Nonsyndromic Sagittal Synostosis Research Articles

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.

Eye and Orbital Anatomy in Metopic Synostosis.

Metopic synostosis patients have a high prevalence of orthoptic anomalies, including hyperopia, astigmatism, and amblyopia. We hypothesized altered orbital anatomy contributes to suboptimal visual outcomes by adversely affecting eye anatomy and growth from early life onward. Therefore, we aimed to investigate eye and orbital anatomy in metopic synostosis. We conducted a retrospective study in nonsyndromic metopic synostosis patients (n = 134, median age 0.43 years [IQR 0.45]) with nonsyndromic sagittal synostosis patients (n = 134, median age 0.27 years [IQR 0.23]) as controls. Primary analyses focused on eye dimensions (axial length, width, and globe height) and orbital dimensions, correcting for sex and age. Measurements were obtained from preoperative computed tomography scans. Axial length and width in metopic synostosis patients did not differ from sagittal synostosis patients, but globe height was significantly smaller (P = 0.0002). Lateral wall interorbital length, lateral orbital wall length, anterior medial interorbital length, and maximal medial interorbital length were significantly smaller, and anterior vertical orbital height and maximal vertical orbital height were significantly larger (P < 0.001). The central orbital axis and interorbital angle were significantly narrower, and medial-to-lateral orbital wall angle was wider (P < 0.001). Metopic synostosis patients have more shallow, wider, and higher orbits. Eye dimensions are similar in sagittal synostosis patients, although globe height was smaller. Altered orbital and eye dimensions in metopic synostosis probably have a causal relation with an unknown order of development. How these dimensions relate to future orthoptic anomalies (eg, refractive error) needs further investigation.

A Photo Score For Aesthetic Outcome In Sagittal Synostosis: An ERN CRANIO Collaboration.

European Reference Network (ERN) CRANIO is focused on optimizing care for patients with rare or complex craniofacial anomalies, including craniosynostosis and/or rare ear, nose, and throat disorders. The main goal of ERN CRANIO is to collect uniform data on treatment outcomes for multicenter comparison. We aimed to develop a reproducible and reliable suture-specific photo score that can be used for cross-center comparison of phenotypical severity of sagittal synostosis and aesthetic outcome of treatment. We conducted a retrospective study among nonsyndromic sagittal synostosis patients aged <19 years. We included preoperative and postoperative photo sets from 6 ERN CRANIO centers. Photo sets included bird's eye, lateral, and anterior-posterior views. The sagittal synostosis photo score was discussed in the working group, and consensus was obtained on its contents. Interrater agreement was assessed with weighted Fleiss' Kappa and intraclass correlation coefficients.The photo score consisted of frontal bossing, elongated skull, biparietal narrowness, temporal hollowing, vertex line depression, occipital bullet, and overall phenotype. Each item was scored as normal, mild, moderate, or severe. Results from 36 scaphocephaly patients scored by 20 raters showed kappa values ranging from 0.38 [95% bootstrap CI: 0.31, 0.45] for biparietal narrowness to 0.56 [95% bootstrap CI: 0.47, 0.64] for frontal bossing. Agreement was highest for the sum score of individual items [intraclass correlation coefficients agreement 0.69 [95% CI: 0.57, 0.82]. This is the first large-scale multicenter study in which experts investigated a photo score to assess the severity of sagittal synostosis phenotypical characteristics. Agreement on phenotypical characteristics was suboptimal (fair-moderate agreement) and highest for the summed score of individual photo score items (substantial agreement), indicating that although experts interpret phenotypical characteristics differently, there is consensus on overall phenotypical severity.

Comparative Analysis of 2D and 3D Metrics for Evaluation of Postoperative Outcomes Following Endoscopic Suturectomy for Sagittal Craniosynostosis.

