Endoscopic Strip Craniectomy Research Articles

A computational modelling tool for prediction of head reshaping following endoscopic strip craniectomy and helmet therapy for the treatment of scaphocephaly

BackgroundEndoscopic strip craniectomy followed by helmet therapy (ESCH) is a minimally invasive approach for correcting sagittal craniosynostosis. The treatment involves a patient-specific helmet designed to facilitate lateral growth while constraining sagittal expansion. In this study, finite element modelling was used to predict post-treatment head reshaping, improving our comprehension of the necessary helmet therapy duration. MethodSix patients (aged 11 weeks to 9 months) who underwent ESCH at Connecticut Children's Hospital were enrolled in this study. Day-1 post-operative 3D scans were used to create skin, skull, and intracranial volume models. Patient-specific helmet models, incorporating areas for growth, were designed based on post-operative imaging. Brain growth was simulated through thermal expansion, and treatments were modelled according to post-operative Imaging available. Mechanical testing and finite element modelling were combined to determine patient-specific mechanical properties from bone samples collected from surgery.Validation compared simulated end-of-treatment skin surfaces with optical scans in terms of shape matching and cranial index estimation. ResultsComparison between the simulated post-treatment head shape and optical scans showed that on average 97.3 ± 2.1 % of surface data points were within a distance range of −3 to 3 mm. The cranial index was also accurately predicted (r = 0.91). ConclusionsIn conclusion, finite element models effectively predicted the ESCH cranial remodeling outcomes up to 8 months postoperatively. This computational tool offers valuable insights to guide and refine helmet treatment duration. This study also incorporated patient-specific material properties, enhancing the accuracy of the modeling approach.

The Caregiver Burden of Helmet Therapy following Endoscopic Strip Craniectomy: A Phenomenological Qualitative Study

Introduction: This cohort study aimed to elucidate the caregiver burden of helmet therapy (HT), following endoscopic strip craniectomy (ESC) to treat craniosynostosis, in an effort to inform clinicians and future caregivers navigating this therapeutic option. Methods: Fourteen caregivers of children with positional plagiocephaly (6) and craniosynostosis treated by ESC (8) undergoing HT at a single center were recruited via convenience sampling. Using a phenomenological qualitative approach, semi-structured interviews were conducted to understand the experience of HT for caregivers. Data collection and analysis were iterative and conducted until thematic saturation was reached. Results: Emerging themes revealed five domains of caregiver burden: emotional, cognitive, physical, psychosocial, and financial. No caregiver felt the therapy was too burdensome to complete. Caregivers of both groups also expressed positive aspects of HT related to support from the team, the noninvasive nature of treatment, and the outcomes of therapy. Furthermore, caregivers report overall satisfaction with the process, stating willingness to repeat the treatment with subsequent children if required. Conclusion: HT is associated with five major domains of caregiver burden; however, none of the caregivers regret choosing this treatment option, nor was the burden high enough to encourage treatment cessation. This study will inform future prospective analyses that will quantify real-time caregiver burden throughout HT.

Cognitive Outcomes of Children With Sagittal Craniosynostosis Treated With Either Endoscopic or Open Calvarial Vault Surgery

