 months because of its improved morbidity profile.

Pediatric Craniofacial Surgery: A Review for the Multidisciplinary Team

Pediatric craniofacial surgery is a specialty that grew dramatically in the 20th century and continues to evolve today. Out of the efforts to correct facial deformities encountered during World War II, the techniques of modern craniofacial surgery developed. An analysis of the relevant literature allowed the authors to explore this historical progression.

Current advances in technology, tissue engineering, and molecular biology have further refined pediatric craniofacial surgery. The development of distraction osteogenesis and the progressive study of craniosynostosis provide remarkable examples of this momentum. The growing study of genetics, biotechnology, the influence of growth factors, and stem cell research provide additional avenues of innovation for the future. The following article is intended to reveal a greater understanding of pediatric craniofacial surgery by examining the past, present, and possible future direction. It is intended both for the surgeon, as well as for the nonsurgical individual specialists vital to the multidisciplinary craniofacial team.