Correction of sagittal craniosynostosis using a novel parietal bone fixation technique: results over a 10-year period

Computer-Assisted Design and Manufacturing Assists Less Experienced Surgeons in Achieving Equivalent Outcomes in Cranial Vault Reconstruction

PURPOSE

The purpose of this study was to assess whether long-term outcomes were equivalent between computer-assisted design and manufacturing (CAD/CAM) -assisted cranial vault reconstruction performed by an inexperienced surgeon, with fewer years of surgical experience, and traditional reconstruction performed by senior surgeons with many decades of experience.

METHODS

An Institutional Review Board-approved retrospective cohort study was performed for all patients with nonsyndromic craniosynostosis between the ages of 1 month to 18 years who received primary, open calvarial vault reconstruction at the Johns Hopkins Hospital between 1990 and 2017. The primary outcome variable was the Whitaker category (I-IV) for level of required revision at the 2-year follow-up visit. Secondary outcomes included estimated blood loss, length of stay, operative time, and postoperative complications. CAD/CAM-assisted surgery was considered noninferior if the proportion of cases requiring any revision (Whitaker II, III, or IV) was no more than 10% greater than the proportion in the traditional surgery group with multivariate logistic regression analysis. t tests and fisher exact tests were used for secondary outcomes.

RESULTS

A total of 335 patients were included, with 35 CAD/CAM-assisted reconstructions. CAD/CAM-assisted reconstruction was noninferior to traditional after accounting for patient demographics, type of surgery, and experience level of the plastic surgeon. The traditional group required revision more frequently at 29.0% compared to CAD/CAM at 14.3%. Secondary outcomes were not significantly different between groups, but CAD/CAM had significantly longer average operative times (5.7 hours for CAD/CAM, 4.3 hours for traditional, P < 0.01).

CONCLUSION

CAD/CAM technology may lower the learning curve and assist less experienced plastic surgeons in achieving equivalent long-term outcomes in craniofacial reconstruction.

The value of three-dimensional photogrammetry in isolated sagittal synostosis: Impact of age and surgical technique on intracranial volume and cephalic index─a retrospective cohort study

PURPOSE

The aim of this study was to compare the outcome of intracranial volume (ICV) and cephalic index (CI) between two different techniques for surgical therapy of sagittal synostosis.

MATERIAL AND METHODS

Between 2011 and 2015, all patients scheduled for surgical therapy of sagittal synostosis were consecutively enrolled. All patients younger than 6 months underwent early extended strip craniectomy (ESC group), and patients older than 6 months underwent late modified pi-procedure (MPP group). To measure ICV and CI, data acquisition was performed via three-dimensional photogrammetry, 1 day before (T0) and between 10 and 12 weeks after surgery (T1). Results were compared with an age-matched reference group of healthy children. Perioperative parameters, as duration of surgery and the amount of blood loss of both surgical procedures were analyzed.

RESULTS

A total of 85 patients were enrolled. Of the patients, 48 underwent an extended strip craniotomy with parietal osteotomies and biparietal widening and 37 patients underwent a late modified pi-procedure. There was no significant difference between the ESC group and the MPP group regarding the efficacy of improving CI (p > 0.05). Both techniques were able to normalize CI and to improve head shape. ICV was normal compared to age-matched norm-groups with both techniques, pre- and postoperatively. However, duration of the surgical procedure and calculated blood loss were significantly lower in the ESC group (p < 0.05).

CONCLUSION

ESC and MPP were effective techniques to normalize cephalic index (CI) and improve head shape at their recommended time of surgery. Measurement of ICV and CI with 3D photogrammetry is a valid method to objectively evaluate patients before and after surgery without exposing pediatric patients to ionizing radiation.

The Management of Nonsyndromic, Isolated Sagittal Synostosis

AIM

Isolated sagittal synostosis is the commonest form of craniosynostosis. The reasons for surgery are to normalize the head shape and to increase the cranial volume, thus reducing the risk of raised intracranial pressure and allowing for normal brain development. It has been suggested that sagittal synostosis may impair neuropsychological development. This systematic review appraised the literature on the management of sagittal synostosis.