To assess whether 3-dimensional (3D) volumetrics can be used to track and evaluate postoperative course of patients treated with endoscopic suturectomy for nonsyndromic sagittal synostosis, we compared changes in 2-dimensional (2D) measurements along with 3D volumetric correlates throughout the period of helmet therapy. Forty-six patients treated at our institution with endoscopic suturectomy for sagittal synostosis were retrospectively reviewed. Head circumference (HC), cephalic index (CI), and total cranial volumes (TCVs) were measured at 3 timepoints following surgery using optical surface scans obtained for helmet orthotics. All measurements showed significant differences between timepoints on the analysis of variance ( P <0.001). There was a significant correlation between CI and TCV (r=0.35, P =0.004) and between HC and TCV (r=0.81, P <0.001). The normalized rate of change over the course of treatment was significantly higher for TCV (36.7%) than for CI (8.8%) and HC (8.4%, P <0.001), with no difference between HC and CI. The authors conclude that 3D metrics were able to reliably follow the course of postoperative 2D metrics. There was a direct and linear correlation between HC and CI with TCV. Total cranial volumes showed the highest rate of sustained change at every timepoint. Although CI and HC plateau after the first measurement, TCV continues to adapt over the course of treatment. These results demonstrate the feasibility and value of volumetrics from 3D imaging to provide a more comprehensive evaluation of postoperative surgical outcomes than traditional 2D metrics without the ionizing radiation traditionally utilized for CT to obtain 3D metrics.

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.

Evaluation of the clinical efficacy of minimally invasive endoscopic surgery in the treatment of isolated non-syndromic sagittal synostosis in infants

The current study aimed to evaluate the early efficacy in infants with isolated non-syndromic sagittal synostosis who underwent minimally invasive endoscopic-assisted surgery. The clinical data of infants with isolated non-syndromic sagittal synostosis who were admitted to the Department of Neurosurgery of the Children's Hospital of Nanjing Medical University and underwent endoscopic-assisted surgery from October 2018 to December 2021 were retrospectively analyzed. All the infants underwent minimally invasive endoscopic-assisted surgery, and were treated with supine sleeping position after surgery. Computer-aided reconstruction technique was used to reconstruct and measure the thin-slice CT scan images of the head before and 3 months after surgery, and the differences in cranial index (CI), cranial cavity volume and angle drawn between the cranial vertex, nasion, and opisthocranion (VNO angle) of preoperative and postoperative groups were analyzed. A total of 103 infants were included in the final analysis, including 85 males and 18 females. The age at surgery was (2.1±0.8) months, and the weight was (6.1±0.9) kg. The postoperative CI was (84±6)%, which increased obviously compared with the pre-operation [(70±5)%] (P<0.001). The cranial volume of post-operation was (947±130) cm³, which was larger than that of the pre-operation [(748±104) cm³] (P<0.001). The VNO angle after surgery was (45±4)°, which showed a significant reduction compared with the pre-operation [(55±4)°] (P<0.001). The correction of head shape was satisfactory. For the treatment of sagittal synostosis in infants, minimally invasive endoscopic-assisted surgery is safe and effective, and in the case of switching from an auxiliary helmet to a supine position, the postoperative correction efficacy of head shape is better.

Springs Produce Favorable Morphological Outcomes Relative to H-craniectomy According to a Two-center Comparison of Matched Cases.