Several studies have reported a higher incidence of neurodevelopmental delays and cognitive deficits in patients with single-suture craniosynostosis; however, there are few studies examining the associations of repair type with cognitive outcomes. To measure differences in neuropsychological outcomes between school-age children who were treated for sagittal craniosynostosis and unaffected controls and explore differences in cognitive function among children with sagittal craniosynostosis who were previously treated with either endoscopic strip craniectomy or open calvarial vault surgery. This cohort study was performed between 2018 and 2022. Eligible participants included patients aged 5 to 17 years who had previously been seen as infants or toddlers (<3 years) at 1 of 3 surgical centers for craniosynostosis repair with either endoscopic surgery or open calvarial vault surgery. A separate cohort of unaffected controls were included for comparison. Data analysis was conducted from November 2023 to February 2024. Open calvarial vault surgery or endoscopic repair for single-suture craniosynostosis. The primary outcome was the Differential Ability Scales-II (DAS-II) General Conceptual Ability (GCA) score, an index for overall intellectual ability. Secondary outcomes included DAS-II subscale scores (Verbal Ability, Nonverbal Reasoning, Spatial Ability, Working Memory, and Processing Speed), and Patient-Reported Outcomes Measurement Information System (PROMIS) cognitive function scores. A total of 81 patients with sagittal craniosynostosis (59 male [73%]; 22 female [27%]) and 141 controls (81 male [57%]; 60 female [43%]) were included. Of the 81 participants with sagittal craniosynostosis, 46 underwent endoscopic repair and 35 underwent open repair. Median (range) age at time of follow-up assessment was 7.7 (5.0-14.8) years for children with sagittal craniosynostosis and median age at assessment was 8.5 (7.7-10.5) years for controls. After controlling for age at assessment, sex, and socioeconomic status, there was no statistically significant or clinically meaningful difference in GCA scores between children who underwent endoscopic repair (adjusted mean score, 100; 95% CI, 96-104) and open repair (adjusted mean score, 103; 95% CI, 98-108) (P > .99). We found no significant difference in PROMIS scores between repair types (median [range] for endoscopic repair 54 [31-68] vs median [range] for open repair 50 [32-63]; P = .14). When comparing the treatment groups with the unaffected controls, differences in subscale scores for GCA and working memory were observed but were within normal range. In this cohort study, there were no statistically or clinically significant differences in cognitive outcomes among school-age children by and type of surgical procedure used to repair nonsyndromic sagittal craniosynostosis. These findings suggest primary care clinicians should be educated about different options for craniosynostosis surgery to ensure early referral of these patients so that all treatment options remain viable.

Discussion: Comparison of Morphometric Outcomes following Open Posterior Expansion versus Endoscopic Strip Craniectomy for Sagittal Synostosis.

Discussion: Comparison of Morphometric Outcomes following Open Posterior Expansion versus Endoscopic Strip Craniectomy for Sagittal Synostosis.

Evaluation of Head Height After Endoscopic Strip Craniectomy and Orthotic Therapy for Sagittal Craniosynostosis

Background: Achievement of normal head shape is one of the primary goals of all treatment modalities for craniosynostosis, in addition to maintenance of normal intracranial pressure and allowing normal brain development. Pre- and postoperative quantification of head shape in sagittal craniosynostosis has largely relied on cephalic index (width divided by anterior-posterior length of skull). However, many infants with sagittal craniosynostosis have a head that is short in addition to long and narrow. Height is not captured by the cephalic index. Methods: Patients who underwent endoscopic repair of sagittal craniosynostosis between 2016 and 2019 with available pre- and 1-year postoperative head computed tomography (CT) scans were identified. Age-matched controls with available CT scans were used for comparison. Twenty-one patients with sagittal craniosynostosis who underwent endoscopic repair, 10 preoperative, and 10 postoperative age-matched controls were identified. CT scans were measured with Analyze 12.0 software using soft tissue windows. Head height was defined as the vertical distance from the opisthocranion to the top of the head along a line crossing the tragus. Results: Patients with sagittal craniosynostosis had a shorter head height (mean 6.01 cm) than age-matched controls (mean 6.94 cm, P = .0003), and, after endoscopic repair and helmeting, the head height (mean 8.05 cm) was similar to age matched controls (mean 8.22 cm, P = .515). Conclusions: This head height measurement quantifies the third dimension of abnormal head shape in sagittal craniosynostosis. Additionally, it is adequately corrected in endoscopic repair with helmeting.

Isolated Sagittal Craniosynostosis: A Comprehensive Review.

