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

The Need for Additional Surgery after Passive versus Active Approaches to Syndromic Craniosynostosis: A Meta-analysis

Endoscopically assisted craniofacial surgery (EACS) has numerous advantages over traditional, open approaches, such as fronto-orbital advancement in treating nonsyndromic craniosynostosis. However, several articles report high reoperation rates in syndromic patients treated with EACS. This meta-analysis and review examines undesirable outcome rates (UORs), defined as reoperation or Whitaker category III/IV, in syndromic patients undergoing primary EACS compared with procedures that actively expand the cranial vault.

Methods

PubMed and Embase were searched in June 2022 to identify all articles reporting primary reoperation or Whitaker outcomes for syndromic patients undergoing cranial vault expanding surgery or suturectomy. A meta-analysis of proportions was performed comparing UORs, and a trim-and-fill adjustment method was used to validate sensitivity and assess publication bias.

Results

A total of 721 articles were screened. Five EACS articles (83 patients) and 22 active approach articles (478 patients) met inclusion criteria. Average UORs for EACS and active approaches were 26% (14%-38%) and 20% (13%-28%), respectively (P = 0.18). Reoperation occurred earlier in EACS patients (13.7 months postprimary surgery versus 37.1 months for active approaches, P = 0.003). Relapse presentations and reason for reoperation were also reviewed. Subjectively, EACS UORs were higher in all syndromes except Apert, and Saethre-Chotzen patients had the highest UOR for both approaches.

Conclusions

There was no statistically significant increase in UORs among syndromic patients treated with EACS compared with traditional approaches, although EACS patients required revision significantly sooner. Uncertainties regarding the long-term efficacy of EACS in children with syndromic craniosynostosis should be revisited as more data become available.

Predictors of Blood Transfusion for Endoscopic Assisted Craniosynostosis Surgery

ABSTRACT

Blood loss is a main cause of morbidity after craniofacial procedures. The purpose of this study is to identify the incidence and predictors for transfusion of blood products in the endoscopic assisted strip craniectomy population. Data was prospectively collected from a single-center multi-surgeon cohort of 78 consecutive patients who underwent endoscopic assisted strip craniectomy for craniosynostosis between July 2013 and December 2020. The authors reviewed patient and treatment characteristics and outcomes. Of the 78 patients, 26 patients were transfused yielding an overall rate of transfusion of 33%. The most common fused suture was sagittal (n = 42, 54%) followed by metopic (n = 15, 19%), multiple (n = 10, 13%), coronal (n = 7, 9%) and finally lambdoid (n = 4, 5%). On univariate analysis, patients' weight in the transfusion cohort were significantly lower than those who did not receive a transfusion (5.6 ± 1.1 versus 6.5 ± 1.1 kg, P = 0.0008). The transfusion group also had significantly lower preoperative hemoglobin compared to the non-transfusion group (10.6 versus 11.1, P = .049). Eleven percent patients admitted to step-down received a transfusion, whereas 39% of patients admitted to the pediatric intensive care unit received a transfusion (P = 0.042). On multivariate analysis, only higher patient weight (operating room [OR] 0.305 [0.134, 0.693], P = 0.005) was protective against a transfusion, whereas colloid volume (OR 1.018 [1.003, 1.033], P = 0.019) predicted the need for a transfusion. Our results demonstrate that endoscopic craniosynostosis cases carry a moderate risk of transfusion. Individuals with lower weight and those that receive colloid volume are also at elevated risk.

Antifibrinolytics Are Not Associated With Reduced Blood Loss in Minimally-Invasive Endoscopic-Assisted Craniectomy for Repair of Single-Suture Craniosynostosis

ABSTRACT

Minimally-invasive endoscopic-assisted craniectomy (EAC) achieves similar functional and cosmetic outcomes, whereas reducing morbidity risk that is often associated with complex cranial vault reconstruction. Antifibrinolytics (AF) usage to limit blood loss and transfusion requirements during complex cranial vault reconstruction has been studied extensively; however, studies are limited for AF therapy in EAC. The aim of this single-center retrospective observational cohort pilot study was to evaluate whether the use of AF was associated with reduced blood loss in infants undergoing EAC. The authors hypothesized that there would be no difference in blood loss between patients who received AF and those that did not receive AF during EAC. Non-syndromic patients who underwent single-suture EAC were retrospectively evaluated. Primary outcome measure was intraoperative calculated blood loss (mL/kg). Secondary outcome measures included perioperative red blood cells transfusion volumes, number of blood donor exposures, and pediatric intensive care unit and total hospital length of stay. Study cohort demographic and outcome data were analyzed; Fisher exact test was used for categorical data, Student t test was used for continuous data. A P value of < 0.05 was considered statistically significant. Forty-nine EAC patients were included in the study with 34 patients in the AF cohort and 15 patients in the non-AF cohort. There were no significant differences in demographics between the 2 groups. Additionally, there was no significant difference in intraoperative calculated blood loss or any secondary outcome measure. In our single-suture EAC study cohorts, AF administration was not associated with a decrease in blood loss when compared to those that did not receive AF therapy.