Sagittal synostosis is the most common type of premature suture closure, and many surgical techniques are used to correct scaphocephalic skull shape. Given the rarity of direct comparisons of different surgical techniques for correcting craniosynostosis, this study compared outcomes of craniotomy combined with springs and H-craniectomy for non-syndromic sagittal synostosis. Comparisons were performed using available pre- and postoperative imaging and follow-up data from the two craniofacial national referral centers in Sweden, which perform two different surgical techniques: craniotomy combined with springs (Gothenburg) and H-craniectomy (Renier's technique; Uppsala). The study included 23 pairs of patients matched for sex, preoperative cephalic index (CI), and age. CI, total intracranial volume (ICV), and partial ICV were measured before surgery and at 3 years of age, with volume measurements compared against those of pre- and postoperative controls. Perioperative data included operation time, blood loss, volume of transfused blood, and length of hospital stay. Craniotomy combined with springs resulted in less bleeding and lower transfusion rates than H-craniectomy. Although the spring technique requires two operations, the mean total operation time was similar for both methods. Of the three complications that occurred in the group treated with springs, two were spring-related. Importantly, the compiled analysis of changes in CI and partial volume distribution revealed that craniotomy combined with springs resulted in superior morphological correction. The findings showed that craniotomy combined with springs normalized cranial morphology to a greater extent than H-craniectomy based on changes in CI and total and partial ICVs over time.

Sagittal Craniosynostosis: Comparing Surgical Techniques Using 3D Photogrammetry.

The aim of this study was to compare three surgical interventions for correction of sagittal synostosis-frontobiparietal remodeling (FBR), extended strip craniotomy (ESC), and spring-assisted correction (SAC)-based on three-dimensional (3D) photogrammetry and operation characteristics. Patients who were born between 1991 and 2019 and diagnosed with nonsyndromic sagittal synostosis who underwent FBR, ESC, or SAC and had at least one postoperative 3D photogrammetry image taken during one of six follow-up appointments until age 6 were considered for this study. Operative characteristics, postoperative complications, reinterventions, and presence of intracranial hypertension were collected. To assess cranial growth, orthogonal cranial slices and 3D photocephalometric measurements were extracted automatically and evaluated from 3D photogrammetry images. A total of 322 postoperative 3D images from 218 patients were included. After correcting for age and sex, no significant differences were observed in 3D photocephalometric measurements. Mean cranial shapes suggested that postoperative growth and shape gradually normalized with higher occipitofrontal head circumference and intracranial volume values compared with normal values, regardless of type of surgery. Flattening of the vertex seems to persist after surgical correction. The authors' cranial 3D mesh processing tool has been made publicly available as a part of this study. The findings suggest that until age 6, there are no significant differences among the FBR, ESC, and SAC in their ability to correct sagittal synostosis with regard to 3D photocephalometric measurements. Therefore, efforts should be made to ensure early diagnosis so that minimally invasive surgery is a viable treatment option. Therapeutic, III.

Posterior Cranial Retraction Combined With Bilateral Parietal Distraction for Children With Nonsyndromic Craniosynostosis.

The nonsyndromic craniosynostosis is the most common of craniosynostoses in childhood. There are many treatments. We aim to treat 12 cases of nonsyndromic craniosynostosis via posterior cranial vault distraction osteogenesis combined with bilateral parietal distraction. Data of a total of 12 patients (7 boys and 5 girls) with nonsyndromic sagittal synostosis who underwent distraction osteogenesis between January 2015 and August 2020 were retrospectively analyzed. Bilateral parietal bone flaps and posterior occipital flaps were designed and cut. Then, distraction device was placed, which was distracted at 5 days after surgery (twice per day, 0.4-0.6 mm/d, and lasting for 10-15 days). After 6 months of fixation, the secondary surgery was performed to remove the device. The scaphocephaly was corrected, and the appearance was satisfactory. Postoperative follow-up time was 6 to 14 months, with an average of 10 months, and the mean CI was 63.2 and 78.25 before and after surgery, respectively; the mean anterior-posterior skull diameter was shortened (12.63 ± 3.47) mm, the transverse diameter of both temporal regions was lengthened (15.4 ± 4.18) mm, and the scaphocephalic deformity was significantly improved. There was no detachment or rupture of the extender postoperatively. No severe complications, such as radiation necrosis or intracranial infection, were observed. Posterior cranial retraction combined with bilateral parietal distraction in children with nonsyndromic craniosynostosis, in which the proposed technique did not exhibit severe complications, and it is worthy of further promotion and application in clinical practice.