Sagittal craniosynostosis, a rare but fascinating craniofacial anomaly, presents a unique challenge for both diagnosis and treatment. This condition involves premature fusion of the sagittal suture, which alters the normal growth pattern of the skull and can affect neurological development. Sagittal craniosynostosis is characterised by a pronounced head shape, often referred to as scaphocephaly. Asymmetry of the face and head, protrusion of the fontanel, and increased intracranial pressure are common clinical manifestations. Early recognition of these features is crucial for early intervention, and understanding the aetiology is, therefore, essential. Although the exact cause remains unclear, genetic factors are thought to play an important role. Mutations in genes such as FGFR2 and FGFR3, which disrupt the normal development of the skull, are suspected. Environmental factors and various insults during pregnancy can also contribute to the occurrence of the disease. An accurate diagnosis is crucial for treatment. Imaging studies such as ultrasound, computed tomography, magnetic resonance imaging, and three-dimensional reconstructions play a crucial role in visualising the prematurely fused sagittal suture. Clinicians also rely on a physical examination and medical history to confirm the diagnosis. Early detection allows for quick intervention and better treatment outcomes. The treatment of sagittal craniosynostosis requires a multidisciplinary approach that includes neurosurgery, craniofacial surgery, and paediatric care. Traditional treatment consists of an open reconstruction of the cranial vault, where the fused suture is surgically released to allow normal growth of the skull. However, advances in minimally invasive techniques, such as endoscopic strip craniectomy, are becoming increasingly popular due to their lower morbidity and shorter recovery times. This review aims to provide a comprehensive overview of sagittal craniosynostosis, highlighting the aetiology, clinical presentation, diagnostic methods, and current treatment options.

Spring-Assisted Surgery of Unilambdoid Craniosynostosis.

Craniosynostosis is traditionally treated with extensive cranial vault reconstructions (CVRs). Although less invasive techniques, such as endoscopic strip craniectomy with postoperative helmet therapy, have been successful, they also present difficulties. An alternative method is distraction osteogenesis using either manually controlled devices or specially designed springs. In this study, the authors provide the first comparison of spring-assisted surgery (SAS) with CVR for the treatment of unilambdoid synostosis (ULS). Fourteen consecutive patients (8 CVR and 6 SAS) treated for ULS at Sahlgrenska University Hospital between 2005 and 2018 were included. Skull shape and deviations were evaluated using previously defined measurement points on 3-dimensional computed tomography scans preoperatively, at spring removal, and at 3 years of age. Posterior and middle cranial fossa (PCF and MCF, respectively), skull-base cant, facial twist, and mastoid bulge (MB) were measured, and clinical data were obtained from chart reviews. The results indicated that at the 3-year follow-up, PCF, MCF, and MB improved in both groups, with no significant difference in outcome observed between methods. In the SAS group, duration of operation [61±27min (mean±SD)] and perioperative bleeding (3.5±2.8mL/kg body weight) were both significantly lower relative to the CVR group (P<0.05). These findings showed that both SAS and CVR resulted in similar improvements in treating ULS, although neither produced complete normalization of skull shape. The results suggest that early diagnosis and operation allow less extensive SAS to be performed without adversely affecting the results.

Evaluation, treatment, complications, and prognosis of craniosynostosis

Craniosynostosis is a congenital craniofacial anomaly that typically presents at birth and affects the skull's shape. It is characterized by the premature fusion of one or more cranial sutures in infants, which can impair brain development and function. While craniosynostosis is considered rare, it has a global prevalence of around three to six cases in 10,000 live births. This review article aims to synthesize the latest developments in diagnostic techniques, treatment strategies, and potential complications for the benefit of healthcare providers, researchers, and affected families. This review commenced on 31 October 2023, following a thorough examination of existing literature. Diverse databases, including PubMed, Web of Science, and Cochrane, were utilized for the literature review. Early diagnosis and evaluation involve a multidisciplinary approach, including clinical assessments, medical history reviews, and advanced imaging techniques like computed tomography (CT) scans and magnetic resonance imaging (MRI). Surgical intervention is the primary treatment option, with the goal of releasing or reshaping the fused sutures to allow for normal skull growth. While open surgical procedures like suturectomy have been prevalent, less invasive methods like minimally invasive endoscopic strip craniectomy are becoming more popular due to reduced complications. Untreated craniosynostosis can lead to complications such as increased intracranial pressure, developmental delays, vision and hearing problems, and psychosocial impacts, emphasizing the importance of timely intervention. However, surgical treatments carry their own risks, necessitating a well-planned and individualized approach. Overall, the prognosis for craniosynostosis is generally positive, and factors such as the specific type of craniosynostosis, the timing of treatment, and the quality of post-operative care all influence outcomes. Prenatal diagnosis and multidisciplinary care have emerged as valuable tools for improving prognosis.

