Search

Background and Objectives: Metopic craniosynostosis can be treated by fronto-orbital advancement or endoscopic strip craniectomy with postoperative helmeting. Infants younger than 6 months of age are eligible for the endoscopic repair. One-year postoperative anthropometric outcomes have been shown to be equivalent, with significantly less morbidity after endoscopic treatment. The authors hypothesized that both repairs would yield equivalent anthropometric outcomes at 5-years postoperative., Methods: This study was a retrospective chart review of 31 consecutive nonsyndromic patients with isolated metopic craniosynostosis treated with either endoscopic or open correction. The primary anthropometric outcomes were frontal width, interfrontal divergence angle, the Whitaker classification, and the presence of lateral frontal retrusion. Peri-operative variables included estimated blood loss, rates of blood transfusion, length of stay, and operating time., Results: There was a significantly lower rate of lateral frontal retrusion in the endoscopic group. No statistically significant differences were found in the other 3 anthropometric outcomes at 5-years postoperative. The endoscopic group was younger at the time of surgery and had improved peri-operative outcomes related to operating time, hospital stay and blood loss. Both groups had low complication and reoperation rates., Conclusions: In our cohort of school-aged children with isolated metopic craniosynostosis, patients who underwent endoscopic repair had superior or equivalent outcomes on all 4 primary anthropometric measures compared with those who underwent open repair. Endoscopic repair was associated with significantly faster recovery and decreased morbidity. Endoscopic repair should be considered in patients diagnosed with metopic craniosynostosis before 6 months of age., Competing Interests: POTENTIAL CONFLICTS OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Introduction: Partial synostosis of cranial sutures has been shown to have clinical and diagnostic significance. However, there is limited published information about how suture fusion progresses over time. In this study, we evaluate patients with nonsyndromic single-suture synostosis. We aim to define the incidence of partial versus complete suture fusion and whether a correlation exists between the degree of suture fusion and age., Methods: Two hundred fifty-four patients with nonsyndromic single-suture synostosis were evaluated. Preoperative computed tomography (CT) scans were rendered in 3-dimensions, all sutures were visualized and assessed for patency or fusion, and length of fusion was measured. Findings were grouped according to suture type (sagittal, coronal, metopic, or lambdoid), the degree of fusion (full, >50%, or <50%), and patient age at time of CT scan (0-90, 91-180, 181-360, or >360 days). Data were analyzed to correlate patient age versus the degree of suture fusion., Results: For all patients, 72% had complete and 28% had partial synostosis. Ratios of full to partial fusion for each suture type were as follows: sagittal 97:36, coronal 35:22, metopic 46:4, and lambdoid 4:10. The sagittal, coronal, and metopic groups demonstrated greater probabilities of complete suture fusion as patient age increases ( P = .021, P < .001, P = .001, respectively). This trend was also noted when all sutures were considered together by age-group ( P < .001)., Conclusion: We note a partial suture fusion rate of 28.3%. Our analysis shows a correlation between the extent of suture synostosis and patient age. Finally, we demonstrate that different sutures display different patterns of partial and complete fusion.

Background: The need for surgical correction of frontal bossing in patients with sagittal synostosis is currently debated. The authors retrospectively analyzed frontal bossing in patients with isolated, nonsyndromic sagittal synostosis who underwent calvarial remodeling with and without frontal craniotomy and compared with control subjects., Methods: The authors analyzed computed tomography (CT) scans of patients with sagittal synostosis <9 months of age (6.2 ± 1.6 months) who underwent modified-pi procedure either with frontal craniotomy (FC, n = 15) or without frontal craniotomy (NFC, n = 10). Only patients treated with both pre-operative and 1-year post-operative CT scans were included. Non-synostotic age-matched control scans were also analyzed. Cephalic index (CI), 3 previously validated measures of frontal bossing (bossing angle, horizontal bossing ratio, and vertical bossing ratio), and pre-nasion volume ratio were obtained. Additionally, three-dimensional photographs of 10 FC patients were evaluated for frontal bossing between 1 and 8 years post-operatively., Results: Pre-operatively, no significant differences were found between the 2 groups (.064