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.

Morphometric Outcomes of Nonsyndromic Sagittal Synostosis following Open Middle and Posterior Cranial Vault Expansion.

This study aimed to quantify the change in three-dimensional skull morphometrics for patients with sagittal synostosis at presentation, after surgery, and at 2-year follow-up. Computed tomography scans from 91 patients with isolated SS were age-, sex-, and race-matched with those from 273 controls. The authors performed vector analysis with linear regressions to model the effect of open middle and posterior cranial vault remodeling on cranial shape and growth. Anterior cranial volume, bossing angle, and frontal shape were not changed by surgery but normalized without surgical intervention by 2 years. Biparietal narrowing and middle cranial volume were corrected after surgery and maintained at 2 years. Occipital protuberance was improved after surgery and normalized at 2 years. Posterior cranial volume was decreased by occipital remodeling and remained slightly lower than control volumes at 2 years, whereas middle vault volume was larger than in controls. Residual deformities that persisted at 2 years were decreased superolateral width at the level of opisthion and increased anterosuperior height (vertex bulge). Linear models suggested older age at surgery resulted in more scaphocephaly and enlarged posterior cranial vault volumes at 2 years but did not affect other volume outcomes. Preoperative severity was the variable most predictive of 2-year morphometrics. Initial severity of sagittal synostosis deformity was the best predictor of 2-year morphometric outcomes. Upper posterior cranial width decreases with time after surgery and an anterior vertex bulge can persist after open surgery, but frontal dysmorphology self-corrects without surgical intervention. Therapeutic, IV.

Retrospective Investigation of Cranial Volume and Cephalic Index in Patients with Nonsyndromic Sagittal Synostosis Operated by Total Vault Remodeling

Background: Premature fusion of cranial sutures affects skull development and leads to head deformity. Intracranial pressure increase and brain growth restriction can occur in untreated craniosynostosis. Operative treatment aims to achieve an immediate and long-lasting correction of skull shape that is close to the average and to prevent or release possible increased intracranial pressure by increasing the intracranial volume (ICV) or normalizing the ICV if it is already below the standards. This study was designed to evaluate the effect of a total calvarial reconstruction on skull development in patients with nonsyndromic sagittal synostosis. Material and Methods: The study population included 19 male and 5 female patients with isolated nonsyndromic sagittal suture synostosis. During the operation, temporarily fixed prebent metal plates provided an intraoperative reference for the desired cranial expansion gain of height and shortening. Preoperative and postoperative ICVs and cephalic indices were measured on computed tomography datasets using the software program ImageJ and were compared with one another and with normative data. Results: The male population presented with a preoperative mean ICV of 863.3 cm³. A postoperative mean ICV increase of 243.5 cm³ (p < 0.001) and a further ICV enlargement (p < 0.001) was measured. The mean CI changed from 71.0% preoperatively to 75.4% postoperatively (p = 0.002) and decreased insignificantly in the follow-up (p = 0.546). The female population had a preoperative mean ICV of 804.9 cm³. Postoperatively, the mean ICV increased by 211.1 cm³ (p = 0.043) and also increased in the follow-up (p = 0.043). Their mean CI values increased from 66.5% preoperatively to 72.8% (p = 0.043) postoperatively and decreased insignificantly in the follow-up (p = 0.345). Conclusion: This method of total vault remodeling provides reliable ICV increase and improvement in length and width of skull proportions beyond the immediate postoperative period together with an ICV increase.

An Investigation of the Relationship Between the Second-to-Fourth Digit Ratio and Sagittal Synostosis.

