Letter to the Editor: Cranial vault remodeling

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TO THE EDITOR: We read with interest the article by Utria et al.5 (Utria AF, Lopez J, Cho RS, et al: Timing of cranial vault remodeling in nonsyndromic craniosynostosis: a single-institution 30-year experience. J Neurosurg Pediatr 18:629–634, November 2016), and we would like to make the following observations on the basis of the literature and our personal experience.

The authors present groundbreaking results or at least call into question one of the most established paradigms in the treatment of craniosynostosis. To date, a young age is regarded as an added value to surgery; that is, the earlier the intervention the better the results,3 whereas delayed surgery is associated with higher complication rates.1 Pediatric neurosurgeons believe that there should be a balance between early intervention and surgical risk in deciding the optimal moment for surgery.

The authors list several reasons to justify their results, some of which we share. We understand that a historical series covering 30 years involves the participation of several neurosurgeons with varying degrees of experience in this type of intervention. For the same reason, throughout the study period craniosynostosis techniques have been modified, as have the systems for fixing bone flaps, for example, passing steel wires and mini-plates of titanium or resorbables.

We agree with the authors that the use of the Whitaker categories is a subjective assessment open to bias and lacking surgical outcomes or measurements such as radiological or anthropometric data permitting objective preoperative and postoperative cephalometric evaluation.6

Strikingly, the authors fail to comment on endoscopic surgery, which should be performed earlier. In most series it is recommended before 3–4 months of age to ensure better outcomes and fewer complications.2,4

Finally, we agree with the authors that future studies should aim to incorporate objective surgical outcome measurements.

References

  • 1

    Iyengar RJKlinge PMChen WSBoxerman JLSullivan SRTaylor HO: Management of craniosynostosis at an advanced age: controversies, clinical findings, and surgical treatment. J Craniofac Surg 27:e435e4412016

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  • 2

    Jimenez DFBarone CM: Early treatment of coronal synostosis with endoscopy-assisted craniectomy and postoperative cranial orthosis therapy: 16-year experience. J Neurosurg Pediatr 12:2072192013

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

    Raimondi AJ: Pediatric Neurosurgery. Theoretical Principles—Art of Surgical Techniques BerlinSpringer1998

  • 4

    Rivero-Garvía MMárquez-Rivas JGiménez-Pando J: Craniosynostosis. J Neurosurg Pediatr 7:2182192011. (Letter)

  • 5

    Utria AFLopez JCho RSMundinguer GSJallo GIAhn ES: Timing of cranial vault remodeling in nonsyndromic craniosynostosis: a single-institution 30-year experience. J Neurosurg Pediatr 18:6296342016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Whitaker LABartlett SPSchut LBruce D: Craniosynostosis: an analysis of the timing, treatment, and complications in 164 consecutive patients. Plast Reconstr Surg 80:1952121987

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    • PubMed
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    • Export Citation

Disclosures

The authors report no conflict of interest.

Keywords:

Response

We thank Dr. Gelabert-González and colleagues for their thoughtful comments regarding our article. There are several key issues that remain unanswered regarding the surgical management of craniosynostosis. Our study aimed to shed some light on the optimal timing for surgery, which remains an important unanswered question. There is a fine balance between the advantages of early intervention 1) to release synostotic sutures to prevent restrictive brain growth and 2) to have the regenerative bone capabilities of a younger child, and the advantages of later intervention 1) to minimize calvarial vault remodeling relapse rates and 2) to have more surgical and anesthetic reserve in an older child. Currently, management is largely dictated by surgeon preference and the timing of patient presentation.1,5 Using 30-year data at a single large academic institution, we sought to examine what the most optimal time of surgery would be in terms of revision rates, as defined by Whitaker categories. Further, we aimed to determine through subanalysis if the type of suture involvement, type of surgical procedure, and surgeon would impact revision rates. While we were able to conclude that, overall, performing early surgery is associated with higher revision rates, we were not able to demonstrate statistical significance for any other factors. Future studies with even greater patient numbers are needed to assess whether this association is found in particular subtypes of craniosynostosis. Our hypothesis, given our experience, is that it may indeed be suture dependent.

