Variants of sagittal synostosis: strategies for surgical correction

Direct Occipital Remodeling in Sagittal Synostosis Improves 2-Year Posterior Morphology after Modified Pi Procedure

BACKGROUND

Modifications of the pi craniectomy technique are meant to address the occipital bullet deformity of sagittal synostosis, but it is not clear whether they result in persistent improvement. The authors' purpose was to use morphometric analysis to determine whether a low occipital osteotomy with verticalization results in improved occipital shape after a modified pi procedure 2 years after surgery.

METHOD

The authors performed a retrospective cohort study comparing modified pi technique with and without a low occipital osteotomy with verticalization immediately and 2 years after surgery relative to age-matched normal controls. The authors used anthropometric measures and population-level anatomical templates using the multivariate template construction script from advanced normalization tools for comparison between groups. A subgroup analysis was performed for severe occipital bullet deformity at presentation.

RESULTS

The authors observed stable improvement in the angle of the inferior occiput with the occipital remodeling modification that persisted 2 years after surgery. This improvement was seen in the entire cohort and was greater in the severe subgroup analysis. Complications and blood transfusion volumes were not different between the 2 techniques. The low occipital osteotomy group demonstrated improved posterior vertical height and cephalic index immediately after surgery, but these did not persist 2 years later.

CONCLUSIONS

Occipital remodeling improves the bullet deformity but does not affect posterior vertical height 2 years after surgery. The authors recommend direct inferior occipital remodeling when using the pi technique for young patients with acute occipital incline angles and occipital constriction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Single sagittal craniosynostosis surgical treatment with the "Peau d́ours" technique. Single-center experience in Mexico

Scaphocephaly (SC) is defined as an elongation of the anteroposterior axis of the skull resulting from the abnormal fusion of the sagittal suture. This study describes the "Peau d'ours" technique and results for correcting SC. We conducted a consecutive and retrospective analysis of patients treated from 2011 to 2016. We evaluated the gender, age, and surgical outcomes. A total of 53 patients were enrolled with a mean age of 19 months old. The advantages of this technique are healthy coronal and lambdoid suture preservation and symmetrical parietal bone flap opening. This technique is safe and simple to reproduce, allowing good surgical outcomes with a low incidence of secondary craniosynostosis. This technique is ideal for patients older than six months old.

Secondary Raised Intracranial Pressure After Cranial Vault Remodeling for Isolated Sagittal Craniosynostosis

ABSTRACT

The management of sagittal craniosynostosis has evolved over the decades as teams seek to refine their surgical approaches to idealize head shape with the least possible morbidity. Here, the authors identify the incidence of raised intracranial pressure (ICP) and its risk factors, requiring secondary surgical intervention after cranial vault remodeling (CVR) procedure at a single tertiary referral craniofacial unit. A retrospective case-control study was performed on the patients with isolated non-syndromic sagittal craniosynostosis. All patients who underwent CVR in our unit and had a minimum of 1.5 years follow-up were included. One hundred and eighty-four patients (134 male and 50 female) who underwent primary CVR surgery for isolated sagittal craniosynostosis were included. Thirteen patients (7.07%) had clinical evidence of late raised ICP resulting in repeat CVR procedures. Higher incidence of raised ICP in patients who had primary surgery before 6 months than after or at 6 months of age (P = 0.001). There were 23.5%, 5.6%, 3.2%, and 1.9% of secondary raised ICP patients who underwent the primary surgery between 1999-2004, 2005-2010, 2011-2015 and 2016-2018, respectively (P = 0.024). The risk of secondary raised ICP was higher in patients with isolated sagittal craniosynostosis whose primary surgery occurred before the age of 6 months (two times more likely). More extensive CVR can be performed safely in sagittal synostosis with promising outcomes. The late presentation with raised ICP reinforces the importance of long-term multidisciplinary protocol-based follow-up.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

New method for quantification of severity of isolated scaphocephaly linked to intracranial volume

PURPOSE

The aim is to implement Utrecht Cranial Shape Quantificator (UCSQ) for quantification of severity of scaphocephaly and compare UCSQ with the most used quantification method, cranial index (CI). Additionally, severity is linked to intracranial volume (ICV).

METHODS

Sinusoid curves of 21 pre-operative children (age < 2 years) with isolated scaphocephaly were created. Variables of UCSQ (width of skull and maximum occiput and forehead) were combined to determine severity. CI was calculated. Three raters performed visual scoring for clinical severity (rating of 6 items; total score of 12 represents most severe form). Pearson's correlation test was used for correlation between UCSQ and visual score and between both CIs. ICV was calculated using OsiriX. ICV was compared to normative values and correlated to severity.

RESULTS

Mean UCSQ was 22.00 (2.00-42.00). Mean traditional CI was 66.01 (57.36-78.58), and mean visual score was 9.1 (7-12). Correlations between both traditional CI and CI of UCSQ and overall visual scores were moderate and high (r = - 0.59; p = 0.005 vs. r = - 0.81; p < 0.000). Mean ICV was 910 mL (671-1303), and ICV varied from decreased to increased compared to normative values. Negligible correlation was found between ICV and UCSQ (r = 0.26; p > 0.05) and between ICV and CI and visual score (r = - 0.30; p > 0.05 and r = 0.17; p > 0.05, respectively).

CONCLUSION

Our current advice is to use traditional CI in clinical practice; it is easy to use and minimally invasive. However, UCSQ is more precise and objective and captures whole skull shape. Therefore, UCSQ is preferable for research. Additionally, more severe scaphocephaly does not result in more deviant skull volumes.

A systematic quantitative morpho-volumetric analysis in infants with sagittal craniosynostosis and relationship with the severity of scaphocephalic deformity

PURPOSE

Among patients with isolated sagittal synostosis (ISS), the head shape varies considerably in relation to the severity of the abnormality. This study aimed to quantify skull base morphometry and intracranial volume to investigate their relationships with the severity of scaphocephaly.

METHODS

We studied 66 infants with ISS identifying three groups according to the morphological severity of cranial deformity (group I: mild deformity; group II: moderate deformity; group III: severe deformity), by combining two scaphocephaly severity indices as descriptors of the relation of three morphological measurements (length, width and height) We perform a quantitative analysis using high-resolution CT images calculating following parameters: cranial fossae dimensions, supratentorial (ICV) and infratentorial (PCFV) cranial volume, supratentorial (WBV) and infratentorial (PCFBV) brain volume, ICV/WBV, PCFV/PCFBV, supratentorial and infratentorial cerebrospinal fluid (CSF).