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.

Anesthetic Considerations for Pediatric Craniofacial Surgery

Anesthetic management of craniosynostosis remains a challenging experience. It requires input and collaboration from multiple specialties to improve patient outcomes. Understanding the surgical corrective techniques and the underlying risks of each is essential to providing the best care to this patient population. The propensity for significant blood loss necessitates fundamental knowledge of pediatric resuscitation and the development of perioperative transfusion protocols that have been shown to reduce transfusion requirements in the peri-operative period.

Diagnosis and treatment of positional plagiocephaly

Positional plagiocephaly is increasing in infants. Positional plagiocephaly is an asymmetric deformation of skull due to various reasons; first birth, assisted labor, multiple pregnancy, prematurity, congenital muscular torticollis and position of head. Positional plagiocephaly can mostly be diagnosed clinically and by physical examinations. The simplest way to assess the severity of plagiocephaly is to use a diagonal caliper during physical examination, which measures the difference between the diagonal lengths on each side of the head. Plagiocephaly can be treated surgically or conservatively. Positional plagiocephaly, which is not accompanied by craniosynostosis, is treated conservatively. Conservative treatments involve a variety of treatments, such as change of positions, physiotherapy, massage therapy, and helmet therapy. Systematic approaches to clinical examination, diagnosis and treatment of positional plagiocephaly can be necessary and the age-appropriate treatment is recommended for patients with positional plagiocephaly.

A 24-month cost and outcome analysis comparing traditional fronto-orbital advancment and remodeling with endoscopic strip craniectomy and molding helmet in the management of unicoronal craniosynostosis: A retrospective bi-institutional review

Introduction

Endoscopic strip craniectomy with helmeting (ESCH) has been shown to be a safe and efficacious alternative to fronto-orbital remodeling (FOR) for selected children with craniosynostosis. In addition to clinical factors, there may be economic benefits from the use of ESCH instead of FOR.

Methods

A retrospective review of 23 patients with nonsyndromic unicoronal craniosynostosis (UCS) treated with FOR was carried out at Great Ormond Street Hospital (GOSH) for Children in London, UK. Secondary data were used for the ESCH cohort from a paper published by Jimenez and Barone (2013). Data were collected on surgical time, transfusion rates, length of hospital stay, adverse event rates, reintervention rates, and overall costs. Costs were categorized and then assigned to the appropriate data sets.

Results

The mean age of patients undergoing FOR (vs. ESCH) was 17.4 mo (vs. 3.1 mo) with a mean surgical time of 234 min (vs. 55 min), mean transfusion volume of 221.6 mL (vs. 80.0 mL), mean transfusion rate of 14/23 (vs. 2/115), and a total immediate overnight stay of 3.13 days (vs. 97% next-day discharge). The FOR group had a higher adverse event rate (5/23 vs. 4/115, p=<0.005) and a higher number requiring extraocular muscle surgery (4/23 vs. 7/109, p=0.16). There was a substantial difference in overall costs between the two groups. Total variance cost for the FOR group was £7436.5 vs. £4951.35, representing a cost difference of £2485.15 over the 24-month study period.

Conclusion

ESCH, in comparison to FOR, appears as a more economical method in the management of USC patients, as well as having clinical benefits including reduced adverse event rate and improved ophthalmic outcomes.

Minimally Invasive Endoscopic Surgery for Infantile Craniosynostosis: A Longitudinal Cohort Study

OBJECTIVE

To evaluate patient outcomes of minimally invasive endoscopic strip craniectomy (ESC) for craniosynostosis.