METHODS

A literature search was performed with the assistance of a professional librarian. Studies selected had to satisfy the criteria set by PICO (patients, intervention, comparison, and outcome). Cranial index and neuropsychological outcome were used as outcome measures. MINORS was used to assess the methodological quality of the selected articles. A score of 75% was deemed to be of satisfactory quality, and the quality of the evidence from the selected studies was graded using the GRADE system.

RESULTS

One hundred forty-eight articles were initially identified. Only 6 articles fulfilled the PICO criteria and scored a minimum of 75% on MINORS. Four studies compared 1 technique to another with documented cranial indices. Two studies compared 1 group to another and assessed the neuropsychological development. According to GRADE, the quality of evidence was deemed to be very low.

CONCLUSIONS

This systematic review assessed cranial index and neuropsychological outcome following surgery for isolated, nonsyndromic sagittal synostosis. The quality of the evidence in the published literature was noted to be of very low quality. There is a need for better-designed, prospective studies to guide surgeons involved in management of sagittal synostosis.

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.

Scaphocephaly and cranial vault reconstruction: Renier's 'H' technique

BACKGROUND

Resulting from an early fusion of the sagittal suture, scaphocephaly (SC) is the most frequent form of all craniosynostosis and represents 40-60% of all cases. The scope of this study is to describe the first series of Renier's 'H' technique to be applied in children with SC outside of France.

METHODS

A consecutive review is made of the medical records of children hospitalized in the last 6 years (between March 2007 and March 2013) with isolated SC in whom Renier's 'H' technique was performed.

RESULTS

Thirteen children met the criteria for inclusion in the study. Considering medical evaluation and parental satisfaction, the evaluation of postsurgical cranial reconstruction was classified as satisfactory in all cases.

CONCLUSIONS

We consider the Renier's H technique to be effective in the cranial reshaping of children with isolated SC, with satisfactory esthetic postsurgical results.

Feature-invariant image registration method for quantification of surgical outcomes in patients with craniosynostosis: a preliminary study

Craniosynostosis consists of a premature fusion of the sutures in an infant skull that restricts skull and brain growth. During the last decades, there has been a rapid increase of fundamentally diverse surgical treatment methods. At present, the surgical outcome has been assessed using global variables such as cephalic index, head circumference, and intracranial volume. However, these variables have failed in describing the local deformations and morphological changes that may have a role in the neurologic disorders observed in the patients. This report describes a rigid image registration-based method to evaluate outcomes of craniosynostosis surgical treatments, local quantification of head growth, and indirect intracranial volume change measurements. The developed semiautomatic analysis method was applied to computed tomography data sets of a 5-month-old boy with sagittal craniosynostosis who underwent expansion of the posterior skull with cranioplasty. Quantification of the local changes between pre- and postoperative images was quantified by mapping the minimum distance of individual points from the preoperative to the postoperative surface meshes, and indirect intracranial volume changes were estimated. The proposed methodology can provide the surgeon a tool for the quantitative evaluation of surgical procedures and detection of abnormalities of the infant skull and its development.

Immediate spontaneous shape correction using expantile zigzag craniectomy in infantile scaphocephaly -is there an improvement in the developmental quotient following surgery?-

There is still debate over which method of the surgery is the most appropriate for the treatment of scaphocephalic infants. In addition, change in psychomotor development following these procedures is a very complex issue that has not yet been resolved. In this paper, the authors describe a surgical technique for immediate spontaneous shape correction of infantile scaphocephaly. There were significant differences between pre- and postoperative cephalic index. We also describe an improvement in the developmental quotient following surgery. Therefore, this expantile zigzag craniectomy should be recommended to correct for isolated sagittal craniosynostosis in infants.

