Calvarial Vault Remodeling Research Articles

Calvarial vault remodeling including pterional decompression for the treatment of nonsyndromic scaphocephaly patients: technical note and retrospective case series.

Surgical techniques to correct scaphocephaly often rely on the implantation of foreign material and/or postoperative helmet therapy and possibly result in minimal correction of frontal bossing. Moreover, foreign material and helmet therapy are associated with extra medical care and financial costs. Frontal bossing is perceived as a prominent, disfiguring feature of scaphocephaly. Herein, authors present the results of a total cranial vault remodeling technique that corrects scaphocephaly features without relying on foreign material or postoperative helmet therapy. It includes frontal release and pterional decompression, which aim to correct frontal bossing. All patients who had been operated on for isolated scaphocephaly at a single institution between January 2011 and December 2020 were included in this retrospective review. Operation time, transfusion volume, hospital stay, complications, cephalic index (CI), and bossing angle (BA) were analyzed. Sixty-five patients with nonsyndromic scaphocephaly were included in this analysis. Imaging to calculate the CI and BA preoperatively, immediately postoperatively, and 1 year postoperatively was available in 22 and 20 patients, respectively. The mean CI increased from 69.2% preoperatively to 74.6% postoperatively and 75.5% 1 year postoperatively. The mean BA decreased from 114.5° preoperatively to 111.6° postoperatively and 108.9° 1 year postoperatively. The mean operating time was 2 hours 4 minutes, and the median blood transfusion volume was 100 ml. There were no major complications or reoperations. The described total cranial vault remodeling technique is a safe procedure that mitigates total treatment burden, as no helmet therapy or implantation of foreign material is needed. It is effective in correcting CI and results in significant frontal bossing correction. The latter is attributed to a distinctive feature of the technique: frontal release and pterional decompression.

Calvarial Vault Remodeling Technique for Lambdoid Craniosynostosis.

Premature fusion of the lambdoid suture is the most uncommon single-suture synostosis. It presents with a classic "windswept" appearance, a trapezoid-shaped head, and significant skull asymmetry notable for an ipsilateral mastoid bulge and contralateral frontal bossing. Because of the rarity of lambdoid synostosis, little is known about optimal techniques for its treatment. In particular, the proximity of the lambdoid suture to critical intracranial structures such as the superior sagittal and transverse sinuses represents a potential for significant intraoperative bleeding. Prior work has shown that parietal asymmetry persists after repair in these cases. In this article, the authors present a technique for the treatment of unilateral lambdoid craniosynostosis along with two representative cases. This calvarial vault remodeling technique requires the removal of both ipsilateral and contralateral parietal bones. These are moved across hemispheres and reinset on opposite sides to help correct the parietal asymmetry. Obliquely orientated barrel stave osteotomies are performed to provide a safe mechanism for correction of occipital flattening. The authors' early results show improvement in correction of volume asymmetry 1 year postoperatively relative to patients treated with prior calvarial vault remodeling techniques. The authors believe the technique presented here corrects the windswept appearance in patients with lambdoid craniosynostosis and also reduces the potential for complications. Further work will be necessary to confirm this technique's long-term efficacy in a larger cohort.

Sagittal synostosis: does choice of intervention and its timing affect the long-term aesthetic and neurodevelopmental outcome? A single-institution study of 167 children.

