Children with suspected craniosynostosis: a cost-effectiveness analysis of diagnostic strategies

Neuroimaging in Nonsyndromic Craniosynostosis: Key Concepts to Unlock Innovation

Craniosynostoses (CRS) are caused by the premature fusion of one or more cranial sutures, with isolated nonsyndromic CRS accounting for most of the clinical manifestations. Such premature suture fusion impacts both skull and brain morphology and involves regions far beyond the immediate area of fusion. The combined use of different neuroimaging tools allows for an accurate depiction of the most prominent clinical-radiological features in nonsyndromic CRS but can also contribute to a deeper investigation of more subtle alterations in the underlying nervous tissue organization that may impact normal brain development. This review paper aims to provide a comprehensive framework for a better understanding of the present and future potential applications of neuroimaging techniques for evaluating nonsyndromic CRS, highlighting strategies for optimizing their use in clinical practice and offering an overview of the most relevant technological advancements in terms of diagnostic performance, radiation exposure, and cost-effectiveness.

MR Protocols for Paediatric Neurosurgical Common Conditions: An Update Guide for Neurosurgeons

The biggest challenge for clinicians and surgeons when it comes to radiological examinations is the ability to request the right modalities and to understand the strengths and limitations of each modality. This is particularly important in paediatric neurosciences where despite magnetic resonance imaging (MRI) being the main imaging modality, there are several protocols, technical limitations of specific scanners and issues related to sedation that need to be taken into account. In this chapter, we describe a simple approach for six common neurosurgical conditions to guide the paediatric neurosurgeons in requesting the right MR protocol and understanding the rationale of it.Paediatric neuro-oncology, epilepsy and neck/skull base protocols are discussed elsewhere in this book and therefore will not be a focus in this chapter (Bernasconi et al., Epilepsia 60:1054-68, 2019; D'Arco et al., Neuroradiology 64:1081-100; 2022; Avula et al., Childs Nerv Syst 37:2497-508; 2021).

Postnatal diagnosis of single-suture craniosynostosis with cranial ultrasound: a systematic review

INTRODUCTION

The optimal protocol for diagnostic workup of craniosynostosis and the role of specific imaging modalities remain controversial. Skull X-rays and 3-dimensional head CTs are options when physical exam is equivocal but involve ionizing radiation. Ultrasound has emerged as an alternative modality for visualization of cranial sutures, but its use is not widespread.

METHODS

The authors performed a systematic review of the literature on the use of ultrasound for the diagnosis of craniosynostosis.

RESULTS

A total of 12 studies involving 1062 patients were included. Overall, 300 patients (28.2%) were diagnosed with craniosynostosis. A total of 369 (34.7%) patients had their diagnosis (craniosynostosis vs. patent sutures) confirmed with another imaging modality in addition to ultrasound. Among studies, the specificity of ultrasound ranged from 86 to 100%, and the sensitivity from 71 to 100%.

CONCLUSIONS

Ultrasonography of cranial sutures is a feasible and accurate tool for the diagnosis of single-suture craniosynostosis when physical exam findings are insufficient. Although technical aspects of ultrasonography and its interpretation have an associated learning curve, ultrasound can achieve high sensitivity and specificity among patients with suspected craniosynostosis.

Challenging the Norm: Is Routine Use of Cranial CT in Evaluation of Craniosynostosis Necessary?

BACKGROUND

Cranial CT is routinely taught to be the gold standard for diagnosis of craniosynostosis and used by craniofacial teams for suspected nonsyndromic single suture craniosynostosis. Given the risks associated with infant CTs, do these scans provide significantly enhanced diagnostic accuracy compared to the physical exam when performed by an experienced clinical provider?

METHOD

A retrospective chart review was performed for children who underwent corrective surgery for nonsyndromic, single-suture craniosynostosis over an 11 year period by a single craniofacial team. Ages at presentation and surgery, preoperative clinical diagnosis and imaging, co-existing radiographic findings, and correlation with the intraoperative diagnosis were analyzed.