Evaluation of Helmeting Therapy Duration After Endoscopic Strip Craniectomy for Metopic and Sagittal Craniosynostosis.

Endoscopic strip craniectomy (ESC) is a minimally invasive option for early surgical treatment of metopic (MC) and sagittal craniosynostosis (SC). For ESC, however, the postoperative duration and compliance of helmet therapy are crucial to correct MC and SC asymmetry. The purpose of this study is to assess the period of postoperative band therapy and determine differences, if any, between MC and SC. A single-institution retrospective review was performed for patients with MC and SC who underwent ESC from November 2015 to 2019. Patients received preoperative, postoperative, and post-band 3-dimensional imaging. Factors recorded included patient sex, insurance type, number of helmets needed, age at surgery, time of first helmet, and at time of completion of helmet therapy, cephalic index, interfrontal angle, and cranial vault asymmetry index. Patients with SC and MC had ESC surgery at 3.3 and 3.4 months of age, respectively.Patients with SC were found to have completed banding therapy at a younger age (7.88 versus 10.0mo), with shorter duration (4.17 versus 6.00mo), and less number of bands (1.54 versus 2.21) than patients with MC. After regression analysis, suture type was found to be a significant predictor of total time in band therapy ( P =0.039) with MC requiring a longer duration of banding therapy when compared with SC. Suture type directly correlates with duration of helmeting therapy for patients, with patients with MC requiring longer periods of postop helmeting and increased number of bands as compared with SC.

Is Postoperative Helmet Molding Therapy Necessary for Craniectomy for Sagittal Suture Synostosis?

Endoscopic strip craniectomy followed by postoperative remodeling helmet therapy for scaphocephaly is widely accepted, but the requirement of several helmets might burden patients or their families. This study examined whether craniectomy via a bicoronal approach without molding helmet therapy is worth considering. The authors retrospectively reviewed patients with nonsyndromic sagittal suture synostosis who underwent the modified Renier H technique between 2016 and 2021. We collected data on preoperative and postoperative cephalic index (CI), operative time, estimated blood loss, and blood transfusion rates. The authors also examined all related literature in English describing endoscopic craniectomy with postoperative helmet molding therapy for sagittal suture craniosynostosis. Among 17 patients, the average operative time was 92.2±15.6 minutes, the mean estimated blood loss was 35.8±22.4mL, and a blood transfusion was needed for 9 patients (52.9%). The mean preoperative and postoperative CIs were 69.1±2.6 and 78.4±2.2, respectively. A comparison of the literature review with the authors' results showed that their procedures required a slightly longer operative time and a higher frequency of blood transfusions. There are no significant differences in blood loss or preoperative and postoperative CIs reported in the literature. The open procedure required a higher operative time than endoscopic suturectomy. However, dealing with bleeding is more challenging with endoscopic suturectomy. The cost of the helmets and the duration patients have to wear them, which might be burdensome for the patients or their families when determining the optimal minimally invasive treatment, should also be considered.

Orbital Dysmorphology Corrects after Endoscopic Strip Craniectomy in Metopic Craniosynostosis

Orbital Dysmorphology Corrects after Endoscopic Strip Craniectomy in Metopic Craniosynostosis

Characterization of Regional Morphological Changes in Metopic Craniosynostosis Following Endoscopic Strip Craniectomy With Postoperative Helmeting: Predictors for Success