RESULTS

In all subgroups, anterior and middle skull base lengths were increased, while posterior hemifossae lengths were unchanged. In mild subgroup, ICV/WBV was significantly different and ICV, WBV and CSF supratentorial volume increased (p < 0.05). In moderate and severe subgroups, FCPV/FCPBV was significantly different and CSF infratentorial volume was reduced (p < 0.05); FCPBV was increased only in the severe subgroup (p < 0.05).

CONCLUSION

This morpho-volumetric study provides new insights in understanding the compensatory changes occurring in infants at different stages of scaphocephaly severity. In particular, our study suggests that patients with severe deformity might have an earlier depletion of reserve mechanisms with a reduced compliance of the overall skull during encephalic growth and these patients might require early surgical cranial expansion.

Evaluation of Direct Surgical Remodeling of Frontal Bossing in Patients With Sagittal Synostosis

BACKGROUND

The need for surgical correction of frontal bossing in patients with sagittal synostosis is currently debated. The authors retrospectively analyzed frontal bossing in patients with isolated, nonsyndromic sagittal synostosis who underwent calvarial remodeling with and without frontal craniotomy and compared with control subjects.

METHODS

The authors analyzed computed tomography (CT) scans of patients with sagittal synostosis <9 months of age (6.2 ± 1.6 months) who underwent modified-pi procedure either with frontal craniotomy (FC, n = 15) or without frontal craniotomy (NFC, n = 10). Only patients treated with both pre-operative and 1-year post-operative CT scans were included. Non-synostotic age-matched control scans were also analyzed. Cephalic index (CI), 3 previously validated measures of frontal bossing (bossing angle, horizontal bossing ratio, and vertical bossing ratio), and pre-nasion volume ratio were obtained. Additionally, three-dimensional photographs of 10 FC patients were evaluated for frontal bossing between 1 and 8 years post-operatively.

RESULTS

Pre-operatively, no significant differences were found between the 2 groups (.064<P < 0.940). Both groups showed greater scaphocephaly and frontal bossing compared to controls (P < 0.001). One-year post-operatively, all measures improved but remained significantly different than normal values except: CI of NFC patients (P = 0.296); bossing angle (P = 0.068) and horizontal bossing ratio (P = 0.129) of FC patients. Compared to NFC patients, horizontal bossing ratio was significantly improved in FC patients (P = 0.017, mean difference of 0.047). No other statistically significant differences were found between the 2 techniques (0.127<P < 0.637).In our long-term study of FC patients up to 9 years of age (n = 10), the authors analyzed forehead inclination as our measure of frontal bossing in three-dimensional photographs. A linear regression analysis showed a significant reduction in forehead inclination with age, decreasing 1.3 ± 0.4 degrees per year (P = 0.021). Forehead inclination for controls did not change significantly with age (P = 0.558).

CONCLUSIONS

At 1-year following modified-pi procedure, FC patients approached normalization of their forehead morphology to a greater extent than NFC patients. However, neither group completely normalized during this time period. Frontal bossing in FC patients continued to decrease with age, which reveals the post-operative dynamic nature of frontal bone morphology during childhood for these patients.

Impact of extra-axial cerebrospinal fluid collection in frontal morphology after surgical treatment of scaphocephaly

Background

Infants with sagittal suture synostosis often present a pathologic dilatation of subarachnoid spaces. The impact of such subarachnoid spaces' enlargement in the morphology of the skull, especially on the forehead and on the surgical outcome, was analyzed.

Methods

Children less than 6 months of age undergoing a surgical correction of the scaphocephaly with Renier's H technique between 2003 and 2008 were included in the study. In these patients, preoperative and postoperative fronto-occipital diameter (FOD), biparietal diameter (BPD), temporal width (TW), and naso-frontal angle (NFA) were measured. Cranial index (CI) and the difference between preoperative and postoperative CI (ΔCI) were calculated. Preoperative cranio-cortical width (CCW) was measured to analyze the subarachnoid spaces' volumes. The children here considered were then divided into two groups: Group 1 with CCW within normal estimated value corrected for age and Group 2 with CCW larger than estimated normal value.

Results

About 159 children were enrolled (72.3% male). CCW was larger than expected in 95 children (59.8%). A positive correlation between CCW and BPD (P ≤ 0.001) and a negative correlation between CCW and NFA (P ≤ 0.001) were found. When comparing the two groups, the mean age at preoperative computed tomography (CT) scan was 121 days in Group 1 and 110 days in Group 2. The mean age at operation was 130 days in Group 1 and 123 in Group 2. The mean age at postoperative examination (RX or CT scan) was 53.4 months in Group 1 and 51.8 months in Group 2. Preoperatively, the mean BPD, TW, and CI were significantly larger in Group 2 (P ≤ 0.01), whereas the NFA was significantly narrower (P = 0.03). Postoperative analysis showed that ΔCI was statistically different between the two groups (Group 1: 10%, Group 2: 7%; P < 0.04). The duration of follow-up period ranged between 19 and 129 months.

Conclusion

Two main subtypes of forehead of infants with scaphocephaly may be distinguished. Indeed, the morphology of the forehead differs when a pathologic subarachnoid spaces' enlargement is present preoperatively and it also affects the postoperative evolution. Such observation highlights the importance of evaluating whether subarachnoid spaces are enlarged when planning a surgical correction in isolated sagittal suture synostosis.

Application of computer assisted three-dimensional simulation operation and biomechanics analysis in the treatment of sagittal craniosynostosis

As a surgical method to treat children with sagittal craniosynostosis, calvarial vault reconstruction is subjected to some limitations. In traditional surgical method to treat children with sagittal craniosynostosis, surgical resection and fixation are performed all by the experience of surgical doctor, which is likely to cause individual differences, insecure fixation, configurational asymmetry, and waste of unnecessary fixtures materials. This study aims to provide surgical doctor with objective indicators via 3D simulation combined with biomechanical calculation, so as to improve the surgical efficiency.

METHODS

The aim of this study is to compare preoperative strategy integrating computer-assisted 3D simulation and biomechanical calculation and traditional strategy. A retrospective method was used to compare the effect and difference between these 2 strategies. The clinical data of 18 patients with sagittal synostosis were collected and compared. Among them, 10 patients were enrolled in Group A applied with traditional treatment method, while 8 were enrolled in Group B applied with preoperative strategy integrating computer-assisted 3D simulation and biomechanical calculation. The aim of this study is to evaluate two treatment methods by investigating indexes between two groups, such as length of operation, blood loss, operation cost, and postoperative complications. Through comparing the cranial index, head circumference, and cranial vault asymmetry index of two groups before and after treatment, the surgical effects of two groups can be evaluated. Moreover, biomechanical analyses for two groups were conducted.