RESULTS

A total of 138 patients were included in this study. The mean age was 4.2 months at initial craniofacial evaluation, and 8.0 months at time of surgery. Twenty-seven patients received imaging prior to our clinic. Of those, 21 had plain radiography and 6 had CT scans. Of the remaining 111 patients referred without imaging, craniosynostosis was clinically diagnosed in 102 (92%), whereas 9 (8%) had an unclear clinical diagnosis. Of these 9, 1 (1%) was diagnosed clinically at follow-up exam, and the remaining 8 (7%) were diagnosed using radiography (3 CT scans, 5 plain radiographs). In all patients, the preoperative diagnosis was confirmed during intraoperative assessment.

CONCLUSIONS

Cranial CT was not needed by experienced craniofacial providers in 93% of nonsyndromic, single-suture craniosynostosis. Imaging obtained before craniofacial clinic referral may have been unnecessary. These findings question the classic teaching that preoperative cranial CT is the gold standard for diagnosis in infants with nonsyndromic, single-suture craniosynostosis.

Preoperative imaging patterns and intracranial findings in single-suture craniosynostosis: a study from the Synostosis Research Group

OBJECTIVE

The diagnosis of single-suture craniosynostosis can be made by physical examination, but the use of confirmatory imaging is common practice. The authors sought to investigate preoperative imaging use and to describe intracranial findings in children with single-suture synostosis from a large, prospective multicenter cohort.

METHODS

In this study from the Synostosis Research Group, the study population included children with clinically diagnosed single-suture synostosis between March 1, 2017, and October 31, 2020, at 5 institutions. The primary analysis correlated the clinical diagnosis and imaging diagnosis; secondary outcomes included intracranial findings by pathological suture type.

RESULTS

A total of 403 children (67% male) were identified with single-suture synostosis. Sagittal (n = 267), metopic (n = 77), coronal (n = 52), and lambdoid (n = 7) synostoses were reported; the most common presentation was abnormal head shape (97%), followed by a palpable or visible ridge (37%). Preoperative cranial imaging was performed in 90% of children; findings on 97% of these imaging studies matched the initial clinical diagnosis. Thirty-one additional fused sutures were identified in 18 children (5%) that differed from the clinical diagnosis. The most commonly used imaging modality by far was CT (n = 360), followed by radiography (n = 9) and MRI (n = 7). Most preoperative imaging was ordered as part of a protocolized pathway (67%); some images were obtained as a result of a nondiagnostic clinical examination (5.2%). Of the 360 patients who had CT imaging, 150 underwent total cranial vault surgery and 210 underwent strip craniectomy. The imaging findings influenced the surgical treatment 0.95% of the time. Among the 24% of children with additional (nonsynostosis) abnormal findings on CT, only 3.5% required further monitoring.

CONCLUSIONS

The authors found that a clinical diagnosis of single-suture craniosynostosis and the findings on CT were the same with rare exceptions. CT imaging very rarely altered the surgical treatment of children with single-suture synostosis.

Appropriateness of Computed Tomography Scanning in the Diagnosis of Craniosynostosis

INTRODUCTION

Although physicians from a variety of specialties encounter infants with possible craniosynostosis, judicious use of computed tomography (CT) imaging is important to avoid unnecessary radiation exposure and healthcare expense. The present study seeks to determine whether differences in specialty of ordering physician affects frequency of resulting diagnostic confirmations requiring operative intervention.

METHODS

Radiology databases from 2 institutions were queried for CT reports or indications that included "craniosynostosis" or "plagiocephaly." Patient demographics, specialty of ordering physician, confirmed diagnosis, and operative interventions were recorded. Cost analysis was performed using the fixed unit cost for a head CT to calculate the expense before 1 study led to operative intervention.