Sagittal craniosynostosis (SC) is the most commonly encountered form of craniosynostosis. Despite its relative frequency, there remains significant heterogeneity in both operative management and follow-up between centers and a relative paucity of long-term outcome data in the literature. At the authors' institution, families of children presenting with SC are offered the following options: 1) conservative management with ophthalmic surveillance, 2) minimally invasive surgery at < 6 months of age (spring-assisted cranioplasty [SAC]) or 3) calvarial vault remodeling at any age (CVR). The authors reviewed outcomes for all children presenting with SC during a 5-year period, regardless of the treatment received. Consecutive children born between January 1, 2008, and December 31, 2012, presenting with SC were identified, and detailed chart reviews were undertaken. Demographic, surgical, perioperative, head shape, scar, and neurodevelopmental (behavioral, education, speech, and language) data were analyzed. The cohort was divided by type of surgery (none, SAC, or CVR) and by age at surgery (early, defined as ≤ 6 months; or late, defined as > 6 months) for comparison purposes. A total of 167 children were identified, 129 boys and 38 girls, with a median age at presentation of 5.0 (range 0.4-135) months. Three families opted for conservative management. Of the 164 children who underwent surgery, 83 underwent SAC, 76 underwent CVR, and 5 underwent a "hybrid" procedure (CVR with springs). At a median age of 7.0 (range 0.5-12.3) years, there was no significant difference in concerns regarding head shape, scar, or neurodevelopmental outcomes between the early and late intervention groups over all procedures performed, or between the early or late SAC and CVR cohorts. There were more head shape concerns in the SAC group than in the CVR group overall (25.7% vs 11.8%, respectively; p = 0.026), although most of these concerns were minor and did not require revision. In this cohort, regardless of operative intervention and timing of intervention, infants achieved similar neurodevelopmental outcomes. Minimally invasive surgery (SAC) appears to result in less complete correction of head shape than CVR, but this may be balanced by advantages in reduced operative time, hospitalization, and blood loss. SAC was equal to CVR in neuropsychological outcomes.

Endoscopic-assisted calvarial vault remodeling without postoperative helmets for treating infants with sagittal synostosis

Objective: Various endoscopically assisted minimally invasive surgical procedures have been described for the management of isolated nonsyndromic sagittal synostosis. All these techniques necessitate the use of postoperative helmets without immediate correction of the head shape. Here, we document the safety and sustainable acceptable outcomes of an endoscopic minimally invasive approach with full barrel staving without using a postoperative cranial helmet. Methods: A single-institution cohort analysis was performed on five patients who underwent endoscopically assisted minimally invasive calvarial vault remodeling without using a postoperative helmet for isolated nonsyndromic sagittal synostosis between 2017 and 2022. Variables analyzed were age at the time of surgery, gender, Estimated Blood Loss (EBL), operative time, postoperative complications, and pre-and postoperative Cephalic Index (CI). Results: Three male and two female infants were treated at our hospital in 2017–2022 with a mean follow-up of 32.6 months. At the time of the surgery, the mean age was ±3.5 months (range 10–58 months), the mean weight was 4.54 kg (standard deviation, SD ± 1.56), the mean EBL was 34.6 ml (range 20 ml – 54 ml) and mean surgical time from skin incision to dressing application was 120.7 min. The mean CI for all patients was 66.88 ± 4 (SD) preoperatively vs. 81.52 ± 2.38 (SD) postoperatively (p &lt; 0.001 by paired Student’s t - test). There were no deaths or intraoperative complications. Conclusions: We present a novel endoscopically assisted minimally invasive procedure without using a postoperative helmet. This was a safe and efficacious procedure for isolated sagittal craniosynostosis, with improvements in CI at a mean follow-up of 32.6 months.

A multi-institutional survey on calvarial vault remodeling techniques for sagittal synostosis and outcomes analysis for patients treated at 12 months and older.