RESULTS

Regarding group B, the length of operation was (217±29.3min), blood loss was (70±11.7ml), operation cost was (34,495±8662¥); while for group A, the length of operation was (276±23.5min), blood loss was (90±15.5ml), operation cost was (25,149±4133¥). No postoperative complication was observed for group B, while there was 1 case of central nervous system infection occurred in group A. The cranial indexes of both groups were significantly improved after treatment. The head circumferences of both groups were insignificantly changed after treatment. Through comparing the cranial vault asymmetry index of two groups before and after treatment, the cranial vaults of patients of group A were not so symmetrical as Group B after treatment.

CONCLUSIONS

This research proposes the application of preoperative strategy integrating computer-assisted 3D technique and biomechanical analysis, which allows surgical doctors to have a clear understanding on the surgical process before operation. In particular, this new treatment method for the first time adopts biomechanical calculation to determine the setting position and setting quantity of fixtures materials, so as to realize a firm and symmetrical effect, reduce waste of unnecessary fixtures materials, increase surgical efficiency, reduce length of operation, blood loss, and occurrence of postoperative complications Computer-assisted 3D technique with biomechanical analysis is a new advanced technique for the treatment of sagittal craniosynostosis.

Review of Past Reports and Current Concepts of Surgical Management for Craniosynostosis

The purposes of surgery for craniosynostosis are to release increased intracranial pressure and to normalize cranial shape. The procedure was developed from a simple strip craniectomy in practice which ranged from the removal of the fused suture before the 1960s to total calvarial remodeling after 1970s and later methods of the 1990s, such as distraction and its modifications. According to its history, craniofacial surgeons might be changing their procedures with more effective, than less invasive ways. Since the late 1990s, when the distraction was applied to the craniofacial surgery, the gradual expansion, in particular of the anterior cranium, common in Japan, has long been controversial until the Caucasians accepted its use for the posterior cranium. Currently, the method may revert to the old procedure because a more sophisticated and better morphological result can be obtained depending on the types of deformity, even if a little more invasive maneuver is required. In other words, if treatment can be performed in optimal time, the procedures that were developed in the last half a century should be altered to each condition.

Odilon Marc Lannelongue (1840–1911) and strip craniectomy for craniosynostosis

In the 19th century, Dr. Odilon Marc Lannelongue was a pioneering French surgeon who introduced a surgical technique for the treatment of craniosynostosis. In 1890, Dr. Lannelongue performed correction of sagittal synostosis by strip craniectomy. From his procedure, multiple techniques have been developed and endorsed for this condition, ranging from simple suturectomies to extensive calvarial vault remodeling. In addition, even today, endoscopically aided strip craniectomy is performed as a surgical treatment of craniosynostosis. This article describes the life and works of the surgeon who revolutionized the management of craniosynostosis.

Craniosynostosis surgery: the legacy of Paul Tessier

Paul Louis Tessier is recognized as the father of craniofacial surgery. While his story and pivotal contributions to the development of the multidisciplinary practice of craniofacial surgery are much highlighted in plastic surgery literature, they are seldom directly discussed in the context of neurosurgeons. His life and legacy to craniosynostosis and neurosurgery are explored in the present paper.

A comparison of costs associated with endoscope-assisted craniectomy versus open cranial vault repair for infants with sagittal synostosis

OBJECT

The surgical management of infants with sagittal synostosis has traditionally relied on open cranial vault remodeling (CVR) techniques; however, minimally invasive technologies, including endoscope-assisted craniectomy (EAC) repair followed by helmet therapy (HT, EAC+HT), is increasingly used to treat various forms of craniosynostosis during the 1st year of life. In this study the authors determined the costs associated with EAC+HT in comparison with those for CVR.

METHODS

The authors performed a retrospective case-control analysis of 21 children who had undergone CVR and 21 who had undergone EAC+HT. Eligibility criteria included an age less than 1 year and at least 1 year of clinical follow-up data. Financial and clinical records were reviewed for data related to length of hospital stay and transfusion rates as well as costs associated with physician, hospital, and outpatient clinic visits.

RESULTS

The average age of patients who underwent CVR was 6.8 months compared with 3.1 months for those who underwent EAC+HT. Patients who underwent EAC+HT most often required the use of 2 helmets (76.5%), infrequently required a third helmet (13.3%), and averaged 1.8 clinic visits in the first 90 days after surgery. Endoscope-assisted craniectomy plus HT was associated with shorter hospital stays (mean 1.10 vs 4.67 days for CVR, p < 0.0001), a decreased rate of blood transfusions (9.5% vs 100% for CVR, p < 0.0001), and a decreased operative time (81.1 vs 165.8 minutes for CVR, p < 0.0001). The overall cost of EAC+HT, accounting for hospital charges, professional and helmet fees, and clinic visits, was also lower than that of CVR ($37,255.99 vs $56,990.46, respectively, p < 0.0001).

CONCLUSIONS

Endoscope-assisted craniectomy plus HT is a less costly surgical option for patients than CVR. In addition, EAC+HT was associated with a lower utilization of perioperative resources. Theses findings suggest that EAC+HT for infants with sagittal synostosis may be a cost-effective first-line surgical option.

Cranial compression using distractors in reverse fashion as an alternative method for correcting scaphocephaly in older patients

BACKGROUND

Intraoperative calvarial contraction of conventional calvarial remodeling is more difficult in scaphocephaly patients who are 1 year or older in age. In our current study, gradual cranial compression with a distractor was used to correct scaphocephaly in this older age group and the surgical results were quantitatively analyzed.

METHODS

Gradual cranial compression was used to treat 7 sagittal craniosynostosis patients. The mean age was 20.9 months (range, 12-32 months) and the mean follow-up period was 65 months (range, 3-81 months). Computed tomography was used to calculate the cephalic index (CI; equal to the maximum width of the head/maximum length of the head ×100), and the ratios of these indices at 3 different time periods (before, immediately after, and at 1 year postoperatively) were evaluated.

RESULTS

An average cranial compression of 18 mm was found to be possible with an average CI increase from 67.9 to 73.5. The CI ratio at 1 year after surgery was found to be the highest, showing a 9.8% increase.

CONCLUSION

Sagittal craniosynostosis patients are less easy to treat with conventional calvarial remodeling surgery if they are older than 1 year. Gradual cranial vault compression with distractors can be another option in these cases.

Endoscopic technique for sagittal synostosis

PURPOSE

This study aimed to present a 16-year experience of treating sagittal synostosis with endoscopic-assisted techniques and postoperative cranial orthotic therapy. In 1996, we introduced the use of endoscopes for the management of sagittal synostosis in four young infants. During the subsequent years, we have treated a total of 256 patients with great success and long-term follow-up. Presented herein are the techniques and results of such clinical experience.