RESULTS

Three hundred eighty-two patients were included. 184 (48.2%) CT scans were ordered by craniofacial surgeons, 71 (18.6%) were ordered by neurosurgeons, and 127 (33.3%) were ordered by pediatricians. One hundred four (27.2%) patients received a diagnosis of craniosynostosis requiring operative intervention. Craniofacial surgeons and neurosurgeons were more likely than pediatricians to order CT scans that resulted in a diagnosis of craniosynostosis requiring operative intervention (P < 0.001), with no difference between craniofacial surgeons and neurosurgeons (P = 1.0). The estimated cost of obtaining an impact CT scan when ordered by neurosurgeons or craniofacial surgeons as compared to pediatricians was $2369.69 versus $13,493.75.

CONCLUSIONS

Clinicians who more frequently encounter craniosynostosis (craniofacial and neurosurgeons) had a higher likelihood of ordering CT images that resulted in a diagnosis of craniosynostosis requiring operative intervention. This study should prompt multi-disciplinary interventions aimed at improving evaluation of pretest probability before CT imaging.

Cost-Effectiveness Analysis in Pediatric Imaging: The Evidence (or Lack Thereof) Thus Far

OBJECTIVE

To systematically review all published cost-effectiveness analyses (CEAs) of imaging technologies in children.

METHODS

We identified all CEAs involving fetal and pediatric imaging included in a publicly available repository of CEAs published since 1976. Information on publication characteristics, methods, costs, quality of life weights, and incremental cost-effectiveness ratios (ICERs) was recorded for each article.

RESULTS

Of 480 diagnostic CEAs, only 10 focused on fetal and pediatric imaging. The 10 studies reported 43 quality of life weights based on previously published adult data (n = 20, 46.5%); pregnant women perspective (n = 11, 25.6%), and treating physician perspective (n = 12, 27.9%). None of the studies elicited quality of life weights from children nor took into consideration the postnatal impact of disease on family's quality of life. All studies used a health care payer perspective without incorporating patients' incurred cost such as loss wages or travel related cost. Of 37 ICERs, 7 (18.9%) were cost saving and 6 (16.2%) were more expensive and less effective. The remaining ICERs ranged from $1,400 per quality-adjusted life-year (MRI versus ultrasound in newborns with moderate risk of occult spinal dysraphism) to $10,000,000 per quality-adjusted life-year (CT versus no imaging in children at low risk for craniosynostosis).

CONCLUSION

There is a striking paucity of cost-effectiveness studies evaluating imaging technologies in children. Existing studies do not incorporate the patient and family perspectives regarding utilities (eg, impact of child's disease on families' quality of life) or cost (eg, loss wages, travel, time off). Future studies should elicit and incorporate the impact of disease on families to better reflect real-world scenarios.

Imaging in craniosynostosis: when and what?

PURPOSE

Currently, the interest on craniosynostosis in the clinical practice is raised by their increased frequency and their genetic implications other than by the still existing search of less invasive surgical techniques. These reasons, together with the problem of legal issues, make the need of a definite diagnosis for a crucial problem, even in single-suture craniosynostosis (SSC). Although the diagnosis of craniosynostosis is primarily the result of physical examination, craniometrics measuring, and observation of the skull deformity, the radiological assessment currently plays an important role in the confirmation of the diagnosis, the surgical planning, and even the postoperative follow-up. On the other hand, in infants, the use of radiation or the need of sedation/anesthesia raises the problem to reduce them to minimum to preserve such a delicate category of patient from their adverse effects.

METHODS, RESULTS AND CONCLUSIONS

This review aims at summarizing the state of the art of the role of radiology in craniosynostosis, mainly focusing on indications and techniques, to provide an update not only to pediatric neurosurgeons or maxillofacial surgeons but also to all the other specialists involved in their management, like neonatologists, pediatricians, clinical geneticists, and pediatric neurologists.

