Endoscopically assisted versus open repair of sagittal craniosynostosis: the St. Louis Children's Hospital experience

Clinical article

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This study investigated the differences in effectiveness and morbidity between endoscopically assisted wide-vertex strip craniectomy with barrel-stave osteotomies and postoperative helmet therapy versus open calvarial vault reconstruction without helmet therapy for sagittal craniosynostosis.


Between 2003 and 2010, the authors prospectively observed 89 children less than 12 months old who were surgically treated for a diagnosis of isolated sagittal synostosis. The endoscopic procedure was offered starting in 2006. The data associated with length of stay, blood loss, transfusion rates, operating times, and cephalic indices were reviewed.


There were 47 endoscopically treated patients with a mean age at surgery of 3.6 months and 42 patients with open-vault reconstruction whose mean age at surgery was 6.8 months. The mean follow-up time was 13 months for endoscopic versus 25 months for open procedures. The mean operating time for the endoscopic procedure was 88 minutes, versus 179 minutes for the open surgery. The mean blood loss was 29 ml for endoscopic versus 218 ml for open procedures. Three endoscopically treated cases (6.4%) underwent transfusion, whereas all patients with open procedures underwent transfusion, with a mean of 1.6 transfusions per patient. The mean length of stay was 1.2 days for endoscopic and 3.9 days for open procedures. Of endoscopically treated patients completing helmet therapy, the mean duration for helmet therapy was 8.7 months. The mean pre- and postoperative cephalic indices for endoscopic procedures were 68% and 76% at 13 months postoperatively, versus 68% and 77% at 25 months postoperatively for open surgery.


Endoscopically assisted strip craniectomy offers a safe and effective treatment for sagittal craniosynostosis that is comparable in outcome to calvarial vault reconstruction, with no increase in morbidity and a shorter length of stay.

Abbreviation used in this paper: AP = anteroposterior.

Article Information

Address correspondence to: Manish N. Shah, M.D., Department of Neurological Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Box 8057, St. Louis, Missouri 63110. email: shahma@wudosis.wustl.edu.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Photographs showing positioning for endoscopic procedure and camera view. A–C: The patient is placed in the modified “sphinx” position (for details see Park et al.). The purple marker lines illustrate the planned bone removal. D: The endoscope affords direct visualization for the dissection of scalp from bone.

  • View in gallery

    Endoscopically assisted technique. A: Preoperatively, a scaphocephalic shape is demonstrated on the AP and lateral reconstructions of a low-dose 3D head CT scan. B: Immediately postoperatively, the removal of the sagittal suture and bilateral parietal and temporal wedge osteotomies improve the head shape. C: A postoperative CT scan at 1 year demonstrates a persistent and improved correction.

  • View in gallery

    Open vault reconstruction. A: Preoperatively, a 3D head CT demonstrates scaphocephaly on the AP and lateral views. B: Immediately postoperatively, there is an improvement in shape due to the remodeling procedure. C: At 1 year postoperatively, there is a persistent improvement in shape. Of note, there is a mild circular artifact from head motion; this artifact is evident in the CT reconstruction.

  • View in gallery

    Photographs showing anecdotal postoperative shape irregularities in both endoscopically assisted and open sagittal synostosis correction. Left: Note the perifontanellar bulge (arrow) near the bregma. Right: Note the shallow dip on the vertex (arrow) just anterior to the lambda.

  • View in gallery

    Bar graph showing outcomes for various methods of correction for nonsyndromic sagittal synostosis. The numbers of open reconstruction and endoscopically treated cases over the study period are displayed. Note the transition from open to endoscopic correction at our institution over time.



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