Background: Metopic craniosynostosis (MC) represents 10% to 25% of craniosynostosis cases. Endoscopic-assisted strip craniectomy (ESC) with orthotic molding therapy provides a minimally invasive alternative to open fronto-orbital advancement. Herein, we describe a 3D photogrammetry methodology for measurement of regional cranial growth and inter-frontal angle (IFA) as well as examine factors that may contribute to successful outcomes after ESC. Methods: A retrospective review was performed on patients with MC treated with ESC and band therapy from 2015 to 2019. Patients obtained 3D photogrammetry preoperatively, postoperatively, and post-helmet therapy. A survey was administered to 14 independent raters, who were asked to determine treatment success based on subjective visual assessment of preoperative and post-banding images. Patients were considered to have successful therapy when ≥75% of raters were in agreeance. Results: Thirteen patients met inclusion criteria. Average age at surgery was 3.5 months, with 53.9% of these patients deemed as a successful outcome on aggregate reviewer scores. For patients with successful treatment, there was a trend toward younger at surgery (2.9 months vs 4.2 months, P = .09) and at initiation of helmeting (3.3 months vs 4.8 months, P = .07). Regional root mean square identified significant differences between frontal and temporal (14.04 mm vs 7.39 mm, P = .02) and temporal and parietal (7.39 mm vs 15.37 mm, P = .002) regions. Average postoperative IFA was significantly improved compared to preoperative values (128.19° vs 117.9°, P = .02). Logistic regression modeling found no significant predictors of success. Discussion: Though not statistically significant, patients with MC with successful outcomes following ESC and banding were younger at surgery and time of helmeting. Our analysis of regional cranial growth and IFA demonstrated significant differences, which coincide with expected morphologic changes in this patient population. Our results demonstrate the potential for this technology in surgical evaluation and support the importance of early diagnosis and treatment by craniofacial surgeons.

Head Shape After Sagittal Craniosynostosis Surgery: Open Versus Endoscopic Strip Craniectomy

Purpose: Nonsyndromic sagittal craniosynostosis is treated surgically to improve skull cosmesis and to decrease the risk of raised intracranial pressure. The purpose of this study is to compare the outcomes of two current surgical techniques for craniosynostosis treatment, open and endoscopic strip craniectomy. Methods: A single institution retrospective chart review was conducted of patients with nonsyndromic sagittal craniosynostosis treated surgically from 2011 to 2016. Patients were divided into two groups based on surgical technique: open or endoscopic strip craniectomy. The head shape was assessed using pre- and postoperative cephalic index (CI). Complications and operative details were compared. Mean absolute CI over time and 95% confidence intervals were graphed. Results: A total of 51 children (36 male, 15 female; 13 open, 38 endoscopic) were included with an average length of follow-up of 27.2 months (range 4-60). The median age at surgery was 4.0 months for open and 3.0 months for endoscopic. There was no significant difference in preoperative CI between endoscopic and open groups (0.67 vs 0.66). The largest improvements in CI were seen 3 to 6 months postoperatively. There was a significant improvement in postoperative CI for both groups (endoscopic 0.75, P = .02; open = 0.74, P &lt; .01). From maximal postoperative CI to &gt;2 year follow up there was no significant regression in CI for the endoscopic group ( P = .12) and a small regression for the open group (−0.02, P = .01). There were no transfusions, brain injuries, or deaths. Patients in the endoscopic group had significantly less blood loss intraoperatively ( P = .01) and a significantly shorter duration of hospital stay compared to the open group ( P &lt; .001). Conclusions: Endoscopic and open surgical techniques are both effective treatments for nonsyndromic sagittal synostosis, with no difference in initial postoperative CI. These findings support the use of either technique and corroborate previous literature.

Multicenter comparison of head shape outcomes for three minimally invasive strip craniectomy techniques for sagittal craniosynostosis.