Surgical treatment of sagittal craniosynostosis is challenging in older patients. This study aimed to assess the effect of increasing age on open surgical technique selection and patient outcomes using the multi-institutional Synostosis Research Group (SynRG) collaboration. Surgeons in SynRG were surveyed for key influences on their preferred open calvarial vault remodeling techniques at various patient ages: < 6, 6-12, and > 12 months. The SynRG database was then queried for open repairs of nonsyndromic sagittal craniosynostosis performed for patients older than 12 months of age. Perioperative measures, complications, and preoperative and postoperative cephalic indices were reviewed. All surgeons preferred to treat patients at an earlier age, and most (89%) believed that less-optimal outcomes were achieved at ages older than 12 months. The modified pi procedure was the dominant technique in those younger than 12 months, while more involved open surgical techniques were performed for older patients, with a wide variety of open calvarial vault remodeling techniques used. Forty-four patients met inclusion criteria, with a mean (± SD) age at surgery of 29 ± 16 months. Eleven patients underwent parietal reshaping, 10 parietal-occipital switch, 9 clamshell craniotomy, 7 geometric parietal expansion, 6 modified pi procedure, and 1 parietal distraction. There were no readmissions, complications, or mortality within 30 days postoperatively. Patients' cephalic indices improved a mean of 6.4% ± 4.0%, with a mean postoperative cephalic index of 74.2% ± 4.9%. Differences in postoperative cephalic index (p < 0.04) and hospital length of stay (p = 0.01) were significant between technique cohorts. Post hoc Tukey-Kramer analysis identified the parietal reshaping technique as being significantly associated with a reduced hospital length of stay. Patient age is an important driver in technique selection, with surgeons selecting a more involved calvarial vault remodeling technique in older children. A variety of surgical techniques were analyzed, with the parietal reshaping technique being significantly associated with reduced length of stay; however, multiple perioperative factors may be contributory and require further analysis. When performed at high-volume centers by experienced pediatric neurosurgeons and craniofacial surgeons, open calvarial vault techniques can be a safe method for treating sagittal craniosynostosis in older children.

Socioeconomic Disparities in the Surgical Management of Craniosynostosis.

The updated ICD-10 coding system introduced partway through 2015 offers codes with increased granularity for disease and procedure types. This is the first study to use ICD-10 codes to investigate disparities in the surgical management for craniosynostosis. Using the Kids' Inpatient Database univariable analyses were performed to compare the relative odds of undergoing strip craniectomy, either endoscopic (ESC) or open (OSC), or calvarial vault remodeling (CVR) based on a variety of demographic and hospital-level variables. Of the 2,874 patients identified, 2,352 underwent CVR while 522 underwent SC. Of those undergoing SC, 295 and 228 had an endoscopic and open procedure, respectively. A greater proportion of patients who had private insurance (58.14% versus 47.49%) or were self-pay (8.06% versus 6.28%) underwent SC, whereas a higher percentage who were covered under Medicaid (46.23% versus 32.8%; P < 0.001) received CVR. ESC patients were 2.16 times more likely to have private insurance and 2.07 times more likely to be from the highest income quartile compared to OSC patients. However, there were no differences in terms of insurance type or income level between those undergoing CVR compared to OSC. Our study found that the difference between CVR and SC can be attributed to the difference in the endoscopic versus open approaches to SC. Although the socioeconomic disparities persisted in the comparison between ESC and OSC, with patients receiving ESC coming from wealthier and commercially insured families, the same differences were not observed when comparing CVR with OSC.

Lambdoid synostosis: endoscopic craniectomy.

Lambdoid craniosynostosis leads to significant deformational changes of the calvaria and cranial fossae. Surgery used to treat the condition typically consists of a calvarial vault remodeling (CVR) procedure whereby the entire occiput is removed and reshaped along with a bandeau advancement to give the patient a rounded occiput. As an option, this video presents the minimally invasive endoscopic craniectomy used at the author's institution, which was developed there and has been successfully used for 25 years. This procedure is simple and can be done rapidly, with minimal to no blood loss. The video details the key steps necessary to successfully perform the procedure.The video can be found here: https://vimeo.com/515746378.

Total Cranial Reconstruction for the Treatment of Sagittal Craniosynostosis in Children.