METHODS

A total of 256 patients with sagittal synostosis have been treated between May 1996 and April 2012. There were 187 males and 69 females. Mean age at time of surgery was 3.9 months. A wide-vertex craniectomy with bilateral barrel stave osteotomies of the temporal and parietal bones using small scalp incisions and endoscopic viewing techniques was performed. Instruments have been developed to assist with the operation. All patients were placed in postoperative molding cranial orthosis.

RESULTS

Mean estimated blood loss was 27 cc. Mean transfusion rate was 7 %. Mean surgical time was 57 min. Mean length of stay was 1.1 days. Using cephalic index (CI) as an anthropometric measurement to judge head shape, our results were classified as excellent (CI>80), good (CI 80-70), or poor (CI<70). A total of 87 % were classified as excellent, 9 % as good, and 4 % as poor.

CONCLUSIONS

Endoscopic-assisted management of sagittal synostosis is a safe, efficacious, and excellent option for treating this condition with long-lasting, superb results. It is associated with minimal morbidity and complications and improved results over traditional procedures.

Unreliability of intraoperative estimated blood loss in extended sagittal synostectomies

OBJECT

Intraoperative blood loss represents a significant concern during open repair of craniosynostosis, and its reliable measurement remains a serious challenge. In this study of extended sagittal synostectomies, the authors analyzed the relationship between estimated blood loss (EBL) and calculated blood loss (CBL), and investigated predictors of hemodynamic outcomes.

METHODS

The authors reviewed outcomes in infants with sagittal synostosis who underwent primary extended synostectomies (the so-called Pi procedure) between 1997 and 2009. Patient demographic data, operating time, and mean arterial pressures (MAPs) were recorded. Serial MAPs were averaged for a MAP(mean). The EBL was based on anesthesia records, and the CBL on pre- and postoperative hemoglobin values in concert with transfusion volumes. Factors associated with EBL, CBL, red blood cell transfusion (RBCT), and hospital length of stay (LOS) were investigated. Hemodynamic outcomes were reported as percent estimated blood volume (% EBV), and relationships were analyzed using simple and multiple linear and logistic regression models. A p value < 0.05 was considered significant.

RESULTS

Seventy-one infants with sagittal synostosis underwent primary extended synostectomies at a mean age and weight of 4.9 months and 7.3 kg, respectively. The average operating time was 1.4 hours, and intraoperative MAP was 54.6 mm Hg (21.3% lower than preoperative baseline). There was no association between mean EBL (12.7% EBV) and mean CBL (23.6% EBV) (r = 0.059, p = 0.63). The EBL inversely correlated with the patient's age (r = -0.07) and weight (r = -0.11) at surgery (p < 0.05 in both instances). With regard to intraoperative factors, EBL positively trended with operating time (r = 0.26, p = 0.09) and CBL inversely trended with MAP(mean) (r = -0.04, p = 0.10), although these relationships were only borderline significant. Intraoperative RBCT, which was required in 59.1% of patients, positively correlated with EBL (r = 1.55, p < 0.001), yet negatively trended with CBL (r = -0.40, p = 0.01). Undertransfusion was significantly more common than overtransfusion (40.8% vs 22.5%, p = 0.02, respectively). The mean hospital LOS was 2.3 days and was not significantly associated with patient demographic characteristics, intraoperative factors, blood loss, RBCT, or total fluid requirements.

CONCLUSIONS

In extended synostectomies for sagittal synostosis, EBL and CBL demonstrated a decided lack of correlation with one another. Intraoperative blood transfusion positively correlated with EBL, but inversely correlated with CBL, with a significantly higher proportion of patients undertransfused than overtransfused. These findings highlight the need for reliable, real-time monitoring of intraoperative blood loss to provide improved guidance for blood and fluid resuscitation.

The management of sagittal synostosis using endoscopic suturectomy and postoperative helmet therapy

OBJECT

Suturectomy as a treatment for craniosynostosis was largely replaced in the late twentieth century by more extensive, but predictable, cranial remodeling procedures. Recent technical innovations, such as using the endoscope combined with postoperative orthotic reshaping, have led to a resurgence of interest in suturectomy as a safer, less invasive method.

METHODS

A retrospective chart review was performed for all cases of sagittal synostosis treated with endoscopic sagittal suture strip craniectomy and helmet therapy between 2004 and 2008. Data collected included gestational age, genetic evaluations and syndromic status, age at operation, duration of procedure, need for blood transfusions, length of hospital stay, preoperative and postoperative head circumference percentile and cranial index, duration of helmet use, length of follow-up, complications, and revisions.

RESULTS

Fifty-six patients with isolated sagittal synostosis were treated using endoscopic suturectomy and completed helmet therapy. Mean age at time of procedure was 3.24 months. Mean operative duration was 45.32 minutes. Mean hospital stay was 1.39 days. There were 2 transfusions and no deaths. The mean length of follow-up was 2.34 years. Helmet therapy was instituted for a mean of 7.47 months. Head circumference percentile increased from 61.42% to 89.27% over 2 years of follow-up. Cranial index increased from a preoperative mean of 0.69 to 0.76 over 2 years of follow-up. Reoperations for synostosis included 1 sagittal suture refusion and 2 cases in which other sutures fused.

CONCLUSIONS

Sagittal synostosis can be safely treated with endoscopic suturectomy and helmet therapy. Improvements in cranial volume and shape are comparable to open procedures and are enduring.

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.

The evolution of surgical management for craniosynostosis

Craniosynostosis, the premature closure of cranial sutures, has been known to exist for centuries, but modern surgical management has only emerged and evolved over the past 100 years. The success of surgery for this condition has been based on the recognition of scientific principles that dictate brain and cranial growth in early infancy and childhood. The evolution of strip craniectomies and suturectomies to extensive calvarial remodeling and endoscopic suturectomies has been driven by a growing understanding of how a prematurely fused cranial suture can affect the growth and shape of the entire skull. In this review, the authors discuss the early descriptions of craniosynostosis, describe the scientific principles upon which surgical intervention was based, and briefly summarize the eras of surgical management and their evolution to present day.

Craniofacial surgery, from past pioneers to future promise

OBJECTIVES

As a surgical subspecialty devoted to restoration of normal facial and calvarial anatomy, craniofacial surgeons must navigate the balance between pathologic states of bone excess and bone deficit. While current techniques employed take root in lessons learned from the success and failure of early pioneers, craniofacial surgery continues to evolve, and novel modalities will undoubtedly arise integrating past and present experiences with future promise to effectively treat craniofacial disorders.

METHODS

This review provides an overview of current approaches in craniofacial surgery for treating states of bone excess and deficit, recent advances in our understanding of the molecular and cellular processes underlying craniosynostosis, a pathological state of bone excess, and current research efforts in cellular-based therapies for bone regeneration.

