Craniotomy of the Fused Sagittal Suture Over the Superior Sagittal Sinus Is a Safe Procedure:

Simplified Postoperative Care After Spring-assisted Strip Craniotomy for Sagittal Synostosis: A Prospective Before-and-After Study

ABSTRACT

Since the development of spring-assisted techniques for corrective craniofacial surgery, routine postoperative admission to intensive care units (ICUs) has been questioned. However, close monitoring is necessary if the continuous infusion of morphine is used as recommended for better pain relief. In this study, the authors evaluated a simplified postoperative protocol without continuous morphine infusion and no indwelling urinary catheter following spring-assisted surgery (SAS) for sagittal synostosis. Ten children were cared for according to a standard protocol with postoperative intravenous (i.v.) infusion of morphine and an indwelling urinary catheter, and 11 consecutive children were treated according to a simplified protocol with pain relief based on intermittent injections of morphine and clonidine [according to Face, Legs, Activity, Cry, Consolability (FLACC) scores >4] without the indwelling catheter. A Mann-Whitney U test was used for comparison of distributions between the two groups. The results revealed no differences between groups regarding the proportion of FLACC scores >4, total amount of administered i.v. morphine and clonidine, total volume of buffered glucose infused, time to first feeding on breast milk or substitute, or the length of stay. Despite the inherent limitations of our small observational study, the authors concluded that at our institution, it was possible to exclude a standard continuous i.v. infusion of morphine and an indwelling urinary catheter from our postoperative care protocol without decreasing the quality of pain relief in children submitted to SAS for sagittal synostosis. This finding supports downgrading the level of care from the ICU to a regular ward after limited immediate postoperative observation.

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.

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.