The Use of Finite Element Method Analysis for Modeling Different Osteotomy Patterns and Biomechanical Analysis of Craniosynostosis Correction

PURPOSE

Several post-processing algorithms for 3D visualization of the skull in craniosynostosis with their specific advantages and disadvantages have been already described. The Finite Element Method (FEM) described herein can also be used to evaluate the efficacy of the cutting patterns with respect to an increase in the projected surface area under assumed uniform loading of the manipulated and cut bone segments.

METHODS

The FEM analysis was performed. Starting with the classic cranial osteotomies for bifrontal craniotomy and orbital bandeau a virtually mirroring of the unaffected triangular shaped frontal bone was performed to achieve a cup-shaped sphere of constant thickness of 2.5 mm with a radius of 65 mm. Mechanical properties required for the analysis were Young's modulus of 340 MPa and Poisson's ratio of 0.22. Four different cutting patterns from straight to curved geometries have been projected onto the inner surface of the sphere with a cutting depth set to 2/3rds of the shell thickness. The necessary force for the deformation, the resulting tensions and the volume loss due to the osteotomy pattern were measured.

RESULTS

Better outcomes were realized with pattern D. The necessary force was 73.6% smaller than the control group with 66N. Best stress distribution was achieved. Curved cutting patterns led to the highest peak of stress and thus to a higher risk of fracture. Straight bone cuts parallel to the corners or to the thighs of the sphere provided a better distribution of stresses with a small area with high stress. Additionally, also with pattern D a surface increase of 20.7% higher than reference was registered.

CONCLUSION

As a proof of concept for different cutting geometries for skull molding in the correction of craniosynostosis, this computational model shows that depending of the cutting pattern different biomechanical behavior is achieved.

Effectiveness of screening for craniosynostosis with ultrasound: a retrospective review

BACKGROUND

Minimizing the ionizing radiation dose to children is fundamental to pediatric radiology. The most widely accepted imaging examination for evaluating craniosynostosis is computed tomography (CT) of the head, an examination that involves ionizing radiation.

OBJECTIVE

To determine if sonography of the cranial sutures is an adequate screening examination for the diagnosis of craniosynostosis in patients with abnormal skull shape.

MATERIALS AND METHODS

A retrospective review of all cranial suture ultrasound (US) examinations performed during the course of a 3-year period (July 2012 - September 2015) was undertaken. Results were compared with clinical follow-up and/or head CT to evaluate the accuracy of this modality as a screening tool to determine the presence or absence of craniosynostosis. Fifty-two sonographic exams were adequate for inclusion.

RESULTS

Forty-five of the examinations did not reveal synostosis. In each of these instances, follow-up physical exam findings and/or CT imaging confirmed that no abnormal premature suture closure was present. US findings demonstrated synostosis in seven cases. CT exam or operative reports of these cases confirmed all seven findings of premature suture closure. Statistical analysis demonstrated a sensitivity of 100% (95% confidence interval [CI]: 56.1-100.0%), a specificity of 100% (95% CI: 90.2-100.0%), and a negative predictive value of 100% (95% CI: 90.2-100.0%).

CONCLUSION

Cranial US is a reliable screening tool to rule out craniosynostosis in patients with abnormal head shape.

Diagnosis of infant synostotic and nonsynostotic cranial deformities: a review for pediatricians

Objective:

To review the current comprehensive care for nonsyndromic craniosynostosis and nonsynostotic cranial deformity and to offer an overall view of these craniofacial conditions.

Data source:

The review was conducted in the PubMed, SciELO, and LILACS databases without time or language restrictions. Relevant articles were selected for the review.

Data synthesis:

We included the anatomy and physiology of normal skull development of children, discussing nuances related to nomenclature, epidemiology, etiology, and treatment of the most common forms of nonsyndromic craniosynostosis. The clinical criteria for the differential diagnosis between positional deformities and nonsyndromic craniosynostosis were also discussed, giving to the pediatrician subsidies for a quick and safe clinical diagnosis. If positional deformity is accurately diagnosed, it can be treated successfully with behavior modification. Diagnostic doubts and craniosynostosis patients should be referred straightaway to a multidisciplinary craniofacial center.