RESULTS

The surgical treatment of bone excess and deficit has evolved to improve both the functional and morphological outcomes of affected patients. Recent progress in elucidating the molecular and cellular mechanisms governing bone formation will be instrumental for developing improved therapies for the treatment of pathological states of bone excess and deficit.

CONCLUSIONS

While significant advances have been achieved in craniofacial surgery, improved strategies for addressing states of bone excess and bone deficit in the craniofacial region are needed. Investigations on the biomolecular events involved in craniosynostosis and cellular-based bone tissue engineering may soon be added to the armamentarium of surgeons treating craniofacial dysmorphologies.

Sagittal synostosis: I. Preoperative morphology of the skull

The aim of this study was to characterise the preoperative morphology of the skull in sagittal synostosis in an objective and quantified way. The shapes of the skulls of 105 patients with isolated premature synostosis of the sagittal suture (SS group) were studied and compared with those of a control group of 72 children with unilateral incomplete cleft lip (UICL). A standardised radiocephalometric technique was used to obtain the images. A modification of a method developed by Kreiborg was used to analyse the radiocephalograms, which included the digitisation of 88 landmarks in the calvaria, skull base, and orbit (42 in the lateral and 46 in the frontal projections), the production of plots of mean shape for each group, and the intergroup comparison of a series of 81 variables (linear distance between selected landmarks, and angles defined by groups of three landmarks). Data from a subgroup of 66 patients aged 5 to 8 months were further compared to age-matched normative data in terms of seven angular and linear calvarial, cranial base and orbital variables. In a comparative analysis of the mean lateral plots, the foreheads of the study group (SS) had a more pronounced anterior slope and were also more convex. The vertex area was located more anteriorly, and was less convex. The occipital curvature was more prominent. Analysis of the mean frontal plots revealed a lack in convexity and lateral projection of the upper parietal regions, as well as a lower location of the line of maximum skull width. Comparison of the mean values of an SS subgroup to age-matched normative data showed a longer (p<0.001) and narrower skull (p<0.001) and a greater interorbital distance (p<0.001). The cranial base angle, the sella to nasion, and sella to basion lengths did not differ significantly. Sagittal synostosis is characterised by an extensive deformity of the cranial vault, with an essentially normal cranial base. The widened interorbital distance is probably related to compensatory metopic hyperactivity.

SPRING-MEDIATED CRANIOPLASTY COMPARED WITH THE MODIFIED PI-PLASTY FOR SAGITTAL SYNOSTOSIS

The aim of this study was to compare the safety, morphological outcome, and degree of parental satisfaction of the new spring-mediated cranioplasty with those of the modified pi-plasty in the management of sagittal synostosis. Ten patients with non-syndromic sagittal synostosis treated with the spring-mediated cranioplasty were followed prospectively. A control group of 10 sex-matched patients operated on with the modified pi-plasty procedure was chosen. Cephalometric radiographs were obtained preoperatively and postoperatively at 1 year of age. Cephalic index, axial width ratio, length ratio, width ratio and height ratio were used as objective measures of outcome. Parents were sent a questionnaire to obtain a subjective aesthetic assessment of outcome. Significantly less blood replacement was required (p = 0.003), and shorter duration of postoperative anaesthesia (p = 0.030) and postoperative hospital stay (p = 0.013) were found in the spring-mediated cranioplasty group. There were no complications or deaths in either group. Also significant was the inter-group difference in the postoperative change in the height ratio (p = 0.030), the most change being seen in the spring group. The change in the subjective parental aesthetic evaluation of skull shape was significant in both groups. In conclusion, the spring-mediated procedure was morphologically more effective than the modified pi-plasty procedure in the management of sagittal synostosis with the additional benefits of less blood transfusion needed and shorter duration of hospital stay.

Sagittal synostosis: II. Cranial morphology and growth after the modified pi-plasty

The aim of this study was to characterise the postoperative cranial growth and morphology after a modified pi-plasty for sagittal synostosis. The shape of the skull of 82 patients with isolated premature synostosis of the sagittal suture (SS group) operated on with a modified pi-plasty was studied longitudinally. Forty-five children with unilateral incomplete cleft lip (UICL), evaluated longitudinally at the ages of 2.4 and 23.2 months were used as controls. A standardised radiocephalometric technique was used for image acquisition. The radiocephalograms were analysed using a modification of a method developed by Kreiborg, which included the digitisation of 89 landmarks of the calvaria, cranial base, and orbit (43 in the lateral and 46 in the frontal projections), the production of mean shape plots for each group, and the intergroup comparison of a series of 78 variables (linear distance between selected landmarks, and angles defined by groups of three landmarks). Paired and unpaired t tests were used to assess the differences between the variables studied. These were accepted as significant for values of p<0.01 and were presented as coloured segments or areas in the respective plots. In a comparative analysis with the mean UICL lateral plots, the mean preoperative lateral plots of the study group (SS) showed that the anterior slope of the forehead was more pronounced and it was also more convex. The vertex area was located more anteriorly and was less convex. The occipital curvature was more prominent. Comparison of the mean frontal plots showed a deficiency in convexity and lateral projection of the upper parietal regions, and the line of maximum skull width was lower. The postoperative mean lateral plots of the study group showed a correction of the exaggerated anterior inclination of the forehead and a reduction of the abnormal occipital convexity. However, there was little change in the vertex region and it remained flatter than in the control group. In the mean frontal plots, the increase in convexity and in the lateral projection of the upper parietal areas led to a shape that was similar to that of the UICL group. The mean (SD) cephalic index changed from 64.9% (1.8%) to 71.4% (3.5%) (p<0.001). The longitudinal comparison between the mean postoperative plots at 3 and 5 years of age showed that there had been little change in cranial shape. In conclusion, after a modified pi-plasty for sagittal synostosis, significant objective changes in cranial shape towards normality were produced. The postoperative profile cranial shape was improved except in the vertex area, which remained flatter than normal. In the frontal projection an almost normal shape was obtained. The postoperative cranial shape obtained at 3 years of age had remained stable at the age of 5 years.

A simple technique for the correction of frontal bossing in synostotic scaphocephaly

INTRODUCTION

Scaphocephaly may be accompanied by bossing of the frontal bones. In severe cases, this frontal deformation must be directly addressed during surgery. We describe a simple and effective surgical technique of reducing frontal bossing in scaphocephalic infants, avoiding the creation and transposition of free bone flaps.