The most common presentation of nonsyndromic craniosynostosis is that of the sagittal suture. Amongst this subgroup there is a significant male preponderance. Although the etiology is largely unknown, androgen exposure in utero has been suggested as a contributing factor. The second-to-fourth digit ratio (2D:4D) is a sexually dimorphic trait, reflective of the levels of androgen and estrogen exposure in utero, with a lower 2D:4D ratio associated with higher androgen exposure.This study aimed to examine the difference in 2D:4D ratio between participants with sagittal synostosis (SS) and gender- matched controls, hypothesizing that alterations in androgen exposure would be reflected in participants' 2D:4D ratio. Participants with nonsyndromic SS and gender-matched controls were prospectively recruited from outpatients clinics. Photographs were taken of the right hand, and 3 independent researchers measured the length of the fingers and 2D:4D ratio, with the mean 2D:4D ratio then calculated. Fifty-six participants were recruited to both groups, with 35 males and 21 females in each. The mean age of the study and control groups were 5.6 and 6.3 years, respectively. There was no difference in the 2D:4D ratio between groups overall ( P = 0.126). However, males with SS had a significantly higher 2D:4D ratio in comparison to male controls (0.969 ± 0.379 versus 0.950 ± 0.354, P = 0.038). Our results suggest that 1 single hormonal pathway is not responsible for suture fusion. Subsequently we consider that an imbalance between testosterone and estrogen signaling may contribute to the development of sagittal craniosynostosis.

Do standard surgical techniques lead to satisfying aesthetic results in nonsyndromic sagittal suture synostosis?

Surgical correction of synostotic cranial sutures is typically performed early in an affected child's life. Depending on the severity of the cranial synostoses, different aspects of the surgical treatment may have varying degrees of importance. In this sense, the aesthetic appearance in children with normal neurological development in single-suture synostosis plays an important role in self-perception and social acceptance for both the patients themselves and their caregivers. Therefore, in this study, the authors aimed to evaluate the aesthetic outcome after surgical correction in a cohort of patients with nonsyndromic sagittal suture synostosis. Between December 2002 and December 2019, a total of 99 patients underwent surgical correction of a synostotic sagittal suture at the Medical University of Vienna. Depending on their age, patients underwent either an extended midline strip craniectomy (EMSC) (< 4 months) or a modified pi procedure (MPP) (≥ 4 months). After the surgical procedure, the outcome was evaluated by the treating neurosurgeon at 1- and 12-month follow-up visits, and after approximately 5 years, before the patient entered elementary school. In addition to that, the patients' caregivers were asked to evaluate the aesthetic outcome of the surgical procedure after 12 months. These results were then compared to evaluate potential differences in the perception of the surgical outcome. After 12 months, the majority of the included patients were evaluated as having a good aesthetic outcome by the treating neurosurgeon (97%) and by their caregivers (89%). These differences did not show statistical significance (p = 0.11). Similarly, no differences in the aesthetic outcome depending on the surgical procedure performed could be found (p = 0.55). At the last follow-up visit, before entering elementary school, all available patients had an excellent or good surgical outcome. Moreover, the majority of caregivers (73%) reported that their child had a normal head shape appearance after surgical correction. The results of this study have suggested that surgical correction of sagittal suture synostosis by simple operative techniques leads to a good aesthetic outcome and a normal head shape appearance in the majority of patients. An analysis of the evaluation of the surgical outcome by either the treating neurosurgeon or the patient caregivers showed comparable results and, thus, early intervention with simple surgical techniques can be recommended.

Cranial Vault Distraction in Nonsyndromic Sagittal Synostosis.

A multitude of operations exists for the treatment of patients with sagittal craniosynostosis presenting after 6 months of age, of which total cranial vault remodeling now provides the most reliable aesthetic outcome. As our national craniofacial center evolved and began to develop a comprehensive multi-disciplinary team to manage complex surgical cases, we offered cranial vault distraction as an alternative to more invasive surgery for late presentation nonsyndromic scaphocephaly. The authors conducted a retrospective review of all patients undergoing this procedure.An average distraction distance of 39.4 mm was achieved in 15 patients aged 1 to 9 years. As a result, the cephalic index changed an average of 4%. The mean transfusion volume in the perioperative period was 32.47% of estimated blood volume. There were 2 complications requiring further operative intervention and distraction was stopped early in 1 patient.The authors propose that internal calvarial distraction is a viable alternative to total cranial vault remodeling for the management of late presentations of sagittal craniosynostosis.

