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

David ChiDivision of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri;

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Ella GibsonDivision of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri;

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Sarah N. ChiangDivision of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri;

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Koeun LeeDivision of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri;

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Sybill D. NaidooDivision of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri;

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Amy LeeDepartment of Neurosurgery, Seattle Children’s Hospital, University of Washington, Seattle, Washington;

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Craig BirgfeldDivision of Plastic Surgery, Seattle Children’s Hospital, University of Washington, Seattle, Washington;

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Ian F. PollackDepartments of Neurosurgery and

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Jesse GoldsteinPlastic Surgery, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pennsylvania;

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Michael GolinkoDepartments of Plastic Surgery and

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Christopher M. BonfieldNeurological Surgery, Vanderbilt University, Nashville, Tennessee;

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Faizi A. SiddiqiDivision of Plastic and Reconstructive Surgery, University of Utah, Salt Lake City, Utah;

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John R. W. KestleDivision of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah, Salt Lake City, Utah;

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Matthew D. SmythDivision of Pediatric Neurosurgery, Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri; and
Division of Pediatric Neurosurgery, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida

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Kamlesh B. PatelDivision of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri;

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the Synostosis Research Group (SynRG)
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OBJECTIVE

Surgical treatment of sagittal craniosynostosis is challenging in older patients. This study aimed to assess the effect of increasing age on open surgical technique selection and patient outcomes using the multi-institutional Synostosis Research Group (SynRG) collaboration.

METHODS

Surgeons in SynRG were surveyed for key influences on their preferred open calvarial vault remodeling techniques at various patient ages: < 6, 6–12, and > 12 months. The SynRG database was then queried for open repairs of nonsyndromic sagittal craniosynostosis performed for patients older than 12 months of age. Perioperative measures, complications, and preoperative and postoperative cephalic indices were reviewed.

RESULTS

All surgeons preferred to treat patients at an earlier age, and most (89%) believed that less-optimal outcomes were achieved at ages older than 12 months. The modified pi procedure was the dominant technique in those younger than 12 months, while more involved open surgical techniques were performed for older patients, with a wide variety of open calvarial vault remodeling techniques used. Forty-four patients met inclusion criteria, with a mean (± SD) age at surgery of 29 ± 16 months. Eleven patients underwent parietal reshaping, 10 parietal-occipital switch, 9 clamshell craniotomy, 7 geometric parietal expansion, 6 modified pi procedure, and 1 parietal distraction. There were no readmissions, complications, or mortality within 30 days postoperatively. Patients’ cephalic indices improved a mean of 6.4% ± 4.0%, with a mean postoperative cephalic index of 74.2% ± 4.9%. Differences in postoperative cephalic index (p < 0.04) and hospital length of stay (p = 0.01) were significant between technique cohorts. Post hoc Tukey-Kramer analysis identified the parietal reshaping technique as being significantly associated with a reduced hospital length of stay.

CONCLUSIONS

Patient age is an important driver in technique selection, with surgeons selecting a more involved calvarial vault remodeling technique in older children. A variety of surgical techniques were analyzed, with the parietal reshaping technique being significantly associated with reduced length of stay; however, multiple perioperative factors may be contributory and require further analysis. When performed at high-volume centers by experienced pediatric neurosurgeons and craniofacial surgeons, open calvarial vault techniques can be a safe method for treating sagittal craniosynostosis in older children.

ABBREVIATIONS

SynRG = Synostosis Research Group.
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Illustration from Wang et al. (pp 538–546). © Ju-lei Wang, published with permission.

  • 1

    Panchal J, Uttchin V. Management of craniosynostosis. Plast Reconstr Surg. 2003;111(6):20322049.