STUDY DESIGN

This is a retrospective cohort analysis (2004-2018) of 500 consecutive infants with craniosynostosis treated by ESC with orthotic therapy at a single center. Operative outcomes included transfusions, complications, and reoperations as well as head circumference change based on World Health Organization percentiles. Multivariable logistic regression was used to identify risk factors associated with blood transfusion. Paired t tests were used for within-patient comparisons and Fisher exact test to compare syndromic and nonsyndromic subgroups.

RESULTS

ESC was associated with low rates of blood transfusion (6.6%), complications (1.4%), and reoperations (3.0%). Risk factors for transfusion included syndromic craniosynostosis (P = .01) and multiple fused sutures (P = .02). Median surgical time was 47 minutes, and hospital length of stay 1 day. Transfusion and reoperation rates were higher among syndromic patients (both P < .001). Head circumference normalized by 12 months of age relative to World Health Organization criteria in infants with sagittal, coronal, and multisuture craniosynostosis (all P < .001).

CONCLUSIONS

ESC is a safe, effective, and durable correction of infantile craniosynostosis. ESC can achieve head growth normalization with low risks of blood transfusion, complications, or reoperation. Early identification of craniosynostosis in the newborn period and prompt referral by pediatricians allows families the option of ESC vs larger and riskier open reconstruction procedures.

Endoscopic Versus Open Repair for Craniosynostosis in Infants Using Propensity Score Matching to Compare Outcomes: A Multicenter Study from the Pediatric Craniofacial Collaborative Group

BACKGROUND

The North American Pediatric Craniofacial Collaborative Group (PCCG) established the Pediatric Craniofacial Surgery Perioperative Registry to evaluate outcomes in infants and children undergoing craniosynostosis repair. The goal of this multicenter study was to utilize this registry to assess differences in blood utilization, intensive care unit (ICU) utilization, duration of hospitalization, and perioperative complications between endoscopic-assisted (ESC) and open repair in infants with craniosynostosis. We hypothesized that advantages of ESC from single-center studies would be validated based on combined data from a large multicenter registry.

METHODS

Thirty-one institutions contributed data from June 2012 to September 2015. We analyzed 1382 infants younger than 12 months undergoing open (anterior and/or posterior cranial vault reconstruction, modified-Pi procedure, or strip craniectomy) or endoscopic craniectomy. The primary outcomes included transfusion data, ICU utilization, hospital length of stay, and perioperative complications; secondary outcomes included anesthesia and surgical duration. Comparison of unmatched groups (ESC: N = 311, open repair: N = 1071) and propensity score 2:1 matched groups (ESC: N = 311, open repair: N = 622) were performed by conditional logistic regression analysis.

RESULTS

Imbalances in baseline age and weight are inherent due to surgical selection criteria for ESC. Quality of propensity score matching in balancing age and weight between ESC and open groups was assessed by quintiles of the propensity scores. Analysis of matched groups confirmed significantly reduced utilization of blood (26% vs 81%, P < .001) and coagulation (3% vs 16%, P < .001) products in the ESC group compared to the open group. Median blood donor exposure (0 vs 1), anesthesia (168 vs 248 minutes) and surgical duration (70 vs 130 minutes), days in ICU (0 vs 2), and hospital length of stay (2 vs 4) were all significantly lower in the ESC group (all P < .001). Median volume of red blood cell administered was significantly lower in ESC (19.6 vs 26.9 mL/kg, P = .035), with a difference of approximately 7 mL/kg less for the ESC (95% confidence interval for the difference, 3-12 mL/kg), whereas the median volume of coagulation products was not significantly different between the 2 groups (21.2 vs 24.6 mL/kg, P = .73). Incidence of complications including hypotension requiring treatment with vasoactive agents (3% vs 4%), venous air embolism (1%), and hypothermia, defined as <35°C (22% vs 26%), was similar between the 2 groups, whereas postoperative intubation was significantly higher in the open group (2% vs 10%, P < .001).

CONCLUSIONS

This multicenter study of ESC versus open craniosynostosis repair represents the largest comparison to date. It demonstrates striking advantages of ESC for young infants that may result in improved clinical outcomes, as well as increased safety.

Analysis of clinical outcomes for treatment of sagittal craniosynostosis: a comparison of endoscopic suturectomy and cranial vault remodeling

The authors compared the effectiveness of two main surgical techniques used for treating sagittal craniosynostosis (SC): endoscopic suturectomy (ES) and cranial vault remodeling (CVR). The safety, head growth, and aesthetic results following ES and CVR were compared by reviewing the charts of more than 200 patients. By comparing the effectiveness of these two treatments, this study will help guide selection of the optimal surgical treatment for patients with SC.