OBJECTIVE Endoscope-assisted repair of sagittal craniosynostosis was adopted at St. Louis Children's Hospital in 2006. This study examines the first 100 cases and reviews the outcomes and evolution of patient care protocols at our institution. METHODS The authors performed a retrospective chart review of the first 100 consecutive endoscopic repairs of sagittal craniosynostosis between 2006 and 2014. The data associated with length of hospital stay, blood loss, transfusion rates, operative times, cephalic indices (CIs), complications, and cranial remolding orthosis were reviewed. Measurements were taken from available preoperative and 1-year postoperative 3D reconstructed CT scans. RESULTS The patients' mean age at surgery was 3.3 ± 1.1 months. Of the 100 patients, 30 were female and 70 were male. The following perioperative data were noted. The mean operative time (± SD) was 77.1 ± 22.2 minutes, the mean estimated blood loss was 34.0 ± 34.8 ml, and the mean length of stay was 1.1 ± 0.4 days; 9% of patients required transfusions; and the mean pre- and postoperative CI values were 69.1 ± 3.8 and 77.7 ± 4.2, respectively. Conversion to open technique was required in 1 case due to presence of a large emissary vein that was difficult to control endoscopically. The mean duration of helmet therapy was 8.0 ± 2.9 months. Parietal osteotomies were eventually excluded from the procedure. CONCLUSIONS The clinical outcomes and improvements in CI seen in our population are similar to those seen at other high-volume centers. Since the inception of endoscope-assisted repair at our institution, the patient care protocol has undergone several significant changes. We have been able to remove less cranium using our "narrow-vertex" suturectomy technique without affecting patient safety or outcome. Patient compliance with helmet therapy and collaborative care with the orthotists remain the most essential aspects of a successful outcome.

Purpose: Treatment of metopic craniosynostosis is performed by either fronto-orbital advancement (FOA) or endoscopic-assisted techniques. Interfrontal angle (IFA) is a validated measure of trigonocephaly, but requires a computed tomography scan. The most common direct measure to assess surgical outcome in patients with trigonocephaly is frontal width (ft-ft). The aim of this study is to determine if frontal width correlates with IFA and successful surgical correction 1 year after treatment. A review of current morphologic assessment techniques is also provided., Methods: Three-dimensional computed tomography scans (preoperative and 1 year postoperative) of patients who underwent FOA (n = 13) or endoscopic (n = 13) treatment of metopic craniosynostosis were reviewed. Age-matched scans of unaffected patients served as controls. Frontal width was measured by a straight line between the bilateral frontotemporal points. Measurements were performed by 2 experienced observers and compared to IFA., Results: Mean frontal width at preoperative scan for endoscopic and open patients was 55 ± 0.6 and 64 ± 0.7 mm, respectively (Z-score 1.6 and -3.7). Mean frontal width at postoperative scan for endoscopic and open patients was 80 ± 0.4 and 81 ± 0.7 mm (Z-score 0.0 for both groups). Frontal width for endoscopic correction significantly correlated with IFA (r = 0.536, P = 0.005), as well as for the open patients (r = 0.704, P < 0.001)., Conclusion: Frontal width normalizes 1 year after operation, regardless of technique. Advantage of frontal width is that it can be measured in the clinic using a spreading vernier caliper. It correlates well with IFA and can be used as a metric for morphologic outcome.

Introduction: Several bioresorbable plating systems have become standard in pediatric craniosynostosis reconstruction. A comparison of these systems is needed to aid surgeons in the preoperative planning process. The authors aim to evaluate 1 institution's experience using Resorb-X by KLS Martin and Delta Resorbable Fixation System by Stryker (Stryker Craniomaxillofacial, Kalamazoo, MI)., Methods: A sample of patients with single-suture nonsyndromic craniosynostosis treated at St Louis Children's Hospital between 2007 and 2014 using either Resorb-X or Delta bioresorbable plating systems were reviewed. Only patients with preoperative, immediate, and long-term 3-dimensional photographic images or computed tomography scans were included. A comparison of plating system outcomes was performed to determine the need for clinic and emergency room visits, imaging obtained, and incidence of subsequent surgical procedures due to complications., Results: Forty-six patients (24 Resorb-X and 22 Delta) underwent open repair with bioabsorbable plating for single suture craniosynostosis. The mean age at each imaging time point was similar between the 2 plating systems (P > 0.717). Deformity-specific measures for sagittal (cranial index), metopic (interfrontotemporale), and unicoronal (frontal asymmetry) synostosis were equivalent between the systems at all time points (0.05 < P < 0.904). A single Delta patient developed bilateral scalp cellulitis and abscesses and subsequently required operative intervention and antibiotics., Conclusion: Bioabsorbable plating for craniosynostosis in children is effective and has low morbidity. In our experience, the authors did not find a difference between the outcomes and safety profiles between Resorb-X and Delta.