To study the effect of total cranial reconstruction for sagittal synostosis (scaphocephaly) deformity in Chinese children. A retrospective analysis was performed involving 23 children with isolated non-syndromic sagittal synostosis who were treated by total calvarial vault remodeling after 1 year of age from May 2015 to June 2019 in the Department of Neurosurgery, Children's Hospital of Nanjing Medical University. The authors reconstruct patients' pre- and post-operative cranial thin-section CT scan images and those of the control group. The cephalic index (traditional, normative), intracranial volume, horizontal point of maximum width (H-PMW), vertical point of maximum width (V-PMW), frontal to head height ratio and occipital to head height ratio data were analyzed using a paired t test or Wilcoxon signed-rank test. Twenty-three patients met the inclusion criteria, including 19 males and 4 females. The ratio of males to females was 4.7:1. All patients underwent total cranial reconstruction. The average age was 26.52 months (13-48 months), the average operation time was 214.13 minutes (150-265 minutes), and the average amount of suspended erythrocytes was 200 ml (100-400 ml). The cranial morphology of all patients improved significantly after the operation. The traditional cephalic index (pre-operative: 0.70 (0.04); post-operative: 0.78 (0.02)) and normative cephalic index (pre-operative: 0.68 (0.03); post-operative: 0.77 (0.02)) were significantly increased (P < 0.0001). The mean horizontal point of maximum width improved from 0.54 to 0.56 (P = 0.0043), the mean vertical point of maximum width decreased from 0.59 to 0.54 (P = 0.0006), the frontal height decreased from 0.89 to 0.77 (P < 0.0001), and the occipital height improved from 0.78 to 0.88 (P < 0.0001). The intracranial volume increased from 1287.35 to 1426.90 cm3 (P < 0.0001). All of the children had a good skull shape and no recurrence of deformity. Total calvarial reconstruction can effectively correct scaphocephaly in Chinese children, expand cranial volume, reduce cranial height, shorten fronto-occipital diameters and enlarge biparietal diameters.

Assessment of the Outcome of Calvarial Vault Remodeling and Spring-Mediated Cranioplasty in the Correction of Isolated Sagittal Suture Synostosis.

Sagittal synostosis is the commonest form of nonsyndromic isolated craniosynostosis. Calvarial vault remodeling (CVR) and spring-mediated cranioplasty (SMC) are the commonly used correction techniques. To study and compare clinical and radiographic outcomes of CVR and SMC in the correction of isolated sagittal suture synostosis. A prospective cohort with the patients were divided into group; I (SMC) and II (CVR), each 15 patients. They were observed to evaluate the outcome and detect complications. Mean operative time was 59.2 minutes in SMC and 184 minutes in CVR. Mean intraoperative blood loss was 26 mL in SMC and 64.7 mL in CVR. Intraoperative complications in SMC were dural tear in 1 patient and superior sagittal sinus injury in another patient, while in CVR 2 patients with dural tears and a 3rd with superior sagittal sinus injury. Postoperative complications in SMC were exposed spring, gaped wound, and parietal eminence elevation, while in CVR 2 patients needed blood transfusion. The mean hospital stays was 1.4 days in SMC and 4.1 days in CVR. In SMC, the relative increase in cephalic index varied between 5.5% and 8.2%, while for CVR, it varied between 5.1% and 7.9%. The SMC and CVR are safe procedures, with good long-term results and significant objective changes toward normalization of the skull morphology in isolated sagittal craniosynostosis. The SMC is less invasive and associated with reduced hospital stays, decreased blood loss, and can be performed at a younger age than CVR with a lower morbidity.

Impact of multidisciplinary engagement in a quality improvement blood conservation protocol for craniosynostosis.

Patients undergoing open cranial vault remodeling for craniosynostosis frequently experience substantial blood loss requiring blood transfusion. Multiple reports in the literature have evaluated the impact of individual blood conservation techniques on blood transfusion rates during craniosynostosis surgery. The authors engaged a multidisciplinary team and assessed the impact of input from multiple stakeholders on the evolution of a comprehensive quality improvement protocol aimed at reducing or eliminating blood transfusion in patients undergoing open surgery for craniosynostosis. Over a 4-year period from 2012 to 2016, 39 nonsyndromic patients were operated on by a single craniofacial plastic surgeon. Initially, no clear blood conservation protocol existed, and specific interventions were individually driven. In 2014, a new pediatric neurosurgeon joined the craniofacial team, and additional stakeholders in anesthesiology, transfusion medicine, critical care, and hematology were brought together to evaluate opportunities for developing a comprehensive blood conservation protocol. The initial version of the protocol involved the standardized administration of intraoperative aminocaproic acid (ACA) and the use of a cell saver. In the second version of the protocol, the team implemented the preoperative use of erythropoietin (EPO). In addition, intraoperative and postoperative resuscitation and transfusion guidelines were more clearly defined. The primary outcomes of estimated blood loss (EBL), transfusion rate, and intraoperative transfusion volume were analyzed. The secondary impact of multidisciplinary stakeholder input was inferred by trends in the data obtained with the implementation of the partial and full protocols. Implementing the full quality improvement protocol resulted in a 66% transfusion-free rate at the time of discharge compared to 0% without any conservation protocol and 27% with the intermediate protocol. The administration of EPO significantly increased starting hemoglobin/hematocrit (11.1 g/dl/31.8% to 14.7 g/dl/45.6%, p < 0.05). The group of patients receiving ACA had lower intraoperative EBL than those not receiving ACA, and trends in the final-protocol cohort, which had received both preoperative EPO and intraoperative ACA, demonstrated decreasing transfusion volumes, though the decrease did not reach statistical significance. Patients undergoing open calvarial vault remodeling procedures benefit from the input of a multidisciplinary stakeholder group in blood conservation protocols. Further research into comprehensive protocols for blood conservation may benefit from input from the full surgical team (plastic surgery, neurosurgery, anesthesiology) as well as additional pediatric subspecialty stakeholders including transfusion medicine, critical care, and hematology.