  • 2

    Massimi L, Caldarelli M, Tamburrini G, Paternoster G, Di Rocco C. Isolated sagittal craniosynostosis: definition, classification, and surgical indications. Childs Nerv Syst. 2012;28(9):13111317.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Schmelzer RE, Perlyn CA, Kane AA, Pilgram TK, Govier D, Marsh JL. Identifying reproducible patterns of calvarial dysmorphology in nonsyndromic sagittal craniosynostosis may affect operative intervention and outcomes assessment. Plast Reconstr Surg. 2007;119(5):15461552.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Marcus JR, Stokes TH, Mukundan S, Forrest CR. Quantitative and qualitative assessment of morphology in sagittal synostosis: mid-sagittal vector analysis. J Craniofac Surg. 2006;17(4):680686.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Persing JA. MOC-PS(SM) CME article: management considerations in the treatment of craniosynostosis. Plast Reconstr Surg. 2008;121(4)(suppl):111.

  • 6

    Alperovich M, Runyan CM, Gabrick KS, et al. Long-term neurocognitive outcomes of spring-assisted surgery versus cranial vault remodeling for sagittal synostosis. Plast Reconstr Surg. 2021;147(3):661671.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Doumit GD, Papay FA, Moores N, Zins JE. Management of sagittal synostosis: a solution to equipoise. J Craniofac Surg. 2014;25(4):12601265.

  • 8

    Kestle JRW, Lee A, Anderson RCE, et al. Variation in the management of isolated craniosynostosis: a survey of the Synostosis Research Group. J Neurosurg Pediatr. 2018;22(6):627631.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Han RH, Nguyen DC, Bruck BS, et al. Characterization of complications associated with open and endoscopic craniosynostosis surgery at a single institution. J Neurosurg Pediatr. 2016;17(3):361370.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Le MB, Patel K, Skolnick G, et al. Assessing long-term outcomes of open and endoscopic sagittal synostosis reconstruction using three-dimensional photography. J Craniofac Surg. 2014;25(2):573576.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Gerety PA, Basta MN, Fischer JP, Taylor JA. Operative management of nonsyndromic sagittal synostosis: a head-to-head meta-analysis of outcomes comparing 3 techniques. J Craniofac Surg. 2015;26(4):12511257.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Dlouhy BJ, Nguyen DC, Patel KB, et al. Endoscope-assisted management of sagittal synostosis: wide vertex suturectomy and barrel stave osteotomies versus narrow vertex suturectomy. J Neurosurg Pediatr. 2016;25(6):674678.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Vogel TW, Woo AS, Kane AA, Patel KB, Naidoo SD, Smyth MD. A comparison of costs associated with endoscope-assisted craniectomy versus open cranial vault repair for infants with sagittal synostosis. J Neurosurg Pediatr. 2014;13(3):324331.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Patel A, Yang JF, Hashim PW, et al. The impact of age at surgery on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg. 2014;134(4):608e617e.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Bruce WJ, Chang V, Joyce CJ, Cobb AN, Maduekwe UI, Patel PA. Age at time of craniosynostosis repair predicts increased complication rate. Cleft Palate Craniofac J. 2018;55(5):649654.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Garza RM, Khosla RK. Nonsyndromic craniosynostosis. Semin Plast Surg. 2012;26(2):5363.

  • 17

    Swanson JW, Haas JA, Mitchell BT, et al. The effects of molding helmet therapy on spring-mediated cranial vault remodeling for sagittal craniosynostosis. J Craniofac Surg. 2016;27(6):13981403.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18

    Nguyen DC, Farber SJ, Skolnick GB, et al. One hundred consecutive endoscopic repairs of sagittal craniosynostosis: an evolution in care. J Neurosurg Pediatr. 2017;20(5):410418.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Chan JW, Stewart CL, Stalder MW, St Hilaire H, McBride L, Moses MH. Endoscope-assisted versus open repair of craniosynostosis: a comparison of perioperative cost and risk. J Craniofac Surg. 2013;24(1):170174.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Panchal J, Marsh JL, Park TS, Kaufman B, Pilgram T, Huang SH. Sagittal craniosynostosis outcome assessment for two methods and timings of intervention. Plast Reconstr Surg. 1999;103(6):15741584.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Shah MN, Kane AA, Petersen JD, Woo AS, Naidoo SD, Smyth MD. Endoscopically assisted versus open repair of sagittal craniosynostosis: the St. Louis Children’s Hospital experience. J Neurosurg Pediatr. 2011;8(2):165170.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Smyth MD, Tenenbaum MJ, Kaufman CB, Kane AA. The “clamshell” craniotomy technique in treating sagittal craniosynostosis in older children. J Neurosurg. 2006;105(4)(suppl):245251.