A literature gap exists comparing whole head shape outcome following correction of sagittal craniosynostosis. The objective of this multicenter study was to provide an analysis of long-term results following three different endoscopic strip craniectomy techniques for correction of sagittal craniosynostosis: 1) spring-assisted strip craniectomy, 2) wide-strip craniectomy with biparietal and bitemporal barrel-stave wedge osteotomies plus helmet orthosis, and 3) narrow-strip craniectomy plus orthosis without barrel staves. Pre- and postoperative 3D stereophotogrammetric images were collected from patients who underwent craniosynostosis surgery. Procedures were divided among institutions as follows: spring-assisted strip craniectomies were performed at Atrium Health Wake Forest Baptist Hospital; narrow-strip craniectomies were performed at St. Louis Children's Hospital by one craniofacial surgeon; and wide-vertex craniectomies were performed at St. Louis Children's Hospital prior to 2010, and then continued at Children's Medical Center Dallas. Pre- and postoperative 3D whole-head composite images were generated for each procedure to visually represent outcomes at final follow-up and compared with age-matched normal controls. Patients in the spring-assisted strip craniectomy group showed normalization of frontal bossing and skull height compared with age-matched controls, whereas patients undergoing wide-strip craniectomy showed greater correction of occipital protrusion. Patients in the narrow-strip craniectomy cohort had intermediate results between these outcomes. Nested aggregate head shapes showed good correction of head shapes from all techniques. This large, retrospective, multicenter study illustrated whole head shape outcomes from three different craniectomy procedures. Although each procedure showed some differences in loci of primary correction, all three surgical methods demonstrated good correction of primary scaphocephalic deformity.

Characterization of Regional Morphological Changes in Sagittal Craniosynostosis Following Endoscopic Strip Craniectomy With Post-operative Helmeting: Predictors for Success.

Sagittal craniosynostosis (SC) restricts craniofacial growth perpendicular to the sagittal plane resulting in scaphocephaly. The cranium grows in the anterior-posterior dimension causing disproportionate changes, which can be corrected with either cranial vault reconstruction (CVR) or endoscopic strip craniectomy (ESC) combined with post-operative helmet therapy. ESC is performed at an earlier age, and studies demonstrate benefits in risk profile and morbidity compared to CVR, with comparable results if the post-operative banding protocol is strictly upheld. We aim to identify predictors of successful outcome and, using three-dimensional (3D) imaging, assess cranial changes following ESC with post-banding therapy. A single institution retrospective review was performed from 2015-19 for patients with SC who underwent ESC. Patients received immediate post-operative 3D photogrammetry for helmet therapy planning and implementation as well as post-therapy 3D imaging. Using these 3D images, the cephalic index (CI) for study patients was calculated before and after helmet therapy. In addition, Deformetrica™ was used to measure volume and shape changes of pre-defined anatomic skull regions (frontal, parietal, temporal, & occipital) based on the pre- and post-therapy 3D imaging results. Fourteen institutional raters evaluated the pre- and post-therapy 3D imaging in order to determine the success of the helmeting therapy. Twenty-one SC patients met our inclusion criteria. Using 3D photogrammetry, 14 raters at our institution rated 16 of the 21 patients to have had successful helmet therapy. There was a significant difference in CI following helmet therapy with both groups, but there was no significant difference in CI between the "successful" and "unsuccessful" groups. Furthermore, the comparative analysis demonstrated that the parietal region had a significantly higher change in mean RMS distance when compared to the frontal or occipital regions. For patients with SC, 3D photogrammetry may be able to objectively recognize nuanced findings not readily detectable when using CI alone. The greatest changes in volume were observed in the parietal region, which falls in line with treatment goals for SC. Patients deemed to have unsuccessful outcomes were found to be older at time of surgery and initiation of helmet therapy. This suggests that early diagnosis and management for SC may increase the likelihood of success.

Comparison of Morphometric Outcomes following Open Posterior Expansion versus Endoscopic Strip Craniectomy for Sagittal Synostosis.