Conclusions:

Pediatricians are in the forefront of the diagnosis of patients with cranial deformities. Thus, it is of paramount importance that they recognize subtle cranial deformities as it may be related to premature fusion of cranial sutures.

Diagnosis of infant synostotic and nonsynostotic cranial deformities: a review for pediatricians

OBJECTIVE

To review the current comprehensive care for nonsyndromic craniosynostosis and nonsynostotic cranial deformity and to offer an overall view of these craniofacial conditions.

DATA SOURCE

The review was conducted in the PubMed, SciELO, and LILACS databases without time or language restrictions. Relevant articles were selected for the review.

DATA SYNTHESIS

We included the anatomy and physiology of normal skull development of children, discussing nuances related to nomenclature, epidemiology, etiology, and treatment of the most common forms of nonsyndromic craniosynostosis. The clinical criteria for the differential diagnosis between positional deformities and nonsyndromic craniosynostosis were also discussed, giving to the pediatrician subsidies for a quick and safe clinical diagnosis. If positional deformity is accurately diagnosed, it can be treated successfully with behavior modification. Diagnostic doubts and craniosynostosis patients should be referred straightaway to a multidisciplinary craniofacial center.

CONCLUSIONS

Pediatricians are in the forefront of the diagnosis of patients with cranial deformities. Thus, it is of paramount importance that they recognize subtle cranial deformities as it may be related to premature fusion of cranial sutures.

Role of "major" and "minor" lambdoid arch sutures in posterior cranial fossa changes: mechanism of cerebellar tonsillar herniation in infants with multisutural craniosynostosis

PURPOSE

This study aimed to explain the functional role of lambdoid arch sutures in the development of cerebellar tonsillar herniation. Posterior cranial fossa (PCF) changes were investigated in infants with premature synostosis of the major and minor sutures of the lambdoid arch without premature synostosis of the PCF synchondroses.

METHODS

Morphometric and volumetric PCF measurements were performed on preoperative high-resolution CT studies in 12 infants with multisutural craniosynostosis involving the lambdoid arch and compared with those of 12 age-matched healthy subjects.

RESULTS

All 12 patients had hypoplasia of PCF bone structures and normal volumes of the PCF and neural structures. PCF hypoplasia was related to exocciput length in infants with isolated involvement of major sutures, while it was related to posterior skull base hemifossae in infants with isolated involvement of minor lambdoid arch sutures. Foramen magnum AP diameter was reduced in babies with major suture involvement and tonsillar herniation, while foramen magnum AP and LL diameters were reduced in babies with minor suture involvement without tonsillar herniation. Right and left jugular foramen (JF) areas differed in all infants; however, the area of the smaller JF was significantly reduced only in infants with involvement of minor lambdoid arch sutures.

CONCLUSION

Hypoplasia of PCF bone structures due to sutural synostosis of the lambdoid arch is a required predisposing but not sufficient factor for the development of cerebellar tonsillar herniation through the foramen magnum. Normal PCF volume and foramen magnum anatomy may partly explain the development of cerebellar tonsil herniation in infants with lambdoid arch synostosis.

Role of 99mTc-ECD SPECT in the management of children with craniosynostosis

PURPOSE OF THE REPORT

There is a paucity of data on correlation of various imaging modalities with clinical findings in craniosynostosis. Moreover, no study has specifically reported the role of (99m)Tc-ECD SPECT in a large number of subjects with craniosynostosis.

MATERIALS AND METHODS

We prospectively analyzed a cohort of 85 patients with craniosynostosis from year 2007 to 2012. All patients underwent evaluation with (99m)Tc-ECD SPECT and the results were correlated with radiological and surgical findings.