Incidence of delayed intracranial hypertension in children with isolated sagittal synostosis following open calvarial vault reconstruction.

Delayed intracranial hypertension (DIH) occurs most frequently in children with syndromic or multi-suture synostosis after surgical correction. The rarity of DIH in children with isolated non-syndromic sagittal synostosis (ISS) warrants follow-up evaluation by large craniofacial centers until skeletal maturity. This study reports the incidence of DIH in children following open repair for ISS by our center's craniofacial team. A single-center retrospective study of patients who underwent open calvarial vault remodeling (CVR) for ISS at our institution between November 2000 and November 2012 was performed. Syndromic and multi-suture synostosis patients were excluded. Demographic and follow-up data were extracted from the medical record for analysis until July 2017. One hundred five patients with ISS were identified who had undergone CVR in the aforementioned timeframe. Average age at initial surgery was 11.7 ± 15.32months. Mean follow-up in our craniofacial clinic was 4.94 ± 3.53years, with 69 patients (65.7%) having follow-up in craniofacial clinic ≥ 3years and 74 (70.5%) having follow-up ≥ 3years in any clinic at our institution. Four patients (3.8%) had intracranial pressure (ICP) monitors placed for symptoms concerning for DIH, one of which (0.95%) had confirmed DIH and underwent a second surgical procedure at 7.4years of age. The patient presented late initially, having his first operation at 1.56years of age. One patient out of 105 (0.95%) developed DIH, confirmed by ICP monitoring, and required reoperation. The occurrence of DIH, albeit rare, remains an important topic to include in parental discussions and mandates long-term follow-up in this population.

S7A-07 SESSION 7A: SAGITTAL SYNOSTOSIS AN UPDATE ON THE OUTCOMES OF SPRING-ASSISTED SURGERY FOR SAGITTAL CRANIOSYNOSTOSIS

Introduction: Spring-assisted surgery (SAS) is an efficacious means for correcting scaphocephaly due to sagittal craniosynostosis. Early intervention for sagittal craniosynostosis using spring-assisted surgery (SAS) is an alternative to calvarial vault remodeling. SAS is performed for patients younger than 6 months of age, and it requires two operations: one for spring placement and a second for spring removal. The long-term safety and efficacy of this technique continue to be reviewed as this technique gains greater acceptance. The nuances of optimizing outcome will also be reviewed. Methods: We performed a retrospective examination of the electronic medical record for all patients treated with SAS for isolated sagittal synostosis at our institution with at least 1 year of follow up (N=179). Cephalic index (CI) was calculated from CT scans, laser Doppler scans, and 3DMD stereophotogammetry. Perioperative data was collected on OR time, blood loss, transfusion rates, and hospital stay, and complications were also collected. Results: There were 179 patients who underwent SAS from 2001 to February 2018. The mean gestationally-corrected age at spring placement and spring removal were 4.4 months and 9.4 months, respectively. Operative time for spring placement was 44.9 minutes, and for spring removal was 26.8 minutes. The mean hospital length of stay for spring placement was 35 hours, and for spring removal was 7.6 hours. One patient required a blood transfusion for the initial placement operation and none for the removal procedure. Mean CI prior to SAS was 70. This improved to 75 after spring placement (p<0.001) and was 74.0 at 1 year after spring placement. This has been maintained with a mean of 75.7 at 12 years post op. Major complications, defined as those requiring a return to the operating room to address spring malposition, exposure, or infection, occurred at a rate of 6.1% with the majority of these occurring during the initial learning curve of the procedure. Conclusion: SAS for isolated craniosynostosis continues to have consistent correction of CI that is maintained over time and a favorable complication profile, as shown by this updated analysis. Outcomes are optimized by earlier placement, accurate positioning in relation to the coronal and lambdoid sutures, and accurate force selection based on type of scaphocephaly and patient profile. The spring removal procedure can be done safely as an outpatient. Finally, after the initial learning curve, the endoscopic approach mirrors the outcomes of the open spring placement.