Open middle and posterior cranial vault expansion (OPVE) or endoscopic (ES) strip craniectomy are two surgical techniques for normalization of head shape in isolated sagittal synostosis. This study aims to compare 2-year cranial morphometrics after these two approaches. The authors performed morphometric analysis on preoperative [time (T) 0], immediately postoperative (T1), and 2-year (T2) postoperative computed tomographic scans of patients who underwent OPVE or ES before 4 months of age. Perioperative data and morphometrics were compared between the two groups and age-matched controls. Nineteen patients were included in the ES cohort, 19 age-matched patients were included in the OPVE cohort, and 57 were included as controls. Median surgery time and blood transfusion volume were less for the ES approach (118 minutes and 0 cc, respectively) compared with OPVE (204 minutes and 250 cc, respectively). Anthropometric measurements after OPVE were closer in normal controls at T1 compared with ES, but the skull shapes were comparable at T2. In the midsagittal plane, anterior vault was higher after OPVE at T2 compared with both ES and controls, but the posterior length was shorter and closer to controls than in the ES cohort. Cranial volumes were like controls for both cohorts at T2. There was no difference in complication rate. Both OPVE and ES techniques result in normalization of cranial shape in patients with isolated sagittal synostosis after 2 years with minimal morphometric differences. Family decision-making between the two approaches should be based on age at presentation, avoidance of blood transfusion, scar pattern, and availability of helmet molding and not on expected outcome. Therapeutic, III.

Orbital and Eyelid Characteristics, Strabismus, and Intracranial Pressure Control in Apert Children Treated by Endoscopic Strip Craniectomy versus Fronto-Orbital Advancement.

Twenty-five patients treated at Boston Children's Hospital met inclusion criteria for this retrospective cohort study. Primary outcomes were magnitude of palpebral fissure downslanting at 1, 3, and 5 years of age, severity of V-pattern strabismus, rectus muscle excyclorotation, and interventions to control ICP. Before craniofacial repair and through 1 year of age, none of the studied parameters differed for FOA versus ESC treated patients. Palpebral fissure downslanting became statistically greater for those treated by FOA by 3 (P < 0.001) and 5 years of age (P = 0.001). Likewise, severity of palpebral fissure downslanting correlated with severity of V-pattern strabismus at 3 (P = 0.004) and 5 (P = 0.002) years of age. Palpebral fissure downslanting and rectus muscle excyclorotation were typically coexistent (P = 0.053). Secondary interventions to control ICP were required in four of 14 patients treated by ESC (primarily FOA) and in two of 11 patients initially treated by FOA (primarily third ventriculostomy) (P = 0.661). Apert patients initially treated by ESC had less severe palpebral fissure downslanting and V-pattern strabismus, normalizing their appearance. Thirty percent initially treated by ESC required secondary FOA to control ICP.

Comparison of Outcomes for Endoscopic Simple Strip Craniectomy versus Endoscopic Strip Craniectomy with Wedge Osteotomies for Treatment of Sagittal Craniosynostosis

Objective: Endoscopic strip craniectomy is a safe and effective treatment for sagittal craniosynostosis in patients less than 4 months old. Although different correction techniques have been described, the most optimal approach remains controversial. This study was performed to compare early outcomes in children undergoing endoscopic strip craniectomy alone versus with bifrontal and biparietal limited or extended wedge osteotomies. Methods: A retrospective IRB-approved chart review was performed on patients with sagittal craniosynostosis treated with minimally invasive strip craniectomy at Children’s Hospital of Michigan in 2009-2022. Operative outcomes of endoscopic strip craniectomy alone (ESC), with limited osteotomies (ESC+LO), or with extended wedge osteotomies (ESC+EO) were compared. All patients underwent postoperative helmet molding therapy. Pre- and post-operative (at 6 weeks, 3 months, 6 months, and 1 year) cephalic indices (CI) were evaluated. Postoperative CI of 75-80 was graded as good result, and greater than 80 as excellent. Results: A total of 31 patients were included in this study; 7 were treated with ESC, 12 with ESC+LO, and 12 with ESC+EO. Mean age at surgery was 2.67 months. Overall, preoperative mean CI was 70.06 (62-81) and postoperative was 77.32 (68-84) at one year, with 17 of the 20 patients (85%) achieving good postoperative CI ≥75 and 5 patients (25%) achieving excellent postoperative CI >80. When assessing early outcomes, mean CI for ESC+LO group was significantly greater than that of ESC alone at 3 months (p=0.036) and 6 months (p=0.042) postoperatively; mean CI for ESC+EO was also significantly greater than that of ESC alone at 3 mo. (p=0.018) and 6 mo. (p=0.047). More dramatic percent increases in CI could be observed in ESC+EO at early time points (16.58% at 3 mo. and 15.14% at 6 mo.) and ESC+LO (13.95% at 3 mo. and 13.58% at 6 mo.) when compared to that of the ESC alone group (8.01% and 10.07% respectively). Conclusions: When comparing amongst the three techniques, endoscopic strip craniectomy with either degree of wedge osteotomies has more dramatic effect on changes in cephalic indices in early time points up to six-month follow-up period. Majority of patients were able to achieve satisfactory normalization of head shape as demonstrated by postoperative mean CI ≥75. Corresponding author: Arlene Rozzelle, MD, 3901 Beaubien Blvd, Detroit, MI 48201, [email protected], 313-745-0247