RESULTS

(99m)Tc-ECD SPECT revealed regional perfusion abnormalities in the cerebral hemisphere corresponding to the fused sutures preoperatively that disappeared postoperatively in all the cases. Corresponding to this, the mean mental performance quotient (MPQ) increased significantly (P < 0.05) postoperatively only in those children with absent perfusion defect postoperatively.

CONCLUSIONS

Our study suggests that early surgery and release of craniosynostosis in patients with preoperative perfusion defects (absent on (99m)Tc-ECD SPECT study) are beneficial, as they lead to improved MPQ after surgery.

Identification of skull base sutures and craniofacial anomalies in children with craniosynostosis: utility of multidetector CT

PURPOSE

Craniosynostosis is a condition characterised by the premature fusion of one or more of the cranial sutures. The aim of the study was to identify, by multidetector computed tomography (CT), the involvement of vault sutures as well as of the skull base sutures (named "minor" sutures). The latter ones are involved in development of craniofacial and skull base deformities.

MATERIALS AND METHODS

We retrospectively reviewed 27 children with complex synostosis (n = 21) and anterior synostotic plagiocephaly (n = 6). High-resolution CT images with bone definition algorithm and tridimensional volume rendering reconstructions were assessed.

RESULTS

In 27 children we found different sutures involved in the synostotic process, including both major and minor skull suture synostosis, and synostosis of synchondroses. Superior orbital rim deformity, nasal root deviation, anterior endocranial axis deviation (ethmoidal axis) are found in children with coronal arch synostosis, while reduced size of the posterior fossa and Chiari 1 malformation are noted in children with lambdoid arch synostosis.

CONCLUSIONS

High-resolution CT allows an accurate identification of both "major" and "minor" skull base suture synostosis and it represents the gold standard for the diagnosis of craniostenosis and for planning the proper surgical approach.

Craniosynostosis: imaging review and primer on computed tomography

Craniosynostosis is encountered in the pediatric population in isolated or syndromic forms. The resulting deformity depends on the number and type of sutures involved and, in multi-sutural synostosis, the order of suture fusion. Primary craniosynostosis needs to be differentiated from the secondary variety and positional or deformational mimics. Syndromic craniosynostoses are associated with other craniofacial deformities. Evaluation with 3-D CT plays an important role in accurate diagnosis and management; however, implementation of appropriate CT techniques is essential to limit the radiation burden in these children. In this article, the authors briefly review the classification, embryopathogenesis and epidemiology and describe in detail the radiologic appearance and differential diagnoses of craniosynostosis.

BaS analysis: suggesting a new cephalometric model in follow-up of patients with craniostenosis who underwent craniofacial advancement surgery after 1 year from the end of the distraction protocol

Evaluation of the relapse in patients with craniofacial malformation who underwent craniofacial advancement surgery is very difficult, and data are often unreliable. This is because common skeletal landmarks move from their original position, making standard cephalometries completely useless. To solve this problem, some authors proposed evaluations based on 2- and 3-dimensional computed tomographies, but the biologic risk and the economic outcome do not consent to repeat this kind of examination too often. In this paper, the authors propose a new cephalometric model based on the evaluation of facial skeletal landmarks on the BaS axis. This method, named BaS analysis, might be useful in evaluating improvements of the splanchnocranium in patients who underwent craniofacial advancement.

Twenty years of cost-effectiveness analysis in medical imaging: are we improving?

PURPOSE

To determine the growth rate, methodologic clarity, and quality changes in cost-effectiveness analyses (CEAs) and to assess whether the U.S. Panel on Cost-effectiveness in Health and Medicine recommendations affected CEA studies in which imaging technologies were evaluated.

MATERIALS AND METHODS

Six databases were systematically searched for CEA reports published between 1985 and 2005. All imaging-related studies were selected and grouped according to year, country, and journal of publication, as well as imaging modality and disease being studied. Two readers with formal training in decision analysis and CEA used a seven-point (1, low; 7, high) Likert scale based on reasonableness of assumptions, quality of presentation, and adherence to guidelines to independently evaluate study quality. Quality scores according to year, country, and journal of publication were compared with the unpaired Student t test.