OBJECTIVE Endoscope-assisted methods for treatment of craniosynostosis have reported benefits over open calvarial vault reconstruction. In this paper, the authors evaluated 2 methods for endoscope-assisted correction of sagittal synostosis: wide vertex suturectomy and barrel stave osteotomies (WVS+BSO) and narrow vertex suturectomy (NVS). METHODS The authors evaluated patients with nonsyndromic sagittal synostosis treated with either wide vertex suturectomy (4-6 cm) and barrel stave osteotomies (WVS+BSO) or narrow vertex suturectomy (NVS) (approximately 2 cm) between October 2006 and July 2013. Prospectively collected data included patient age, sex, operative time, estimated blood loss (EBL), postoperative hemoglobin level, number of transfusions, complications, and cephalic index. Fourteen patients in the NVS group were age matched to 14 patients in the WVS+BSO group. Descriptive statistics were calculated, and Student t-tests were used to compare prospectively obtained data from the WVS+BSO group with the NVS group in a series of univariate analyses. RESULTS The mean age at surgery was 3.9 months for WVS+BSO and 3.8 months for NVS. The mean operative time for patients undergoing NVS was 59.0 minutes, significantly less than the 83.4-minute operative time for patients undergoing WVS+BSO (p < 0.05). The differences in mean EBL (NVS: 25.4 ml; WVS+BSO: 27.5 ml), mean postoperative hemoglobin level (NVS: 8.6 g/dl; WVS+BSO: 8.0 g/dl), mean preoperative cephalic index (NVS: 69.9; WVS+BSO: 68.2), and mean cephalic index at 1 year of age (NVS: 78.1; WVS+BSO: 77.2) were not statistically significant. CONCLUSIONS The NVS and WVS+BSO produced nearly identical clinical results, as cephalic index at 1 year of age was similar between the 2 approaches. However, the NVS required fewer procedural steps and significantly less operative time than the WVS+BSO. The NVS group obtained the final cephalic index in a similar amount of time postoperatively as the WVS+BSO group. Complications, transfusion rates, and EBL were not different between the 2 techniques.

OBJECTIVE The goal of this study was to identify the rate of neosuture formation in patients with craniosynostosis treated with endoscope-assisted strip craniectomy and investigate whether neosuture formation in sagittal craniosynostosis has an effect on postoperative calvarial shape. METHODS The authors retrospectively reviewed 166 cases of nonsyndromic craniosynostosis that underwent endoscope-assisted repair between 2006 and 2014. Preoperative and 1-year postoperative head CT scans were evaluated, and the rate of neosuture formation was calculated. Three-dimensional reconstructions of the CT data were used to measure cephalic index (CI) (ratio of head width and length) of patients with sagittal synostosis. Regression analysis was used to calculate significant differences between patients with and without neosuture accounting for age at surgery and preoperative CI. RESULTS Review of 96 patients revealed that some degree of neosuture development occurred in 23 patients (23.9%): 16 sagittal, 2 bilateral coronal, 4 unilateral coronal, and 1 lambdoid synostosis. Complete neosuture formation was seen in 14 of those 23 patients (9 of 16 sagittal, 1 of 2 bilateral coronal, 3 of 4 unilateral coronal, and 1 of 1 lambdoid). Mean pre- and postoperative CI in the complete sagittal neosuture group was 67.4% and 75.5%, respectively, and in the non-neosuture group was 69.8% and 74.4%, respectively. There was no statistically significant difference in the CI between the neosuture and fused suture groups preoperatively or 17 months postoperatively in patients with sagittal synostosis. CONCLUSIONS Neosuture development can occur after endoscope-assisted strip craniectomy and molding helmet therapy for patients with craniosynostosis. Although the authors did not detect a significant difference in calvarial shape postoperatively in the group with sagittal synostosis, the relevance of neosuture formation remains to be determined. Further studies are required to discover long-term outcomes comparing patients with and without neosuture formation.