Vascularized Pericranial Flap as a Method to Prevent Persistent Skull Defects After Craniectomy for Sagittal Synostosis.

Some cranial defects resulting from sagittal craniectomy for craniosynostosis never completely close and require cranioplasty. This study evaluates the results of 2 methods to minimize such defects: (1) trapezoidal craniectomy that is narrower posteriorly (2) vascularized pericranial flap that is sewn to the dura under a rectangular craniectomy.Children who underwent primary open sagittal craniectomy with biparietal morcellation (with/without frontal cranioplasty) for single-suture nonsyndromic sagittal synostosis from 2013 through 2018 were included. Children were excluded if there was a dural tear, if they had no 1-year follow-up, or if they had unmeasured and/or uncounted skull defects. Surgeries were divided into (1) standard craniectomy, (2) trapezoidal craniectomy, or (3) craniectomy with pericranial flap. Differences in percentage of children with defects and mean total defect area 1 year postsurgery were compared between the 3 groups.We reviewed 148 cases. After exclusions, 34 of 53 children (64%) who underwent standard craniectomy, 6 of 17 children (35%) who had pericranial flaps, and 5 of 11 children (46%) who underwent trapezoidal craniectomy had defects 1 year postsurgery. The percentage of children with defects (P = 0.0364) but not the defect area was significantly higher in the standard craniectomy than in the pericranial flap group. The percentage of subjects with defects was not significantly different between the standard and the trapezoidal craniectomy groups.Sewing a vascularized pericranial flap to the dura at the craniectomy site may protect against persistent bony defects after sagittal craniectomy for craniosynostosis. Longer follow-up is needed to determine if this technique leads to lower rates of cranioplasty.

Evaluating Surgical Decision-making in Nonsyndromic Sagittal Craniosynostosis Using a Digital 3D Model.

Background:Surgical correction of craniosynostosis addresses potentially elevated intracranial pressure and the cranial deformity. In nonsyndromic sagittal synostosis, approximately 15% of patients have elevated intracranial pressure. The decision to operate therefore likely reflects a combination of aesthetic goals, prevention of brain growth restriction over time, surgeon training and experience, and parental expectations. This study examines clinical factors that influence surgical decision-making in nonsyndromic sagittal synostosis.Methods:An online survey sent to craniofacial and neurosurgeons presented 5 theoretical patients with varying severities of sagittal synostosis. For each cephalic index, 4 separate clinical scenarios were presented to assess influences of parental concern and developmental delay on the decision to operate.Results:Fifty-six surveys were completed (response rate = 28%). Participants were predominantly from North America (57%), had over 10 years of experience (75%), and performed over 20 craniosynostosis procedures annually (50%). Thirty percent of respondents indicated they would operate regardless of head shape and without clinical and/or parental concern. Head shape was the greatest predictor of decision to operate (P < 0.001). Parental concern and developmental delay were independently associated with decision to operate (P < 0.001). Surgeons with more experience were also more likely to operate across all phenotypes (OR: 2.69, P < 0.004).Conclusions:Surgeons responding to this survey were more strongly compelled to operate on children with nonsyndromic sagittal craniosynostosis when head shape was more severe. Additional factors, including parental concern and developmental delay, also influence the decision to operate, especially for moderate phenotypes. Geographic and subspecialty variations were not significant.