RESULTS

The first radiology-related CEA was published in 1985; 111 radiology-related CEAs were published between 1985 and 2005. The average number of studies increased from 1.6 per year between 1985 and 1995 to 9.4 per year between 1996 and 2005. Eighty-six studies were performed to evaluate diagnostic imaging technologies, and 25 were performed to evaluate interventional imaging technologies. Ultrasonography (35.0%), angiography (31.5%), magnetic resonance imaging (22.5%), and computed tomography (19.8%) were evaluated most frequently. Forty-nine studies received government funds; 42 did not disclose the source of funding. The mean quality score was 4.23 +/- 1.12 (standard deviation), without significant improvement over time. Scores in studies performed in the United States were significantly higher than scores in studies that were not performed in the United States (4.45 +/- 1.02 vs 3.61 +/- 1.17, respectively; P < .01). Scores were also higher in journals with three or more CEA articles published during the study period than in journals with two or fewer CEA articles published during this period (4.54 +/- 1.09 vs 3.91 +/- 1.06, respectively; P < .01).

CONCLUSION

CEAs are an important tool with which to analyze the value of diagnostic imaging. However, improvement in the quality of analyses is needed.

SUPPLEMENTAL MATERIAL

http://radiology.rsnajnls.org/cgi/content/full/249/3/917/DC1.

Cost-effectiveness of neonatal surgery: first greeted with scepticism, now increasingly accepted

Mortality rates in neonatal surgery have dropped markedly, illustrating the enormous progress made. Yet, new questions have arisen. To mention one, health care budgets have tightened. It follows that the effects of medical interventions should be weighted against their costs. As evidence was particularly sparse, we set out to analyse cost-effectiveness of neonatal surgery. The purpose of this article is to summarise our findings and to review recent studies. Moreover, this article explains the relevance of cost-effectiveness analysis and explores how cost-effectiveness interacts with other determinants of health care priority setting. Our research revealed that treatments for two common diagnostic categories in neonatal surgery (congenital anorectal malformations and congenital diaphragmatic hernia) produce good cost-effectiveness. Other groups also published cost-effectiveness studies in the field of neonatal surgery, although their number is still small. Contemporaneously, the economic aspects of health care have captured the interest of policy makers. Importantly, this is not to say that there are no other factors playing a role in priority setting, foremost among which are ethical questions and arguments of equity. This article concludes that, according to present evidence, neonatal surgery yields good value for money and contributes to equity in health.

3D visualization and simulation of frontoorbital advancement in metopic synostosis

OBJECTIVES

Current multislice computed tomography (CT) technology can be used for diagnosis and surgical planning applying computer-assisted three-dimensional (3D) visualization and surgical simulation. The usefulness of a technique for surgical simulation of frontoorbital advancement is demonstrated here in a child with metopic synostosis.

MATERIALS AND METHODS

Postprocessing of multi-slice CT data was performed using the software 3D slicer. 3D models were created for the purpose of surgical simulation. These allow planning the course of the osteotomies and individually placing the different bony fragments by an assigned matrix to simulate the surgical result. Photo documentation was obtained before and after surgery. Surgical simulation of the procedure allowed determination of the osteotomy course and assessment of the positioning of the individual bony fragments.

CONCLUSIONS

Computer-assisted postprocessing and simulation is a useful tool for surgical planning in craniosynostosis surgery. The time-effort for segmentation currently limits the routine clinical use of this technique.

Quality-adjusted life-years lack quality in pediatric care: a critical review of published cost-utility studies in child health

OBJECTIVES

Cost-utility analysis in which health benefits are quantified in terms of quality-adjusted life-years (QALYs) has now become the standard type of cost-effectiveness analysis. These studies are potentially influential in determining the extent of funding for particular pediatric interventions, and so their methodologic quality is extremely important. The objective of this study was twofold: first, to critically appraise published cost-utility analyses of interventions in child and adolescent health care in terms of the methods used to derive QALYs and, second, to discuss unresolved methodologic issues that are pertinent to the measurement of QALYs in pediatric populations.

