What to do with an incidental finding of a fused sagittal suture: a modified Delphi study

Sarah N. Chiang Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri;
Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, California;

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Jocelyn Reckford Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri;

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Allyson L. Alexander Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora, Colorado;

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Craig B. Birgfeld Department of Surgery, Division of Plastic Surgery, University of Washington School of Medicine, Seattle, Washington;

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Christopher M. Bonfield Departments of Neurological Surgery and

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Daniel E. Couture Departments of Neurological Surgery and

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Lisa R. David Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina;

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Brooke French Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Colorado Anschutz School of Medicine, Aurora, Colorado;

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Barbu Gociman Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, Salt Lake City, Utah;

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Jesse A. Goldstein Departments of Plastic Surgery and

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Michael S. Golinko Plastic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee;

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John R. W. Kestle Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah;

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Amy Lee Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington;

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Suresh N. Magge Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan;

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Ian F. Pollack Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania;

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S. Alex Rottgers Division of Plastic and Reconstructive Surgery, and

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Christopher M. Runyan Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina;

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Matthew D. Smyth Department of Neurosurgery, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida; and

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C. Corbett Wilkinson Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora, Colorado;

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Gary B. Skolnick Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri;

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Jennifer M. Strahle Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri

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

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 MD, MSc , for the Synostosis Research Group (SynRG)
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OBJECTIVE

As many as 5% of normocephalic children may have a prematurely fused sagittal suture, yet the clinical significance and best course of management of this finding remain unclear. Providers in the Synostosis Research Group were surveyed to create a multicenter consensus on an optimal treatment and monitoring algorithm for this condition.

METHODS

A four-round modified Delphi method was utilized. The first two rounds consisted of anonymous surveys distributed to 10 neurosurgeons and 9 plastic surgeons with expertise in craniosynostosis across 9 institutions, and presented 3 patients (aged 3 years, 2 years, and 2 months) with incidentally discovered fused sagittal sutures, normal cephalic indices, and no parietal dysmorphology. Surgeons were queried about their preferred term for this entity and how best to manage these patients. Results were synthesized to create a treatment algorithm. The third and fourth feedback rounds consisted of open discussion of the algorithm until no further concerns arose.

RESULTS

Most surgeons preferred the term "premature fusion of the sagittal suture" (93%). At the conclusion of the final round, all surgeons agreed to not operate on the 3- and 2-year-old patients unless symptoms of intracranial hypertension or papilledema were present. In contrast, 50% preferred to operate on the 2-month-old. However, all agreed to utilize shared decision-making, taking into account any concerns about future head shape and neurodevelopment. Panelists agreed that patients over 18 months of age without signs or symptoms suggesting elevated intracranial pressure (ICP) should not undergo surgical treatment.

CONCLUSIONS

Through the Delphi method, a consensus regarding management of premature fusion of the sagittal suture was obtained from a panel of North American craniofacial surgeons. Without signs or symptoms of ICP elevation, surgery is not recommended in patients over 18 months of age. However, for children younger than 18 months, surgery should be discussed with caregivers using a shared decision-making process.

ABBREVIATIONS

ICP = intracranial pressure; OCT = optical coherence tomography.

Supplementary Materials

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