SURGICAL TECHNIQUE

After sagittal suturectomy and parietal barrel stave incisions, four (or five) lanceolate pieces of the frontal bone, extending in a radial orientation from the cranial base towards the fontanel, are excised, resulting in three (or four) vertical bone bridges. Small strips (rectangular to the apico-basal axis) are cut out from these bridges, leaving basal and apical bone tongues. The tabula externa at the base of the basal tongues is drilled off and the tongues are bent inward to correct the inferior aspect of the frontal bossing. Corresponding basal and apical bone tongues are then re-approached and fixated with sutures.

RESULTS

This results in an immediate cosmetic improvement. There are no transposition and re-insertion of free bone flaps necessary, as all bone elements stay attached to the basal or apical calvaria. Plate and screw fixation is not needed.

PATIENTS AND METHODS

This procedure was applied in 15 scaphocephalic infants (<1-year old) with severe frontal bossing; it needed an additional 30 min operating time compared with suturectomy and barrel stave cuts alone.

CONCLUSION

The described technique is easy and fast and resulted in satisfactory cosmetic improvement in all patients. We recommend it for the correction of frontal bossing in scaphocephalic infants undergoing surgery in the first year of life.

Endoscopic-assisted osteotomies for the treatment of craniosynostosis

INTRODUCTION

The development of multidisciplinar units for Craniofacial Surgery has led to better postoperative results and a considerable decrease in morbidity in the treatment of complex craniofacial patients.

MATERIALS AND METHODS

Standard correction of craniosynostosis involves calvarial remodeling, often considerable blood losses that need to be replaced and lengthy hospital stay. The use of minimally invasive techniques for the correction of some of these malformations are widespread and allows the surgeon to minimize the incidence of complications by means of a decreased surgical time, blood salvage, and shortening of postoperative hospitalization in comparison to conventional craniofacial techniques.

DISCUSSION AND CONCLUSION

Simple and milder craniosynostosis are best approached by endoscopy-assisted osteotomies and render the best results. Extended procedures other than simple suturectomies have been described for more severe patients. Different osteotomies resembling standard fronto-orbital have been developed for the correction, and the use of postoperative cranial orthesis may improve the final cosmetic appearance. Thus, endoscopic-assisted procedures differ from the simple strategy of single suture resection that rendered insufficient results in the past, and different approaches can be tailored to solve these cases in patients in the setting of a case-to-case bases.

Morphometric analysis of untreated adult skulls in syndromic and nonsyndromic craniosynostosis

The aim of this study was to perform a morphometric analysis of untreated adult skulls displaying syndromic and nonsyndromic craniosynostosis. We analyzed, in detail, 42 adult craniosynostoses (18 scaphocephaly, 11 anterior plagiocephaly, 2 trigonocephaly, 9 oxycephaly, and 2 brachycephaly) from archeological (three skulls) and pathoanatomical samples (39 skulls). The univariate and bivariate measurements from the pathological skulls were compared with 40 anatomical skulls with normal cranial vault morphology. Bony signs of chronic elevated intracranial pressure (ICP) are (1) diffuse beaten copper pattern, (2) dorsum sellae erosion, (3) suture diastasis, and (4) abnormalities of venous drainage that particularly affect the sigmoid-jugular sinus complex. The mean cranial length was significantly greater in scaphocephaly than in anatomical skulls (20.3 vs 18.0 cm), and the sagittal suture was also longer (14.3 vs 11.8 cm). There were three types of suture course in the bregma region in scaphocephaly: anterior spur (28%), normal configuration (61%), and posterior spur (11%). The plagiocephaly measurements showed nonsignificant differences, and there was no correlation between the length of the anterior and middle skull base (ipsilateral anterior-posterior shortening of the skull) and incomplete or complete suture synostosis. Bony signs of chronic elevated ICP were found in 82% of cases of oxycephaly and brachycephaly. In three such cases of oxycephaly, we found a marked (1.8-2.1 cm) elevation of bregma region. One skull (Saethre-Chotzen syndrome) yielded human DNA sufficient for polymerase chain reaction (PCR)-based amplification procedures. Mutation analyses in the FGFR3 gene revealed nucleotide alterations located in the mutational hot spot at amino acid residue 250 (g.C749). The mean cranial length in adult scaphocephaly was 12% greater than anatomical skulls. A unilateral complete or incomplete coronal synostosis can be found with or without plagiocephalic deformation. Elevation of the bregma region is a bony sign of chronic elevated ICP. These data on adult craniosynostosis could be of interest for physicians dealing with craniosynostotic children.

Sagittal synostosis: A review of 53 cases of sagittal suturectomy in one unit

The role of sagittal suturectomy in the treatment of scaphocephaly remains controversial. The purpose of this study was to report the experience of the National Craniofacial Unit in Dublin. This unit is the referral centre for the Republic of Ireland and serves a population of approximately 3.5 million. Quantitative assessments were made using radiographs and the pre- and postoperative cephalic index (CI) was calculated. Patients were asked to score their head shapes in a questionnaire. The mean age at surgery for the 53 children was 4.9 months with a mean follow up of 8 years. Pre- and postoperative radiographs were available for analysis in 24 patients. The mean preoperative CI was 65.3. There was a statistically significant increase in the CI postoperatively to 73.7. Seventy five per cent of children achieved a 'normal' CI and 86% scored their head shapes as good to excellent. There was no correlation between the age at surgery and the CI achieved. Although only one child was not happy with the shape of the head, the impression was that the CI correlated poorly with the clinical assessment of the head shape. There were no significant complications. We therefore conclude that the sagittal suturectomy is a safe procedure that has a limited but definite potential to improve the CI. This procedure still has a place in the surgical repertoire of the craniofacial surgeon dealing with scaphocephaly.

Sagittal synostosis in X-linked hypophosphatemic rickets and related diseases

BACKGROUND

The recent observations of two new cases of X-linked hypophosphatemic rickets associated with premature closure of the sagittal suture prompted a review of similar cases seen in this institution.

OBJECTIVES

To review the clinical records and skull radiographs of 28 children with hypophosphatemic rickets in order to investigate the frequency and type of craniosynostosis and other cranial vault changes seen in these conditions and to review the literature for relevant findings.

MATERIALS AND METHODS

Clinical and imaging records were reviewed on 28 patients with hypophosphatemic rickets, all younger than 18 years. Most patients had X-linked hypophosphatemic rickets and a few had autosomal-dominant hypophosphatemic rickets or were non-familial cases.

RESULTS

Of the 28 patients, 13 had sagittal synostosis. Dolichocephaly was present in ten patients. The configuration of the cranial vault in some of these ten patients with dolichocephaly varied somewhat from that seen in nonsyndromic sagittal synostosis. In one patient, a Chiari I malformation was demonstrated by MRI. In another patient with increased intracranial pressure the sagittal suture closure was associated with lambdoidal synostosis. Dolichocephaly was not present in three patients, suggesting that the synostosis started later than in the other patients, probably in the second year of life, a period of slower brain growth than in the first year. The two patients in this group of three showed thickening and sclerosis of the cranial vault of uncertain etiology.