    • Search Google Scholar
    • Export Citation
  • 23

    Baker CM, Ravindra VM, Gociman B, et al. Management of sagittal synostosis in the Synostosis Research Group: baseline data and early outcomes. Neurosurg Focus. 2021;50(4):E3.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24

    Boulos PT, Lin KY, Jane JA Jr, Jane JA Sr. Correction of sagittal synostosis using a modified Pi method. Clin Plast Surg. 2004;31(3):489498,vii.

  • 25

    Warren SM, Proctor MR, Bartlett SP, et al. Parameters of care for craniosynostosis: craniofacial and neurologic surgery perspectives. Plast Reconstr Surg. 2012;129(3):731737.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Ruane EJ, Garland CB, Camison L, et al. A treatment algorithm for patients presenting with sagittal craniosynostosis after the age of 1 year. Plast Reconstr Surg. 2017;140(3):582590.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Jimenez DF, Barone CM, Cartwright CC, Baker L. Early management of craniosynostosis using endoscopic-assisted strip craniectomies and cranial orthotic molding therapy. Pediatrics. 2002;110(1 Pt 1):97104.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Monte TM, Denadai R, Raposo-Amaral CA, Ghizoni E, Raposo-Amaral CE. Long-term morphologic changes on sagittal synostosis patients who underwent a modified pi technique. J Craniofac Surg. 2021;32(1):5557.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Goyal A, Lu VM, Yolcu YU, Elminawy M, Daniels DJ. Endoscopic versus open approach in craniosynostosis repair: a systematic review and meta-analysis of perioperative outcomes. Childs Nerv Syst. 2018;34(9):16271637.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Yan H, Abel TJ, Alotaibi NM, et al. A systematic review and meta-analysis of endoscopic versus open treatment of craniosynostosis. Part 1: The sagittal suture. J Neurosurg Pediatr. 2018;22(4):352360.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Fearon JA, Ruotolo RA, Kolar JC. Single sutural craniosynostoses: surgical outcomes and long-term growth. Plast Reconstr Surg. 2009;123(2):635642.

  • 32

    Ghenbot RG, Patel KB, Skolnick GB, Naidoo SD, Smyth MD, Woo AS. Effects of open and endoscopic surgery on skull growth and calvarial vault volumes in sagittal synostosis. J Craniofac Surg. 2015;26(1):161164.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Ha AY, Skolnick GB, Chi D, et al. School-aged anthropometric outcomes after endoscopic or open repair of metopic synostosis. Pediatrics. 2020;146(3):e20200238.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    Greensmith AL, Holmes AD, Lo P, Maxiner W, Heggie AA, Meara JG. Complete correction of severe scaphocephaly: the Melbourne method of total vault remodeling. Plast Reconstr Surg. 2008;121(4):13001310.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Sharma JD, O’Hara JL, Borghi A, et al. Results following adoption of a modified Melbourne technique of total scaphocephaly correction. J Craniofac Surg. 2018;29(5):11171122.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Thwin M, Schultz TJ, Anderson PJ. Morphological, functional and neurological outcomes of craniectomy versus cranial vault remodeling for isolated nonsyndromic synostosis of the sagittal suture: a systematic review. JBI Database Syst Rev Implement Reports. 2015;13(9):309368.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 37

    Dvoracek LA, Skolnick GB, Nguyen DC, et al. Comparison of traditional versus normative cephalic index in patients with sagittal synostosis: measure of scaphocephaly and postoperative outcome. Plast Reconstr Surg. 2015;136(3):541548.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Pfeifauf KD, Said AM, Naidoo SD, et al. Evaluation of the patient-practitioner consultation on surgical treatment options for patients with craniosynostosis. J Craniofac Surg. 2020;31(5):11861190.

    • PubMed
    • Search Google Scholar
    • Export Citation

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