OBJECT The authors present a retrospective cohort study examining complications in patients undergoing surgery for craniosynostosis using both minimally invasive endoscopic and open approaches. METHODS Over the past 10 years, 295 nonsyndromic patients (140 undergoing endoscopic procedures and 155 undergoing open procedures) and 33 syndromic patients (endoscopic procedures in 10 and open procedures in 23) met the authors' criteria. Variables analyzed included age at surgery, presence of a preexisting CSF shunt, skin incision method, estimated blood loss, transfusions of packed red blood cells, use of intravenous steroids or tranexamic acid, intraoperative durotomies, procedure length, and length of hospital stay. Complications were classified as either surgically or medically related. RESULTS In the nonsyndromic endoscopic group, the authors experienced 3 (2.1%) surgical and 5 (3.6%) medical complications. In the nonsyndromic open group, there were 2 (1.3%) surgical and 7 (4.5%) medical complications. Intraoperative durotomies occurred in 5 (3.6%) endoscopic and 12 (7.8%) open cases, were repaired primarily, and did not result in reoperations for CSF leakage. Similar complication rates were seen in syndromic cases. There was no death or permanent morbidity. Additionally, endoscopic procedures were associated with significantly decreased estimated blood loss, transfusions, procedure length, and length of hospital stay compared with open procedures. CONCLUSIONS Rates of intraoperative durotomies and surgical and medical complications were comparable between endoscopic and open techniques. This is the largest direct comparison to date between endoscopic and open interventions for synostosis, and the results are in agreement with previous series that endoscopic surgery confers distinct advantages over open surgery in appropriate patient populations.

Background: Preoperative severity and postoperative success for patients with sagittal synostosis are measured by cephalic index, but this metric does not describe the appropriateness of euryon location. The authors hypothesize that cephalic index in patients with sagittal synostosis is an inaccurate measure of scaphocephaly., Methods: Preoperative and 1-year postoperative cranial computed tomographic scans of children with sagittal synostosis treated before 6 months of age by either total calvarial reconstruction or endoscope-assisted craniectomy and helmet therapy (n = 10 for each) were reviewed retrospectively. The location of euryons in age-matched controls was measured as a fraction of the glabella-opisthocranion distance (horizontal point of maximum width) and as the fraction of the nasion-vertex vertical distance (vertical point of maximum width). Cephalic index at this ideal location (normative cephalic index) and traditional cephalic index were determined in all patients., Results: Ideal euryon location from preoperative controls was 56 percent by the horizontal point of maximum width and 56 percent by the vertical point of maximum width. Normative cephalic index (0.60) was significantly less than traditional cephalic index (0.66) in patients preoperatively (p < 0.001) and remained smaller postoperatively (0.68 versus 0.73) for patients who underwent open reconstruction (p < 0.001). Patients treated endoscopically also had a smaller normative cephalic index (0.71) than traditional cephalic index (0.76) postoperatively (p < 0.001)., Conclusions: Anterocaudal displacement of euryon in patients with sagittal synostosis influences cephalic index. Normative cephalic index, assessed at ideal euryon location, is a more accurate measure of preoperative severity and postoperative outcome., Clinical Question/level of Evidence: Diagnostic, III.

Background: Patients with metopic craniosynostosis are traditionally treated with fronto-orbital advancement to correct hypotelorism and trigonocephaly. Alternatively, endoscopic-assisted treatment comprises narrow ostectomy of the fused suture followed by postoperative helmet therapy. Here we compare the preoperative and 1-year postoperative results in open versus endoscopic repairs., Methods: We reviewed preoperative and 1-year postoperative three-dimensional reconstructed computed tomography scans of patients treated for nonsyndromic metopic craniosynostosis by either open (n = 15) or endoscopic (n = 13) technique. Hypotelorism was assessed by interzygomaticofrontal distance and intercanthal distance. Trigonocephaly was assessed by 2 independent angles: first, an axial-plane two-dimensional angle between zygomaticofrontal suture bilaterally and the glabella (ZF(R)-G-ZF(L)); second, an interfrontal angle (IFA) between the most anterior point from a reconstructed midsagittal plane and supraorbital notch bilaterally. Age-matched scans of unaffected patients (n = 28) served as controls for each postoperative scan., Results: Patients with open repair (9.5 ± 1.8 months) were older at time of surgery than patients with endoscopic repairs (3.3 ± 0.4 months) (P = 0.004). Male-to-female ratios were equivalent at roughly 7:3 in both groups. Preoperatively, the endoscopic group had worse hypotelorism and ZF(R)-G-ZF(L) than the open group (P ≤ 0.04). After accounting for preoperative differences, all of the postoperative measurements (ie, interzygomaticofrontal distance, intercanthal distance, ZF(R)-G-ZF(L) angle, IFA) of the 2 groups were statistically equivalent (P ≥ 0.135). Trigonocephaly was significantly improved after repair in both the open (8 degrees [ZF(R)-G-ZF(L)] and 18 degrees [IFA]) and endoscopic (13 degrees [ZF(R)-G-ZF(L)] and 16 degrees [IFA]) groups (P < 0.001). Postoperative measures in both groups were equivalent to controls (0.12 < P < 0.89). Intrarater reliability ranged from 0.93 to 0.99 for all measurements., Conclusion: Our retrospective series shows that endoscopic and open repairs of metopic craniosynostosis are equivalent in improving hypotelorism and trigonocephaly at 1-year follow-up. Additional studies are necessary to better define minor differences in morphology, which may result from the different techniques.