Regression of cephalic index following endoscopic repair of sagittal synostosis

OBJECTIVEMetrics used to quantify preoperative severity and postoperative outcomes for patients with sagittal synostosis include cephalic index (CI), the well-known standard, and the recently described adjusted cephalic index (aCI), which accounts for altered euryon location. This study tracks the time course of these measures following endoscopic repair with orthotic helmet therapy. The authors hypothesize that CI and aCI show significant regression following endoscope-assisted repair.METHODSCT scans or 3D photographs of patients with nonsyndromic sagittal synostosis treated before 6 months of age by endoscope-assisted strip craniectomy and postoperative helmet therapy (n = 41) were reviewed retrospectively at three time points (preoperatively, 0-2 months after helmeting, and > 24 months postoperatively). The CI and aCI were measured at each time point.RESULTSMean CI and aCI increased from 71.8 to 78.2 and 62.7 to 72.4, respectively, during helmet treatment (p < 0.001). At final follow-up, mean CI and aCI had regressed significantly from 78.2 to 76.5 and 72.4 to 69.7, respectively (p < 0.001). The CI regressed in 33 of 41 cases (80%) and aCI in 39 of 41 cases (95%). The authors observed a mean loss of 31% of improvement in aCI achieved through treatment. A strong, positive correlation existed between CI and aCI (R = 0.88).CONCLUSIONSRegression following endoscope-assisted strip craniectomy with postoperative helmet therapy commonly occurs in patients with sagittal synostosis. Future studies are required to determine whether duration of helmet therapy or modifications in helmet design affect regression.

Evaluation of anesthesia in endoscopic strip craniectomy: A review of 121 patients

OBJECTIVE

The aim of this study was to evaluate pre-, intra-, and postoperative anesthetic parameters in endoscopic strip craniectomy in order to improve anesthesiological care.

MATERIALS AND METHODS

This is a retrospective patient cohort study of our first 121 patients treated by endoscopic strip craniectomy. Preoperative as well as intra- and postoperative anesthesiological and neurological parameters were analyzed. Furthermore, the need for intensive care unit admission, blood loss, and blood transfusion rate were measured.

RESULTS

The mean age of patients was 3.9 months (standard deviation = 1) at a mean weight of 6.3 kg (standard deviation = 1.3). Comorbidity was registered in 13 (11%) patients of which 5 had syndrome-related comorbidities. Mean duration of anesthesia was 131 minutes (standard deviation = 32) . One hundred and sixteen patients were induced by mask induction with sevoflurane and 5 patients were induced intravenously. In 10 patients, mild intraoperative hypothermia (between 35 and 36 degrees Celsius) occurred. The mean estimated blood loss was 35.4 mL (standard deviation = 28.9) and blood transfusion rate was 21.5%. Brief and small intraoperative oxygen saturation drops were common during this study. No indication for venous air embolism was found based on endtidal CO₂ . Postoperative temperature above 38 degrees Celsius occurred 16 times and benign deviations in postoperative cardiopulmonary parameters occurred in 17 patients. Postoperative pain management was mainly established by paracetamol and low-dose morphine when necessary. No postoperative neurological symptoms were reported and no deaths occurred.

CONCLUSION

These patients had a relatively short intraoperative course with stable vital parameters during surgery. We report a low incidence of significant venous air embolism, a blood transfusion rate of 21% and only minor perioperative disturbances in vital parameters.

Minimally invasive approaches to craniosynostosis

Craniosynostosis (CS) is defined as the premature fusion of one or more calvarial sutures. This carries several consequences, including abnormal/asymmetric cranial vault development, increased intracranial pressure, compromised neurocognitive development, and craniofacial deformity. Definitive management is surgical with the goal of protecting cerebral development by re-establishing normal cranial vault expansion and correcting cosmetic deformity. In today's practice, CS surgery has advanced radically from simple craniectomies to major cranial vault reconstructive (CVR) procedures. More recently there has been considerable interest in endoscopic assisted surgery (EAS). Theoretical benefits include decreased operative time, morbidity, blood loss, postoperative pain, cost and faster recovery times. In this focused review, we summarize the current body of literature reporting clinical outcomes in EAS and review the data comparing EAS and CVR.