Debunking a Surgical Myth: Do Not Touch the Temporalis.

A longstanding dictum exists to avoid surgical manipulation of the temporalis muscle out of concern for an exceedingly high rate of muscle atrophy and recurrent temporal hollowing. The authors challenge this surgical myth, considering such advice to be erroneous. The authors hypothesize that elevation of the temporalis muscle, if performed using standard muscle flap principles, will demonstrate excellent results. To assess temporalis response to surgical manipulation, the authors reviewed patients who underwent calvarial vault remodeling by the senior author for craniosynostosis between 1988 and 2011. Nonsyndromic patients with single-suture synostosis and 5 years of follow-up were eligible for inclusion. The medical record was used to measure rates of reoperation, recurrent temporal hollowing, and persistent temporalis overcorrection. Of the cohort reviewed, 196 patients met inclusion criteria. Ten patients (5.1%) exhibited recurrent bitemporal constriction. One patient (0.5%) underwent a revision temporalis turnover flap, and 2 patients (1.0%) underwent soft tissue augmentation. The overall reoperation rate was 1.5%. Temporalis overcorrection, in an attempt to prophylactically rectify the expected atrophy after temporalis manipulation, persisted in 11 patients (5.6%). Three of these patients required treatment with steroid injections, Botox injections, or operative muscle debulking. The overall reoperation rate for temporalis overcorrection was 1.5%. The authors' low reoperation rates for recurrent deformity, in combination with persistent temporalis overcorrection in 5.6% of patients, should dispel the myth that manipulation of the temporalis invariably results in atrophy. The muscle may be surgically manipulated, as long as plastic surgery principles are followed.

Endoscopy-assisted early correction of single-suture metopic craniosynostosis: a 19-year experience.

In BriefThe long-term results of treating infants with metopic craniosynostosis by using endoscopic, minimally invasive techniques are reported. The impetus arose from the lack of consistent and favorable outcomes associated with calvarial vault remodeling techniques and from the very traumatic and invasive nature of these procedures. The results presented show excellent and consistent long-term outcomes that are superior to traditional methods and are associated with minimal trauma, blood loss, and anesthetic exposure, and with short surgical times.

Ensuring a Safe Surgical Experience for the Patient Likely to Require an Intraoperative Blood Transfusion

We serve a patient population which includes many complex pediatric patients who often present for surgery with an extensive list of comorbidities. When the surgical plan includes a spinal fusion, pelvic or femoral osteotomy, calvarial vault remodeling, or the patient has a known coagulopathy, there is a great likelihood that the patient will require a blood transfusion intraoperatively. Patients who have had previous blood transfusions are at risk for developing antibodies, which can make cross matching blood difficult and time consuming.

Modification of the Melbourne Method for Total Calvarial Vault Remodeling.