Craniosynostosis and its associated abnormalities can pose unique challenges to surgeons caring for these patients. Cephalohematomas, although rare, add to the complexities of managing a patient with craniosynostosis. Here, we present the case of a 4-month-old male infant with concurrent sagittal craniosynostosis and a calcified cephalohematoma who underwent an endoscopic-assisted strip craniectomy and management of the hematoma with good results.

Following surgical management of craniosynostosis, residual calvarial defects may require reconstruction, frequently with the use of cranial bone grafts. Knowledge of optimal sites for harvest would be beneficial in such situations. The goal of this study is to compare calvarial thickness (CALV) and diploic thickness (DIPL) in children with corrected sagittal synostosis to normal controls (n = 47) using postoperative CT scans. We also compare the results from children who had undergone open (OPEN) (n = 26) and endoscopic (ENDO) (n = 26) surgery. On each skull, CALV and DIPL were measured at 44 points over 5 regions. Multiple regression analysis was used to compare CALV and DIPL controlling for gender and age. Children who had undergone previous craniosynostosis correction tended to have thinner CALV compared to controls in operated regions but thicker CALV in unoperated regions (P < 0.001). Adjusted mean CALV was thinner overall in ENDO compared to OPEN (P = 0.020). Children with corrected sagittal synostosis have thinner DIPL than controls (P = 0.002). No difference was found in DIPL comparing OPEN and ENDO (P = 0.977) approaches. Children who had undergone previous craniosynostosis correction tended to have thinner CALV when compared to controls in operated regions but thicker CALV in unoperated regions. ENDO calvaria were thinner than OPEN calvaria. Children with corrected sagittal synostosis have thinner DIPL than controls; no difference was found in DIPL comparing OPEN and ENDO approaches. Due to irregularities in bone development among children who had previously undergone calvarial reconstruction, individualized preoperative CT assessment is recommended in all patients undergoing secondary split calvarial bone grafting procedures.

Introduction: Partial synostosis of cranial sutures has been shown to have clinical and diagnostic significance. However, there is limited published information about how suture fusion progresses over time. In this study, we evaluate patients with nonsyndromic single-suture synostosis. We aim to define the incidence of partial versus complete suture fusion and whether a correlation exists between the degree of suture fusion and age. Methods: Two hundred fifty-four patients with nonsyndromic single-suture synostosis were evaluated. Preoperative computed tomography (CT) scans were rendered in 3-dimensions, all sutures were visualized and assessed for patency or fusion, and length of fusion was measured. Findings were grouped according to suture type (sagittal, coronal, metopic, or lambdoid), the degree of fusion (full, >50%, or <50%), and patient age at time of CT scan (0-90, 91-180, 181-360, or >360 days). Data were analyzed to correlate patient age versus the degree of suture fusion. Results: For all patients, 72% had complete and 28% had partial synostosis. Ratios of full to partial fusion for each suture type were as follows: sagittal 97:36, coronal 35:22, metopic 46:4, and lambdoid 4:10. The sagittal, coronal, and metopic groups demonstrated greater probabilities of complete suture fusion as patient age increases (P =.021, P <.001, P =.001, respectively). This trend was also noted when all sutures were considered together by age-group (P <.001). Conclusion: We note a partial suture fusion rate of 28.3%. Our analysis shows a correlation between the extent of suture synostosis and patient age. Finally, we demonstrate that different sutures display different patterns of partial and complete fusion. [ABSTRACT FROM AUTHOR]