METHODS

A comprehensive search using computerized databases (including Medline, Embase, Econlit, and databases specific to economic evaluation), Web searches, and citation tracking was undertaken to identify cost-utility studies of interventions that were aimed at those who were younger than 16 years and published before April 2004. The methods of individual studies were compared with the recognized published guidelines of the US Panel on Cost-Effectiveness in Health and Medicine and the National Institute for Clinical Excellence in England and Wales, which recommend the use of a generic health state classification system (eg, Health Utility Index, EuroQol-5D), a choice-based valuation method (eg, standard gamble or time trade-off) and preferences of the general public in estimating QALYs. Studies therefore were categorized and evaluated according to the methods used to describe the health state, the valuation technique, and source of preferences.

RESULTS

Fifty-four studies were reviewed, 34 (63%) of which were published in the past 5 years. A generic health status classification instrument was used in 22 (35%) cases; the remainder developed study-specific health state descriptions or elicited preferences directly from patients or proxies. In 3 (5%) cases, sources were unclear. Preference weights were elicited using choice-based techniques in 28 (42%) cases, either as tariffs for health status classification instruments (17 cases) or by directly valuing health state descriptions or patient health (11 cases). Preferences of the general public were used in only 23 (37%) cases. Four studies aggregated QALYs for mother/child or parents/child pairs without giving any theoretical justification. Although there was an increasing tendency for studies to use generic health status classification instruments, choice-based methods, and preferences of the general public, the majority of studies still did not adhere to these standard recommendations even in the period between January 2000 and March 2004. Despite increasing standardization in the methods advocated for economic evaluation over the past 10 years, there remains extensive variation in the actual methods used by researchers to calculate QALYs for children and adolescents. It is unclear whether these results suggest poor practice or a set of positive (or reactive) choices made by analysts in a methodologically uncertain area in which specific guidance is lacking regarding how to address the complexities of pediatric outcomes within the QALY framework. Many aspects of QALY measurement in children are not yet fully developed. In particular, there is (1) a lack of appropriate health state classification instruments that take account of the dynamics of child development, (2) a lack of health state classification instruments for use in children and infants who are younger than 5 years, and (3) the need to understand fully the role of proxies for measuring and valuing child health. Additional research efforts are also required to develop methods that account for the health benefits of parents or caregivers of the child and to consider the implications of combining different forms of utility measurement in childhood and adulthood.

CONCLUSIONS

Although variations from standard recommendations may be attributable to poor practice among researchers who are either unaware of these recommendations or choose not to follow them, they could equally be the result of attempts to make research more rigorous and more defensible than it might be if the standard recommendations were followed. There are 4 potential approaches to conducting cost-utility analysis in pediatric populations: (1) the explicit development of a generic instrument designed to be applicable across both child and adult populations (likely to be difficult in practice), (2) insistence on use of a generic instrument developed for adults, (3) the use of generic instruments specifically developed for children without being concerned about comparability with interventions aimed at adults, and (4) abandoning attempts to use single outcome measures that combine mortality with quality weights. In the absence of a clear way forward, it is suggested that an expert panel be convened to debate and further consider these potential solutions and recommendations for best practice and future research. In the interim, comparisons of the relative cost-effectiveness reported as cost per QALY gained across interventions for different diseases and populations should be treated with extreme caution.

CT imaging of craniofacial malformations

Because of its superior depiction of bone detail, CT is a useful tool in the characterization of CF deformities and presurgical planning. Modern CT scanners and workstations provide 2D techniques such as multiplanar reformats and 3D techniques, such as MIP and volume renderings, which may be used effectively in the diagnosis and management of patients with CF malformations.