Background:Sagittal synostosis is the most common form of single suture synostosis. It often results in characteristic calvarial deformities, including a long, narrow head, frontal bossing, a bullet-shaped occiput, and an anteriorly placed vertex. Several methods for correcting the phenotypic deformities have been described, each with their own advantages and challenges. In this study, we describe a modification of the Melbourne method of total calvarial remodeling for correcting scaphocephaly.Methods:We conducted a retrospective review of all consecutive patients who underwent total calvarial remodeling using a modified version of the Melbourne technique from 2011 to 2015. We evaluated clinical photographs, computed tomographic imaging, and cephalic indices both pre- and postoperatively to determine morphologic changes after operation.Results:A total of 9 patients underwent the modified Melbourne technique for calvarial vault remodeling during the study period. Intraoperative blood loss was 260 mL (range, 80–400 mL), and mean intraoperative transfusion was 232 mL (range, 0–360 mL). The average length of stay in the hospital was 3.9 days. The mean cephalic indices increased from 0.66 to 0.74 postoperatively (P < 0.01).Conclusions:A modified Melbourne method for calvarial vault reconstruction addresses the phenotypic aspects of severe scaphocephaly associated with isolated sagittal synostosis and maintains a homeotopic relationship across the calvaria. It is associated with shorter operative times, lower blood loss, and lower transfusion requirements.

Endoscopic assisted suturectomy for primary craniosynostosis in infancy

Background: Multiple procedures have been used for the treatment of craniosynostosis, ranging from simple suturectomy to extensive calvarial vault remodeling. The optimal timing for surgery is still controversial. The goal of therapy is to provide adequate intracranial volume, in addition to an aesthetically almost normal skull shape. Endoscopic synostosis repair described in 1998 by Jimenez and Baron [1]. This technique allows for a less invasive method that can result in excellent longstanding reconstruction of the cranial skeleton. This method is a minimally invasive approach that has less morbidity involved with traditional reconstruction techniques. Aim: Evaluation of early endoscopic suturectomy and its impact on both neurological functions and cosmetic appearance of infants up to 6 months of age suffering primary craniosynostosis. Methodology: This is a prospective analytical study of 50 patients with primary non syndromic craniosynostosis either single suture or multiple sutures, up to sixth months of age; with evident of skull shape deformity and or manifestations of increase intracranial pressure. from; October 2009 to October 2016 were managed byendoscopic assisted suturectomy the approach of Jimenez and Baron, in both Neurosurgery Department Shebin Elkom teaching hospital and Neurosurgery Department in Elsahel teaching hospital. Clinical and radiological follow up for six months postoperative. Results: This is a prospective analytical study of 50 patients with primary craniosynostosis, 28 patients are male and 22 patients are female. The age of patients range from one and half months to sixth months. The majority of cases presented with deformity alone 68%. Other clinical presentations as manifestations of increased intracranial pressure, fits, and delayed milestones plus deformity was 20%, 8%, and 4% respectively. Estimated blood loss, the mean loss was 56cc, minimum 30cc, and maximum was 100cc, with stander deviation ±18cc.The minimum hospital stay was one day and maximum was three days.There is significant change of head shape and head circumference postoperatively this observed by highly significant P value in head circumference (&lt; 0.001). Conclusion: Endoscopic assisted suturectomy is minimally invasive approach with a very narrow range of complications, very limited need to blood transfusion and if it occurs, it is small volume in relation to total volume. Very short ICU and hospital stay also decrease the economic load.

Tranexamic Acid Reduces Blood Loss in Craniosynostosis Surgery.

The authors retrospectively reviewed 79 patients with craniosynostosis who underwent either bifrontal or biparietal-occipital calvarial vault remodeling before institution of tranexamic acid (TXA) administration (non-TXA group) and 35 patients after institution of TXA administration (TXA group). The patients were analyzed in 2 groups: all open calvarial vault remodeling patients (anterior and posterior) as a whole, and anterior vaults only as a subset analysis. Primary outcomes accessed were: total intraoperative blood transfused, postoperative blood transfused, and estimated blood loss (EBL). Secondary outcomes evaluated were length of stay in the pediatric intensive care unit and hospital length of stay. When comparing all open calvarial vault remodeling patients, patients who received TXA required significantly less total blood transfusion during their operation (264 cc TXA group versus 428 cc non-TXA, P < 0.0001). Patients who received TXA required no blood transfusions postoperatively, compared with the non-TXA group, in which 45% of patients required postoperative blood transfusion. Weight-based EBL was also significantly lower in those patients receiving TXA (25 cc/kg in the TXA group versus 34 cc/kg in the non-TXA group [P = 0.0143]). All patients required transfusion intraoperatively. Pediatric intensive care unit length of stay was shorter in the TXA group, but there was no significant difference in total hospital length of stay. These findings also reached statistical significance when comparing only the anterior vault patients. Intraoperative TXA administration has a correlation with reduced blood transfusion requirements, as well as EBL, in patients undergoing open calvarial vault remodeling. There were no adverse events related to TXA administration.