CONCLUSION

There is an increased risk of sagittal synostosis in hypophosphatemic rickets and related diseases in children. The appearance of the cranial vault in this type of synostosis can vary from that seen in nonsyndromic synostosis. In this setting, careful clinical and imaging follow-up is warranted.

History of craniosynostosis surgery and the evolution of minimally invasive endoscopic techniques: the University of Florida experience

Craniosynostosis is the premature and abnormal fusion of 1 of the 6 suture lines that form the living skull and can occur as part of a syndrome or as an isolated defect (nonsyndromic). The first reported surgical procedure for correction of craniosynostosis was performed in 1890 by Lannelongue who advocated releasing, but not resecting, the fused suture. Craniofacial surgery has developed its own identity in the last 3 decades, with the Frenchman Tessier seen as the founding father. There have been many new developments such as distraction osteogenesis, biodegradable miniplate fixation, and the development of minimally invasive endoscopic techniques. Through the pioneering work of Jimenez and Barone, minimally invasive approaches to the surgical correction of craniosynostosis are now gaining wider acceptance. Here the authors review the history of craniosynostosis, the current literature and technique for endoscopic repair of craniosynostosis, as well as their own experience at the University of Florida, with minimally invasive endoscope-assisted techniques.

Identifying reproducible patterns of calvarial dysmorphology in nonsyndromic sagittal craniosynostosis may affect operative intervention and outcomes assessment

BACKGROUND

The authors tested the premise that there are four distinctive patterns of calvarial dysmorphology in nonsyndromic sagittal craniosynostosis that can be reproducibly recognized.

METHODS

Twenty-nine computed tomographic scan data sets of infants met the following criteria: nonsyndromic sagittal craniosynostosis, age younger than 12 months, and satisfactory computed tomographic data. Osseous reformations were constructed in the anteroposterior, right lateral, and vertex projections for each patient. From these images, four templates--coronal constriction, occipital protuberance, bifrontal bossing, and bitemporal protrusion--were selected as prototypes of the specific dysmorphologies the authors observed in patients with sagittal craniosynostosis. Four residents assigned the 29 calvarial image sets to one of the four templates or, if they were unable to do so, to the group "other." The sortings were then assessed for clustering. The same patient computed tomographic data were reformatted with osseous color images, which were then sorted according to template group by eight senior craniofacial surgeons, who repeated the task approximately 3 months later. The repeatability and assessment of clustering of image sets using the templates was evaluated.

RESULTS

In the residents' pilot study, 41 percent (12 of 29) of patients had 100 percent concordance rates, 31 percent (nine of 29) had 75 percent concordance, 24 percent (seven of 29) had 50 percent, and 3 percent (one of 29) had 25 percent concordance. In summary, greater than 70 percent of the patient image sets could be sorted with at least 75 percent concordance by residents. In the senior surgeons' study, 90 percent of patients could be identified as falling into two of five possible groups. Senior raters demonstrated nearly 70 percent repeatability between sortings.

CONCLUSION

These findings support the hypothesis that there are identifiable and reproducible patterns of varying calvarial dysmorphology in patients with sagittal craniosynostosis.

Quantitative and qualitative assessment of morphology in sagittal synostosis: mid-sagittal vector analysis

Consensus remains lacking regarding the optimal surgical treatment modality for sagittal synostosis. There is, however, wide agreement that objective analytical methods are required to demonstrate the characteristic morphology of the condition and to substantiate the benefits of specified surgical techniques. Simple calculated anthropomorphic indices, such as the cranial index, are commonly used but fail to provide satisfactory representation of morphology, which is far more complex than can be represented by its simple length-width ratio. Techniques to provide more comprehensive, yet practical, assessment of morphology are needed for analytic purposes. Herein, we introduce vector analysis as an objective, computed tomography (CT)-based morphometric technique for assessment of cranial morphology; this work represents the first application of the technique mid-sagittal vector analysis (MSVA). MSVA is a single plane application that was devised to address dysmorphology in sagittal synostosis. It was our hypothesis that MSVA would quantitatively and qualitatively depict preoperative morphology and postoperative correction in specific regions. Sixteen patients undergoing cranial reshaping surgery for sagittal synostosis were included in the study. All patients underwent routine preoperative and 1 year postoperative CT scans, from which the MSVA was derived. MSVA is a radial vector analysis in which distances to the cranial surface are measured from a single reference point origin in the sagittal plane. Preoperative morphology, characterized by respective vectors, was analyzed in three regions: the frontal, vertex, and occipital regions. Comparison with postoperative paired data was conducted for each patient. The analysis of postoperative change demonstrated (1) decrease in prominence in the frontal and occipital regions, (2) increase in height and forward translation of the vertex, and (3) ability to distinguish and qualify frontal versus occipital bossing and correction thereof. We conclude that the longitudinal differences associated with scaphocephaly are well characterized and differentiated by MSVA. Quantitative and qualitative assessment identifies three relevant regions affected by the condition and its treatment: the frontal, vertex, and occipital regions. The transverse dimension is not addressed in this single plane analysis; a more comprehensive application will require additional planes of analysis and the development of a normative database.

Long-term anthropometric outcomes following surgery for isolated sagittal craniosynostosis

OBJECT

A number of studies have shown good short-term cosmetic outcomes following surgery for isolated sagittal craniosynostosis. Whether the improvement in head shape persists in the longer- term is less clear. The aim of this study was to investigate the long-term anthropometric outcomes following surgery for isolated sagittal craniosynostosis.

METHODS

Records were retrospectively reviewed for children with isolated sagittal synostosis who underwent surgical revision between 1987 and 2000. Only children who underwent surgery before 8 months of age and for whom serial anthropometric data (skull width, skull length, and cephalic index) were available were included in the study. The operative procedure consisted of vertex and parietal craniectomies involving removal of the sagittal suture and a 1.5- to 2.5-cm piece of adjacent parietal bone on each side as well as bilateral parietal barrel-stave osteotomies. Ninety cases satisfied the eligibility criteria. The mean age of the patients at surgery was 5 months (range 1.9-7.5 months). The mean preoperative cephalic index was 66.78. The follow-up period ranged from 1.8 to 167 months (mean 39.6 months). In 24 cases, the follow-up period was longer than 36 months. Eighteen (75%) and five (20.8%) of these 24 cases were followed up for longer than 5 and 10 years, respectively. The mean increase in cephalic index at the last follow up was 8.69% (p < 0.0001). The maximum improvement in the cephalic index occurred within 6 months of surgery, at which point it had improved by a mean of 11.1% (p < 0.0001). The cephalic index remained increased throughout the follow-up period, with a mean change of -1.84% (standard deviation, 4.28%; 99% confidence interval -3.33 to -0.37%) from the first postoperative to the final measurement.