Improved cephalic index following early cranial vault remodeling in patients with isolated nonsyndromic sagittal synostosis

Isolated nonsyndromic sagittal synostosis (SS) is the most common form of craniosynostosis in children, accounting for approximately 60% of all craniosynostoses. The typical cranial measurement used to define and follow SS is the cephalic index (CI). Several surgical techniques have been suggested, but agreement on type and timing of surgery is lacking. This study aimed to evaluate the authors' institutional experience of surgically treating SS using a modified subtotal cranial vault remodeling technique in a population-based cohort. Special attention was directed toward the effect of patient age at time of surgery on long-term CI outcome. A retrospective analysis was conducted on all patients with isolated nonsyndromic SS who were surgically treated from 2003 to 2011. Data from electronic medical records were gathered. Eighty-two patients with SS were identified, 77 fulfilled inclusion criteria, and 72 had sufficient follow-up data and were included. CI during follow-up after surgery was investigated with ANOVA and a linear mixed model. In total, 72 patients were analyzed, consisting of 16 females (22%) and 56 males (78%). The mean ± SD age at surgery was 4.1 ± 3.1 months. Blood transfusions were received by 81% of patients (26% intraoperatively, 64% postoperatively, 9% both). The mean ± SD time in the pediatric ICU was 1.1 ± 0.25 days, and the mean ± SD total hospital length of stay was 4.6 ± 2.0 days. No patient required reoperation. The mean ± SD CI increased from 69 ± 3 to 87 ± 5 for patients who underwent surgery before 45 days of age. Surgery resulted in a larger increase in CI for patients who underwent surgery at a younger age compared with older patients (p < 0.05, Tukey's HSD test). In the comparison of patients who underwent surgery before 45 days of age with patients who underwent surgery at 45-90, 90-180, and more than 180 days of age, the linear mixed model estimated a long-term loss of CI of 3.0, 5.5, and 7.4 points, respectively. The modified subtotal cranial vault remodeling technique used in this study significantly improved CI in patients with SS. The best results were achieved when surgery was performed early in life.

Evolution of Surgical Management of Sagittal Synostosis.

Numerous methods for surgical correction of sagittal synostosis have been described in the literature, yielding similar outcomes. At the authors' institution, surgical approaches to correct this condition have evolved over the past few decades, including Π, H-type craniectomies (Renier), endoscopic suturectomy, and our current technique, the FLAG procedure. Our aim is to review the evolution of these surgical techniques at our institution and compare patient outcomes. A retrospective review was performed on consecutive patients undergoing correction for craniosynostosis from 2008 to 2018. All patients with a diagnosis of nonsyndromic isolated sagittal craniosynostosis were included and classified into one of 4 groups by the type of surgical correction performed (H-type, FLAG, endoscopic, other). The authors identified 166 consecutive patients with a mean age at time of surgery of 6.7 ± 4.0 months. 91 (54.8%) carried a diagnosis of nonsyndromic sagittal synostosis. 63 patients underwent H-type procedures, 9 underwent FLAG procedures, 5 underwent endoscopic procedures, and 14 were classified as other (distraction or other implant). Perioperatively, the FLAG group had the shortest ICU stay (1.3 days, P < 0.05), postoperative transfusion requirement (42cc pRBC, P < 0.001), and complication rate (0.0%). The endoscopic group had the shortest surgical time at 2.00 hours (p < 0.001). No statistically significant difference in cranial index or revision procedures between the four groups was identified. Overall, the mean length of follow-up was 25.3 months. All procedures had similar results for cranial index with decreased surgical time, transfusion volume, and hospital stay seen in FLAG and endoscopic groups.

A Case of Non-syndromic Craniosynostosis

Craniosynostosis refers to skull deformities secondary to the premature closure of cranial suture. Isolated or multiple sutures craniosynostosis is more common than syndromic craniosynostosis. Deformities with synostosis are stigmatizing, and this provides a strong aesthetic indication for surgical correction in the non-syndromic group of patients. We present a case of non-syndromic sagittal synostosis in a ten months old patient underwent open surgical repair for skull deformity.International Journal of Human and Health Sciences Vol. 05 No. 02 April’21 Page: 254-257