Less is more: does the addition of barrel staves improve results in endoscopic strip craniectomy for sagittal craniosynostosis?

OBJECTIVE Endoscopic strip craniectomy (ESC) with postoperative helmet orthosis is a well-established treatment option for sagittal craniosynostosis. There are many technical variations to the surgery ranging from simple strip craniectomy to methods that employ multiple cranial osteotomies. The purpose of this study was to determine whether the addition of lateral barrel-stave osteotomies during ESC improved morphological outcomes. METHODS An IRB-approved retrospective review was conducted on a consecutive series of cases involving ESC for sagittal craniosynostosis at 2 different institutions from March 2008 to August 2014. The patients in Group A underwent ESC and those in Group B had ESC with lateral barrel-stave osteotomies. Demographic and perioperative data were recorded; postoperative morphological outcomes were analyzed using 3D laser scan data acquired from a single orthotic manufacturer who managed patients from both institutions. RESULTS A total of 73 patients were included (34 in Group A and 39 in Group B). Compared with Group B patients, Group A patients had a shorter mean anesthetic time (161.7 vs 195 minutes; p < 0.01) and operative time (71.6 vs 111 minutes; p < 0.01). The mean hospital stay was similar for the 2 groups (1.2 days for Group A vs 1.4 days for Group B; p = 0.1). Adequate postoperative data on morphological outcomes were reported by the orthotic manufacturer for 65 patients (29 in Group A and 36 in Group B). The 2 groups had similar improvement in the cephalic index (CI): Group A, mean change 10.5% (mean preoperative CI 72.6, final 80.4) at a mean follow-up of 13.2 months; Group B, mean change 12.2% (mean preoperative CI 71.0, final 79.6) at a mean follow-up of 19.4 months. The difference was not statistically significant (p = 0.15). CONCLUSIONS Both ESC alone and ESC with barrel staving produced excellent outcomes. However, the addition of barrel staves did not improve the results and, therefore, may not be warranted in the endoscopic treatment of sagittal craniosynostosis.

Multivariable predictors of substantial blood loss in children undergoing craniosynostosis repair: implications for risk stratification

BACKGROUND

Operative treatment of craniosynostosis is associated with substantial blood loss, often requiring transfusion of packed red blood cells (PRBC) and coagulation products.

AIMS

The aim of this prospective study was to analyze thromboelastographic (TEG) parameters and platelet fibrinogen product to determine predictors of substantial blood loss, and the need for PRBC transfusion and coagulation products.

METHODS

With IRB approval, we enrolled 120 children undergoing craniosynostosis repair with a standardized anesthetic, fluid management, and TEG measurements at predefined times. Outcomes of interest were intraoperative blood loss, and need for PRBC transfusion and coagulation products. Multivariable logistic regression and receiver operating characteristic (ROC) curve analysis was applied to determine independent predictors of substantial blood loss and need for coagulation products.

RESULTS

One hundred and eighteen children were included in the analysis. Forty-four required PRBC transfusion (median 26 ml·kg(-1) ; IQR: 22-42) with median blood loss of 56 ml·kg(-1) (IQR: 43-83). Factors associated with the PRBC transfusion included type of surgery, duration of surgery, and three TEG parameters, α-angle, MA, and K-time (all P < 0.001). A predictive algorithm was developed by subgroup analysis of cranial vault reconstruction (CVR) patients for substantial intraoperative blood loss (defined as ≥60 ml·kg(-1) ) and need for coagulation products with ROC-derived cut-off values: platelet fibrinogen product, <343; α-angle, <62°; MA, <55 mm; K-time, >2.1 min. The best prognostic combination included at least two of these four predictors (sensitivity 89%, specificity 90%). Multivariable regression identified MA as the only independent predictor of coagulation product administration (P < 0.001) and ROC analysis identified MA <46 mm as the optimal cut-off (sensitivity 86%, specificity 94%).

CONCLUSIONS

Risk for substantial intraoperative blood loss can be assessed using TEG parameters and platelet fibrinogen product, whereas the need for coagulation products is strongly related to low MA. Patients susceptible to substantial blood loss can be risk stratified based on their TEG/platelet fibrinogen product profile.