Open Craniosynostosis Surgery: Effect of Early Intraoperative Blood Transfusion on Postoperative Course.

Correction of craniosynostosis can result in blood loss when the patient already has physiologic anemia. The aim of this study was to determine whether patients benefit from early blood transfusion and whether the timing of blood transfusion affects metabolic disturbances and the postoperative course. In this retrospective review, 71 patients who underwent open calvarial vault remodeling for correction of craniosynostosis were separated into 2 groups according to whether they received blood transfusions early (within the first 30 minutes of surgery) or later (after the first 30 minutes of surgery). Patients were further separated into nonsyndromic and syndromic cohorts. Tracked variables included hemoglobin, hematocrit, arterial blood gas values, lactate level, length of stay, estimated blood loss, and amount of blood transfused in the operating room, amount transfused postoperatively, and total amount transfused.Among all patients, the early transfusion group had a higher hemoglobin nadir overall and received less postoperative blood. Within the nonsyndromic cohort, the early transfusion group had a higher estimated blood loss and received more transfused blood. In the syndromic cohort, the early transfusion group had a hemoglobin nadir that was significantly higher than in the late transfusion group and a lower estimated blood loss, shorter pediatric intensive care unit stay, and less postoperative blood transfused. Syndromic patients also received significantly more blood overall. For syndromic patients undergoing open calvarial vault remodeling, transfusion within the first 30 minutes of surgery should be considered.

Operative Management of Nonsyndromic Sagittal Synostosis: A Head-to-Head Meta-analysis of Outcomes Comparing 3 Techniques.

The timing and surgical technique for the treatment of sagittal synostosis remain controversial. Calvarial vault remodeling (CVR), strip craniectomy (SC), and spring-mediated cranioplasty (SMC) are currently in use. We perform a meta-analysis of the literature to compare these 3 techniques. A literature search identified articles involving operative management of nonsyndromic sagittal synostosis. Comparison of 2 operative techniques was required, and methodology was assessed via the American Society of Plastic Surgeons' Levels of Evidence. Three techniques were considered: CVR, SC, and SMC. Meta-analysis was conducted for change in cephalic index (CI), reported as weighted mean difference (WMD). Pooled subgroup comparisons were performed for operative time, length of stay, blood loss, and cost. Twelve studies providing level 2 or 3 evidence were included. All studies involved CVR (n = 187), 8 involved SC (n = 299), and 7 involved SMC (n = 158). Head-to-head comparison of change in CI demonstrated a greater, yet statistically insignificant change for CVR versus SMC, WMD = 0.94 (-0.23 to 2.11) (P = 0.12, I(2) = 55%). Calvarial vault remodeling showed a statistically greater change in CI versus SC, WMD = 1.47 (0.47-2.48) (P = 0.004, I(2) = 66%). Compared with SMC/SC, CVR had longer operative length (170 vs 97 minutes), higher blood loss (238 vs 47 mL), longer length of stay (5.1 vs 2.9 days), and higher costs ($35,280 vs $13,147), all with P < 0.0001. This study, the first meta-analysis comparing 3 primary operations for correcting nonsyndromic sagittal synostosis, demonstrates no difference in CI for CVR versus SMC and a small but statistically greater improvement in CI favoring CVR over SC. Secondary outcomes favored SC/SMC procedures over CVR. However, long-term studies are still needed to adequately assess the risk-benefit ratios.