Gelabert-González et al. astutely pointed out that endoscopic surgery is normally performed earlier, typically before 3 months of age. This is also the case at our institution. Although we included in our analysis 101 patients (Table 2 in the original article) who underwent multiple strip craniectomies in the younger-than-6-months cohort, we examined patients who predated the widespread use of endoscopic craniectomies at our hospital. Consistent with the literature, which has shown that outcomes are similar between open and endoscopic craniosynostosis repair,2,3,4 we too have anecdotally found no difference in the relapse rates between these groups. Perhaps postoperative helmeting techniques are contributing to decreased revision rates in this particular subgroup? We hope to further explore this question more robustly in a subsequent study.

Our study provides evidence that an association exists between early surgical intervention and higher revision rates (as indicated by Whitaker scores). Although the drivers behind this strong association are unclear, future efforts should focus on exploring whether this association can be replicated 1) in all or only certain types of craniosynostosis and 2) with open cranial vault and endoscopic repair.

References

  • 1

    Foster KAFrim DMMcKinnon M: Recurrence of synostosis following surgical repair of craniosynostosis. Plast Reconstr Surg 121:70e76e2008

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    • Export Citation
  • 2

    Han RHNguyen DCBruck BSSkolnick GBYarbrough CKNaidoo SD: Characterization of complications associated with open and endoscopic craniosynostosis surgery at a single institution. J Neurosurg Pediatr 17:3613702016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Kung TAVercler CJMuraszko KMBuchman SR: Endoscopic strip craniectomy for craniosynostosis: do we really understand the indications, outcomes, and risks?. J Craniofac Surg 27:2932982016

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

    Rottgers SALohani SProctor MR: Outcomes of endoscopic suturectomy with postoperative helmet therapy in bilateral coronal craniosynostosis. J Neurosurg Pediatr 18:2812862016

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

    Whitaker LABartlett SPSchut LBruce D: Craniosynostosis: an analysis of the timing, treatment, and complications in 164 consecutive patients. Plast Reconstr Surg 80:1952121987

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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Article Information

Contributor Notes

INCLUDE WHEN CITING Published online January 13, 2017; DOI: 10.3171/2016.9.PEDS16550.
Headings
References
  • 1

    Iyengar RJKlinge PMChen WSBoxerman JLSullivan SRTaylor HO: Management of craniosynostosis at an advanced age: controversies, clinical findings, and surgical treatment. J Craniofac Surg 27:e435e4412016

    • Search Google Scholar
    • Export Citation
  • 2

    Jimenez DFBarone CM: Early treatment of coronal synostosis with endoscopy-assisted craniectomy and postoperative cranial orthosis therapy: 16-year experience. J Neurosurg Pediatr 12:2072192013

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

    Raimondi AJ: Pediatric Neurosurgery. Theoretical Principles—Art of Surgical Techniques BerlinSpringer1998

  • 4

    Rivero-Garvía MMárquez-Rivas JGiménez-Pando J: Craniosynostosis. J Neurosurg Pediatr 7:2182192011. (Letter)

  • 5

    Utria AFLopez JCho RSMundinguer GSJallo GIAhn ES: Timing of cranial vault remodeling in nonsyndromic craniosynostosis: a single-institution 30-year experience. J Neurosurg Pediatr 18:6296342016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Whitaker LABartlett SPSchut LBruce D: Craniosynostosis: an analysis of the timing, treatment, and complications in 164 consecutive patients. Plast Reconstr Surg 80:1952121987

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 1

    Foster KAFrim DMMcKinnon M: Recurrence of synostosis following surgical repair of craniosynostosis. Plast Reconstr Surg 121:70e76e2008

    • Search Google Scholar
    • Export Citation
  • 2

    Han RHNguyen DCBruck BSSkolnick GBYarbrough CKNaidoo SD: Characterization of complications associated with open and endoscopic craniosynostosis surgery at a single institution. J Neurosurg Pediatr 17:3613702016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Kung TAVercler CJMuraszko KMBuchman SR: Endoscopic strip craniectomy for craniosynostosis: do we really understand the indications, outcomes, and risks?. J Craniofac Surg 27:2932982016

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

    Rottgers SALohani SProctor MR: Outcomes of endoscopic suturectomy with postoperative helmet therapy in bilateral coronal craniosynostosis. J Neurosurg Pediatr 18:2812862016

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

    Whitaker LABartlett SPSchut LBruce D: Craniosynostosis: an analysis of the timing, treatment, and complications in 164 consecutive patients. Plast Reconstr Surg 80:1952121987

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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