Characterization of complications associated with open and endoscopic craniosynostosis surgery at a single institution

OBJECT The authors present a retrospective cohort study examining complications in patients undergoing surgery for craniosynostosis using both minimally invasive endoscopic and open approaches. METHODS Over the past 10 years, 295 nonsyndromic patients (140 undergoing endoscopic procedures and 155 undergoing open procedures) and 33 syndromic patients (endoscopic procedures in 10 and open procedures in 23) met the authors' criteria. Variables analyzed included age at surgery, presence of a preexisting CSF shunt, skin incision method, estimated blood loss, transfusions of packed red blood cells, use of intravenous steroids or tranexamic acid, intraoperative durotomies, procedure length, and length of hospital stay. Complications were classified as either surgically or medically related. RESULTS In the nonsyndromic endoscopic group, the authors experienced 3 (2.1%) surgical and 5 (3.6%) medical complications. In the nonsyndromic open group, there were 2 (1.3%) surgical and 7 (4.5%) medical complications. Intraoperative durotomies occurred in 5 (3.6%) endoscopic and 12 (7.8%) open cases, were repaired primarily, and did not result in reoperations for CSF leakage. Similar complication rates were seen in syndromic cases. There was no death or permanent morbidity. Additionally, endoscopic procedures were associated with significantly decreased estimated blood loss, transfusions, procedure length, and length of hospital stay compared with open procedures. CONCLUSIONS Rates of intraoperative durotomies and surgical and medical complications were comparable between endoscopic and open techniques. This is the largest direct comparison to date between endoscopic and open interventions for synostosis, and the results are in agreement with previous series that endoscopic surgery confers distinct advantages over open surgery in appropriate patient populations.

Preoperative ultrasound localization of the lambda in patients with scaphocephaly: a technical note for minimally invasive craniectomy

Sagittal craniosynostosis, the most common single suture craniosynostosis, is treated by numerous surgical techniques. Minimally invasive endoscopy-assisted procedures with postoperative helmeting are being used with reports of good cosmetic outcomes with decreased morbidity, shortened hospital stay, and less blood loss and transfusion. This procedure uses small skin incisions, which must be properly placed to provide safe access to the posterior sagittal and lambdoid sutures. However, the lambda is often hard to palpate through the skin due to the abnormal head shape. The authors describe their experience with the use of intraoperative, preincision ultrasound localization of the lambda in patients with scaphocephaly undergoing a minimally invasive procedure. This simple technique can also be applied to other operations where proper identification of the cranial sutures is necessary.

Endoscopic craniosynostosis repair

INTRODUCTION

Craniosynostosis is a rare condition that affects approximately one child in every 2,000 live births, and involves pathological fusion of two or more skull bones. Consequences of craniosynostosis include possible limitation of brain growth and cosmetic effects on the appearance of the child. Traditional repairs for these conditions over the past 3-4 decades have involved an open operation with a large skin incision and major manipulations of the skull bones. More recently, minimally invasive endoscopic techniques have been developed to release the skull bones, followed by postoperative treatment with either an external orthosis or internal springs and distractors to achieve the desired correction.

METHODS

In this review minimally invasive endoscopic repair will be reviewed. A general overview of the condition and techniques for correction will be discussed, followed by specific application of these surgeries for different craniosynostosis diagnoses. Attention to the subtleties of each specific condition will be highlighted.

SUMMARY

Over the past two decades clinical experience and a large number of publications have substantiated the benefits of minimally invasive endoscopic techniques for the treatment of craniosynostosis. These techniques have clear benefits for selected patients, and should be part of the standard of care for this condition at craniofacial centers.

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.

Evidence-based medicine: Craniosynostosis

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Make the appropriate diagnosis for each of the single-sutural synostoses, based on the physical examination. (2) Explain the functional concerns associated with these synostoses and why surgical correction is indicated. (3) Distinguish between the different types of surgical corrections available, the timing for these various interventions, and in what ways these treatments achieve overall management objectives. (4) Identify the basic goals involved in caring for the syndromic synostoses.

SUMMARY

This article provides an overview of the diagnosis and management of infants with craniosynostosis. This review also incorporates some of the treatment philosophies followed at The Craniofacial Center in Dallas, but is not intended to be an exhaustive treatise on the subject. It is designed to serve as a reference point for further in-depth study by review of the reference articles presented. This information base is then used for self-assessment and benchmarking in parts of the Maintenance of Certification process of the American Board of Plastic Surgery.