Endoscopic Strip Craniectomy and Helmet Therapy for Sagittal Craniosynostosis: An Analysis of Cranial Growth Changes in the Early Postoperative Period.

The purpose of this study is to analyze cranial width and length growth curves in the early postoperative period of patients by undergoing endoscopic sagittal strip craniectomy (ESC) to determine the timing of the maximal growth curve change. By analyzing the complex interplay of cephalic length and width measurements, we hope to better understand the cephalic index (CI) growth curve during this early period. This is the first of a multistep process to elucidate the ideal cranial remolding orthosis (CRO) treatment duration. Retrospective review. Tertiary academic institution. Children with isolated sagittal craniosynostosis. ESC and postoperative CRO treatment (2015-2019). One cranial orthotist obtained preoperative and postoperative measurements. The maximal rate of change of width, length, and CI were compared against the postoperative week these occurred. Thirteen children (mean age: 3.3 months, average preoperative CI: 73.4) underwent this intervention. CI reached its highest growth rate by 4.9 average weeks postoperatively, which correlated with the maximal width growth rate (5.2 weeks). Length curves reached their maximal growth rate by 15.5 weeks. CI peaked (81.3) by 22.7 weeks postoperatively, a significant increase from baseline. Following ESC, in the early postoperative period, the CI growth curve has 4 phases: initial rapid expansion, early and late slowed expansion, and plateau, followed by possible regression phases. This highlights the importance of early postoperative CRO initiation, CRO compliance, and properly fitting CROs, especially in the first 2 phases. This data sets the stage for investigating the ideal treatment length.

3-Dimensional Morphometric Outcomes After Endoscopic Strip Craniectomy for Unicoronal Synostosis.

Endoscopic strip craniectomy with postoperative helmeting (ESCH) for unicoronal synostosis has shown to be a less morbid procedure when compared with fronto-orbital remodeling (FOR). We aim in this pilot study to report objective methods and quantitative morphologic outcomes of endoscopically treated unicoronal synostosis using 3-dimensional surface scans. Our electronic records were reviewed for ophthalmological, neurodevelopmental outcomes, and helmet-related complications. For morphologic outcomes, the following parameters were used: Cranial Index, Cranial Vault Asymmetry Index, Anterior Symmetry Ratio (ASR), and Root Mean Square between the normal and synostotic sides of the head. Three-dimensional stereophotogrammetry scans were evaluated at 3 time points preoperative, 6 months post-op, and at the end of the treatment, which was compared with age-matched scans of normal controls and FOR patients. Nonparametric tests were used for statistical analysis. None of the ESCH cases developed strabismus, major neurodevelopmental delay, or helmet complications. All morphologic parameters improved significantly at 6 months post-op except for the Cranial Vault Asymmetry Index. The ASR was the only parameter to change significantly between 6 months post-op and final scans. At end of helmet treatment, ASR and Root Mean Square differed significantly between the ESCH and both FOR and control groups. Endoscopic strip craniectomy with postoperative helmeting for single unicoronal synostosis had excellent clinical outcomes. Most of the improvement in head morphology occurred in the first 6 months of treatment. Despite the normalization of the overall head shape, there was residual asymmetry in the frontal and temporal regions of the head.