CONCLUSIONS

Surgery for isolated sagittal craniosynostosis leads to a significant improvement in the cephalic index, which is most marked in the early postoperative period. Improvement in the cephalic index is still present after prolonged follow up.

Endoscopic-assisted repair of craniosynostosis

Object

The goal of the craniofacial surgeon has always been the correction of form and function with prevention of associated morbidity and death. Through the pioneering work of Jimenez and Barone, minimally invasive approaches to the surgical correction of craniosynostosis are now gaining wider acceptance. Here the authors review the technique for endoscopic-assisted repair of craniosynostosis from the perspective of a new minimally invasive approach. They also assess the safety, efficacy, and results of the early treatment of infants with craniosynostosis in a small series of children who underwent surgery at this institution.

Methods

Data regarding synostosis type, operative time, patient age, blood loss, transfusion rates, duration of hospitalization, and complications were collected. Nineteen patients (12 girls and seven boys) between the ages of 1.2 and 5 months of age were treated with the endoscope-assisted technique. The mean operative time was 97 minutes. Five (26%) of 19 children received a blood transfusion. Most patients were discharged home the morning after surgery. The clinical courses of two patients who required additional major craniofacial reconstructions are discussed. There were no deaths, dural sinus tears, cerebrospinal fluid leaks, neurological injuries, or infections, and there were no complications related to the use of helmet therapy. Seventeen of the 19 patients achieved excellent cosmetic results with a single surgery.

Conclusions

This small series supports larger experiences and indicates that early treatment of craniosynostosis with minimally invasive, endoscope-assisted techniques is safe; limits blood transfusion, hospital stay, and operative time; and represents a valuable alternative to the traditional calvarial reconstruction methods.

Étude des variations morphologiques des scaphocéphalies. Implication pour leur systématisation

PURPOSE

The scaphocephaly is the most frequent craniosynostosis secondary to a premature synostosis of the sagittal suture. Despite this univocal pathogeny there are a great heterogeneity in the skull deformation and their systematisation stay imprecise. The aim of this study was to analyse the different morphology of the scaphocephaly by 3D CT-scan to clarify the different shapes.

MATERIAL AND METHODS

This retrospective study was done from the morphometric analysis of forty-two 3D CT-scan (10 girls and 32 boys). The scaphocephaly was classified in two groups according to the systematisation of Stricker and Montaut: the sphenocephaly (large forehead) and the leptocephaly (narrow forehead). The variation of the calvaria shape was analysed and different index were calculated.

RESULTS

There were 30 sphenocephaly and 12 leptocephaly. Excepted for the forehead deformation there was a morphometric difference of the occipital pole that was backward rotated in the leptocephaly. In the two groups there were retro-coronal constriction (40.5%) or pre-lambdoid constriction (9.5%) independently of the sagittal synostosis degree.

CONCLUSIONS

The morphometric analysis shows that the deformation of the skull secondary to the premature synostosis of the sagittal suture can be different. The adaptative defect of the metopic suture can be to explain this difference. This deformation can be harmonious, or with a retro-coronal constriction resulting in a bitemporal narrowing, or with a pre-lambdoid constriction resulting in an occipital chignon. These results conduce to qualify the surgical correction to adapt at the different shapes.

Cranial reshaping employing distraction and contraction in the treatment of sagittal synostosis

We treated four patients with scaphocephaly using a combination of distraction and contraction techniques and achieved satisfactory results. Radial osteotomies in the frontal and occipital bones flattened these abnormal bossing bones and accelerated the disappearance of bony bumps created by distraction. This technique facilitates the achievement of the desired shape of the skull through fine adjustments of the distraction and contraction devices.

Bilateral peninsula-shaped linear craniectomy for mild degrees of craniosynostosis: indication, technique and long-term results

OBJECTIVE

The goals of surgery in craniosynostosis are to reduce increased intracranial pressure and to achieve a good aesthetic result with minimal mortality and morbidity. A new type of strip craniectomy according to these principles is presented.

PATIENTS

The technique was applied to seven cases of oxycephaly and three cases of scaphocephaly under 5 years of age. None of them had major cranial base involvement, facial deformity or marked psychomotor retardation. There was no syndromic case of craniosynostosis included in this group.

METHODS

A curvilinear parasagittal craniectomy was combined with coronal and lambdoid craniectomies bilaterally. These craniectomies were curved postero- and antero-inferiorly, respectively, in order to create bilateral 'peninsula-shaped' parieto-temporal bones with their neck still attached to the temporal bone. A linear craniectomy, crossing the superior sagittal sinus and combining right and left curvilinear craniectomies was added.

RESULTS

The operative time varied between 45 min and 1h, without any complications. Correction of the skull shape was successful in all cases.

CONCLUSION

This technique is simple and effective. But, it is only applicable to a minority of craniosynostoses. Patient selection is the key to better results.

Delayed cranial vault reconstruction for sagittal synostosis in older children: an algorithm for tailoring the reconstructive approach to the craniofacial deformity

An algorithm for the management of sagittal synostosis in older children who underwent delayed cranial vault reconstruction is presented. This algorithm tailors the surgical approach to the specific craniofacial deformity present in each case. The scaphocephalic deformity characteristic of sagittal synostosis varies significantly when presentation is delayed beyond the first year of life, the time during which reconstruction is usually performed. Sixteen patients with sagittal synostosis who presented after 12 months of age, and were a mean of 3.2 years of age at the time of cranial vault reconstruction, were reviewed. Four patients demonstrated preoperative symptoms and objective findings indicative of increased intracranial pressure, including frequent headaches and emesis, papilledema, or digital markings on computed tomographic scan. Each of the 16 patients underwent either (1) single-stage total vault reconstruction with or without concomitant fronto-orbital expansion; (2) two-stage total vault reconstruction with anterior two-thirds vault expansion followed by transverse occipital expansion and recession a mean of 8.7 months later; or (3) anterior two-thirds vault reconstruction with or without fronto-orbital expansion. In each case, the extent of the scaphocephalic deformity determined the procedure used. The presence of severe frontal bossing associated with transverse restriction of the orbitotemporal region was an indication for fronto-orbital expansion in addition to vault reconstruction, whereas significant occipital protrusion was an indication for transverse posterior vault expansion and recession in addition to anterior two-thirds vault reconstruction. Excellent aesthetic results were obtained in all cases regardless of the type of reconstruction performed. However, it is essential that the extent of the deformity be carefully evaluated preoperatively to permit selection of the appropriate technique for reconstruction.