Anesthesia for craniofacial surgery in infancy

Anesthetic management of infants undergoing craniofacial surgery can be challenging. Primary concerns for the anesthesiologist include blood loss and its management. The evolution of procedures to treat craniosynostosis has resulted in improvements in perioperative morbidity, including decreased blood loss and transfusion, shorter operations, and shorter hospital stays. An understanding of the procedures performed to treat craniosynostosis is necessary to provide optimal anesthetic management. Descriptions of current surgical techniques and approaches to anesthetic care are presented in this review.

Endoscope-assisted repair of metopic synostosis

PURPOSE

Endoscopic treatment of nonsyndromic craniosynostosis has been used in recent decades. The aim of this study is to present the results of endoscope-assisted surgery of the patients with metopic synostosis.

METHODS

Nineteen patients with metopic synostosis underwent endoscope-assisted surgery between 2005 and 2012. The frontal angle was measured on CT scans pre- and postoperatively. A midline strip craniectomy was made, making sure that the removal extended inferiorly to the nasofrontal suture. Postoperatively, all patients wear a custom molding helmet. The helmet was then worn for 23 h daily and worn for the next 10-12 months.

RESULTS

There were 15 boys and 4 girls, ranging in age from 4 to 24 weeks. Mean operative time and transfused blood volume were 43.42 min and 76.31 ml, respectively. Mean follow-up was 59.3 weeks. Good esthetic results, judged by radiological examination and photograph comparison, were obtained in all patients.

CONCLUSIONS

Endoscope-assisted repair of metopic synostosis is safe and offers promising results in infants before the age of 6 months. Molding helmet therapy following surgery is very important in obtaining the good results. Early diagnosis and referral for surgery are crucial.

Venous air embolism from Tisseel use during endoscopic cranial vault remodeling for craniosynostosis repair: a case report

Venous air embolism (VAE) is a potential complication during cranial vault remodeling requiring early detection and prompt therapeutic intervention. The incidence of VAE has been reported to be as high as 82.6% during open craniectomy for craniosynostosis repair. On the other hand, two separate studies reported a much lower incidence of VAE (8% and 2%) during endoscopic strip craniectomy. As surgical advancements progress, minimally invasive neurosurgical procedures are increasing in the pediatric population with reported benefits of decreased blood loss and need for transfusion, shorter hospital stay, decreased cost, lower morbidity, and mortality. In addition, there is a heightened emphasis on achieving hemostasis, which has led to the use of products such as antifibrinolytics and fibrin sealants. We present a case where a VAE causing significant hemodynamic instability (grade III) ensued immediately following aerosolized fibrin sealant application. Exploration of the potential source of VAE pointed to the high pressure and close proximity (between spray device and tissue) during application of the sealant, likely forcing air into the vascular system.

Novel use of an ultrasonic bone-cutting device for endoscopic-assisted craniosynostosis surgery

PURPOSE

Endoscopic-assisted craniosynostosis surgery is associated with less blood loss and shorter operative times as compared to open surgery. However, in infants who have low circulating blood volumes, the endoscopic approach is still associated with significant blood loss. A major source of blood loss is the bone that is cut during surgery. We discuss the novel use of an ultrasonic bone-cutting device for craniosynostosis surgery, which decreases bone bleeding. This device, which has primarily only been used for spine and skull base surgery, may help reduce blood loss in these infants.

METHODS

All patients with single suture craniosynostosis who were operated on with the use of an ultrasonic bone-cutting device were identified. The information retrospectively recorded from patient charts included patient age, suture involved, blood loss, operative times, complications, preoperative hemoglobin, postoperative hemoglobin, length of hospital stay, and follow-up times.

RESULTS

Thirteen patients (12 males, 1 female) underwent surgery with an ultrasonic bone-cutting device during the reviewed period. The average age (±standard deviation) of the patients was 11.8 (±1.6) weeks. Four patients had metopic synostosis and nine patients had sagittal synostosis. The average surgery time was 84 (±13) min. The median (interquartile range) blood loss was 20 (10-70) cc. No patients required blood transfusions. Three patients had dural tears.

CONCLUSION

We demonstrate the novel use of an ultrasonic bone-cutting device for endoscopic-assisted craniosynostosis surgery. This device limited blood loss while maintaining short operative times for infants with low circulating blood volumes.