The trans-sutural distraction osteogenesis for 22 cases of craniosynostosis: a new, easy, safe, and efficient method in craniosynostosis surgery

BACKGROUND

Distraction osteogenesis for the treatment of craniosynostosis is becoming more widely used as it is simple, there are less transfusions, and a decreased incidence of complications, although a secondary procedure for the removal of the distractors is necessary. However, to date all previous procedures have still been complicated. The authors present a novel trans-sutural distraction osteogenesis method (TSuDO) for the treatment of all types of craniosynostosis.

METHODS

The TSuDO consisted of simple suturectomy of the pathologic suture followed by direct distraction of the suturectomy site only. Types of TSuDO conducted were sagittal TSuDO in 6 patients, coronal TSuDO in 5 patients, unilateral coronal TSuDO in 8 patients, lambdoid TSuDO in 2 patients, and metopic TSuDO in 1 patient (total = 22). Mean age was 9.3 ± 12.7 months.

RESULTS

The mean operation time was 143.6 ± 50.2 min, and mean total transfusion volume of blood components was 131.1 ± 78.3 ml. Immediate correction of the abnormal head contour after distraction was observed in all patients, and no complications were encountered except for 1 patient whose distractor malfunctioned and 2 who showed prolonged discharges from the pin sites (controlled by antibiotics).

CONCLUSION

TSuDO is a simple, effective, and safe method for the treatment of all types of craniosynostosis, and is especially effective for the correction of unilateral coronal craniosynostosis.

Surgical treatment of single-suture craniosynostosis: an argument for quantitative methods to evaluate cosmetic outcomes

The traditional reasons for surgical intervention in children with single-suture craniosynostosis (SSC) are cosmetic improvement and the avoidance/treatment of intracranial hypertension, which has been thought to contribute to neurocognitive deficits. Despite considerable work on the topic, the exact prevalence of intracranial hypertension in the population of patients with SSC is unknown, although it appears to be present in only a minority. Additionally, recent neuropsychological and anatomical literature suggests that the subtle neurocognitive deficits identified in children with a history of SSC may not result from external compression. They may instead reflect an underlying developmental condition that includes disordered primary CNS development and early suture fusion. This implies that current surgical techniques are unlikely to prevent neurocognitive deficits in patients with SSC. As such, the most common indication for surgical treatment in SSC is cosmetic, and most patients benefit from considerable subjective cosmetic normalization following surgery. Pediatric craniofacial surgeons have not, however, agreed upon objective means to assess postoperative cranial morphological improvement. We should therefore endeavor to agree upon objective craniometric tools for the assessment of operative outcomes, allowing us to accurately compare the various surgical techniques that are currently available.

Maternal reports of satisfaction with care and outcomes for children with craniosynostosis

Craniosynostosis is a congenital deformity caused by premature fusion of cranial suture(s). Surgical outcomes of craniosynostosis have been well documented; however, limited published data are available regarding access to care and social and psychological health outcomes for children with craniosynostosis. The authors conducted a population-based, multistate study of maternal perceptions of care and outcomes for children with craniosynostosis born from January 1998 through December 2003. Mothers of 147 children were contacted and asked to complete a structured telephone interview; 82 mothers (55.8%) participated. Overall, the mean ages of children and their mothers at the time of interview were 4.4 and 34.8 years, respectively. Mothers interviewed tended to be white and, at a minimum, high school graduates. Most mothers reported being satisfied with the craniosynostosis-related information and support provided by medical care providers, and access to primary and specialty care was most often rated as satisfactory. Mothers tended to report the physical health of their child to be good; however, delays in cognitive and emotional development, hearing loss, and speech problems were identified. In addition, statistically significant differences among mothers in each state were noted for reports of the quality of team care, primary care, learning interventions, and perceived need for additional surgeries. These results suggest some limitations in craniosynostosis-related care and provide guidance to medical and surgical care providers in making need-based improvements in craniosynostosis surgery and care. Future studies are recommended to replicate this evaluation in additional populations.