Endoscopic-assisted treatment of trigonocephaly

Minimally invasive, endoscopic repair of metopic craniosynostosis has emerged as a potentially efficacious, safe, and aesthetically acceptable alternative to open procedures. Potential advantages of an early endoscopic approach to repair metopic craniosynostosis include a reduction in blood loss and consequent decreases in transfusion volumes, decreased hospital costs, shorter operative times, and limited duration of hospitalization. Other benefits of minimally invasive techniques would be avoidance of anaesthetic surgical scarring, decrease in postoperative swelling and discomfort, and lower rate of complications such as duramater tears, postoperative hyperthermia, or infection. However, a concern is usually raised about the achievements of the "endoscopic" techniques when compared to "standard" open approaches. The indications for endoscopic-assisted surgery in the treatment of trigonocephaly remain controversial and further series and follow-up of these patients are necessary to set up the role of these approaches.

Controlled hypotension and blood loss during frontoorbital advancement

OBJECT

Controlled hypotension is routinely used during open repair of craniosynostosis to decrease blood loss, although this benefit is unproven. In this study the authors analyzed the longitudinal relationships between intraoperative mean arterial pressure (MAP) and calculated blood loss (CBL) during frontoorbital advancement (FOA) for craniosynostosis.

METHODS

The authors reviewed the records of infants with craniosynostosis who had undergone primary FOA between 1997 and 2009. Anesthesia records provided preoperative and serial intraoperative MAP. Interval measures of CBL had been determined during the course of the operation. The longitudinal relationships between MAP(mean), MAP(change), and CBL(change) were assessed over the same time interval and compared between adjacent time intervals to determine the directionality of associations.

RESULTS

Ninety infants (44 males and 46 females) underwent FOA at a mean age and weight of 10.7 ± 12.9 months and 9.0 ± 7.0 kg, respectively. The average intraoperative MAP was 56.1 ± 4.8 mm Hg, 22.6 ± 12.1% lower than preoperative baseline. A negative correlation was found between CBL(change) and MAP(mean) over the same interval (r = -0.31, p < 0.05), and an inverse relationship was noted between CBL(change) of the previous interval and MAP(change) of the next interval (r = -0.07, p < 0.05). Finally, there was no significant association between MAP(change) of the previous interval and CBL(change) of the next interval.

CONCLUSIONS

Calculated blood loss demonstrated a negative correlation with MAP during FOA. Directionality testing indicated that MAP did not affect intraoperative blood loss; instead, blood loss drove changes in MAP. Overall, these findings challenge the benefit of controlled hypotension during open craniofacial repair.

Chiari malformation associated with craniosynostosis

OBJECT

Chiari malformation (CM) Type I is frequently associated with craniosynostosis. Optimal management of CM in patients with craniosynostosis is not well-established. The goal of this study was to report on a series of pediatric patients with both craniosynostosis and CM and discuss their management.

METHODS

The authors searched the medical records of 383 consecutive patients treated for craniosynostosis at a single institution over a 15-year period to identify those with CM. They recorded demographic data as well as surgical treatment and outcomes for these patients. When MR imaging was performed, cerebellar tonsillar descent was recorded and any other associated findings, such as hydrocephalus or spinal syringes, were noted.

RESULTS

A total of 29 patients with both CM and craniosynostosis were identified. Of these cases, 28% had associated occipital venous abnormalities, 45% were syndromic, and 52% also had hydrocephalus. Chiari malformation was more likely to be present in those patients with isolated lambdoid synostosis (55%), multisuture synostosis (35%), and pansynostosis (80%), compared with patients with coronal synostosis (6%) or sagittal synostosis (3%). All patients underwent surgical repair of craniosynostosis: 16 had craniosynostosis repair as well as CM decompression, and 13 patients did not undergo CM decompression. Of the 7 patients in whom craniosynostosis repair alone was performed, 5 had decreased tonsillar ectopia postoperatively and 5 had improved CSF flow studies postoperatively. Both patients with a spinal syrinx had imaging-documented syrinx regression after craniosynostosis repair. In 12 patients in whom CM was diagnosed after primary craniosynostosis repair, 5 had multiple cranial vault expansions and evidence of elevated intracranial pressure. In 5 cases, de novo CM development was documented following craniosynostosis repair at a mean of 3.5 years after surgery.

CONCLUSIONS

Chiari malformation is frequently seen in patients with both multi- and single-suture lambdoid craniosynostosis. Chiari malformation, and even a spinal cord syrinx, will occasionally resolve following craniofacial repair. De novo development of CM after craniosynostosis repair is not unusual.

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.