A systematic review and meta-analysis of endoscopic versus open treatment of craniosynostosis. Part 1: the sagittal suture

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OBJECTIVE

In this systematic review and meta-analysis the authors aimed to directly compare open surgical and endoscope-assisted techniques for the treatment of sagittal craniosynostosis, focusing on the outcomes of blood loss, transfusion rate, length of stay, operating time, complication rate, cost, and cosmetic outcome.

METHODS

A literature search was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant articles were identified from 3 electronic databases (MEDLINE, EMBASE, and CENTRAL [Cochrane Central Register of Controlled Trials]) from their inception to August 2017. The quality of methodology and bias risk were assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Effect estimates between groups were calculated as standardized mean differences with 95% CIs. Random and fixed effects models were used to estimate the overall effect.

RESULTS

Of 316 screened records, 10 met the inclusion criteria, of which 3 were included in the meta-analysis. These studies reported on 303 patients treated endoscopically and 385 patients treated with open surgery. Endoscopic surgery was associated with lower estimated blood loss (p < 0.001), shorter length of stay (p < 0.001), and shorter operating time (p < 0.001). From the literature review of the 10 studies, transfusion rates for endoscopic procedures were consistently lower, with significant differences in 4 of 6 studies; the cost was lower, with differences ranging from $11,603 to $31,744 in 3 of 3 studies; and the cosmetic outcomes were equivocal (p > 0.05) in 3 of 3 studies. Finally, endoscopic techniques demonstrated complication rates similar to or lower than those of open surgery in 8 of 8 studies.

CONCLUSIONS

Endoscopic procedures are associated with lower estimated blood loss, operating time, and days in hospital. Future long-term prospective registries may establish advantages with respect to complications and cost, with equivalent cosmetic outcomes. Larger studies evaluating patient- or parent-reported satisfaction and optimal timing of intervention as well as heterogeneity in outcomes are indicated.

ABBREVIATIONS EPHPP = Effective Public Health Practice Project; LOS = length of hospital stay; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SMD = standardized mean difference.

OBJECTIVE

In this systematic review and meta-analysis the authors aimed to directly compare open surgical and endoscope-assisted techniques for the treatment of sagittal craniosynostosis, focusing on the outcomes of blood loss, transfusion rate, length of stay, operating time, complication rate, cost, and cosmetic outcome.

METHODS

A literature search was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant articles were identified from 3 electronic databases (MEDLINE, EMBASE, and CENTRAL [Cochrane Central Register of Controlled Trials]) from their inception to August 2017. The quality of methodology and bias risk were assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Effect estimates between groups were calculated as standardized mean differences with 95% CIs. Random and fixed effects models were used to estimate the overall effect.

RESULTS

Of 316 screened records, 10 met the inclusion criteria, of which 3 were included in the meta-analysis. These studies reported on 303 patients treated endoscopically and 385 patients treated with open surgery. Endoscopic surgery was associated with lower estimated blood loss (p < 0.001), shorter length of stay (p < 0.001), and shorter operating time (p < 0.001). From the literature review of the 10 studies, transfusion rates for endoscopic procedures were consistently lower, with significant differences in 4 of 6 studies; the cost was lower, with differences ranging from $11,603 to $31,744 in 3 of 3 studies; and the cosmetic outcomes were equivocal (p > 0.05) in 3 of 3 studies. Finally, endoscopic techniques demonstrated complication rates similar to or lower than those of open surgery in 8 of 8 studies.

CONCLUSIONS

Endoscopic procedures are associated with lower estimated blood loss, operating time, and days in hospital. Future long-term prospective registries may establish advantages with respect to complications and cost, with equivalent cosmetic outcomes. Larger studies evaluating patient- or parent-reported satisfaction and optimal timing of intervention as well as heterogeneity in outcomes are indicated.

ABBREVIATIONS EPHPP = Effective Public Health Practice Project; LOS = length of hospital stay; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SMD = standardized mean difference.

The incidence of craniosynostosis is estimated to be 3.0–6.4 per 10,000 live births; the majority of the cases are sporadic and a minority occur as part of a syndrome.6,24,29 There is a predominance of isolated sagittal synostosis or scaphocephaly, which accounts for more than half of all reported craniosynostosis cases and is estimated to occur at a rate of 1.0–2.5 in 5000 live births.10,24 Indications for surgical management of sagittal synostosis focus heavily on correcting dysmorphism (scaphocephaly) and the remote possibility of resolving elevated intracranial pressure. It has been hypothesized that untreated sagittal craniosynostosis may lead to early speech and language problems and subsequent literacy issues, and to problems in related functions such as working memory, attention, and planning.20 Such adverse outcomes are the result of the elongation of the skull affecting the dorsolateral prefrontal cortex.

Infants with sagittal synostosis can be managed surgically with either traditional open surgery or the more contemporary technique of minimally invasive endoscope-assisted craniectomy followed by helmet therapy. As detailed in Bir et al.,3 Lannelongue26 and Lane25 described the earliest treatment of sagittal craniosynostosis relying on suturectomies, and since then the treatment options for sagittal craniosynostosis greatly overshadow those for any other type of craniosynostosis.10 Open surgery historically includes a large range of techniques—from strip craniectomy, to the pi procedure, to occipital reduction–biparietal widening, which are each associated with longer operating time, longer hospital stay, and greater blood loss.34 Recognizing these suboptimal outcomes, Jimenez and colleagues18,19 proposed the novel technique of using endoscopy to perform sagittal suturectomy, followed by 4–6 months of helmet therapy to prevent anteroposterior growth. This technique is offered during the first 6 months of life, optimizing cosmetic and functional results.

Despite numerous adopters of the endoscopic technique, the clinical efficacy of the endoscopic method as it compares to traditional open techniques remains debated. Thus, in this systematic meta-analysis we aimed to directly compare open surgical and endoscope-assisted techniques for the treatment of sagittal craniosynostosis, focusing on the outcomes of blood loss, transfusion rate, length of hospital stay (LOS), operating time, complications, cost, and cosmetic outcome.

Methods

Search Strategy

This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and recommendations.30,40 A literature search was performed on MEDLINE, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) on August 17, 2017, by a librarian (M.A.). The database searches used keywords (individually and/or in combination) such as “craniosynostosis,” “endoscopic,” and “neuroendoscope” with the appropriate subject headings. The reference lists of retrieved articles were reviewed to identify additional relevant articles. An additional search was conducted prior to publication for inclusion of newly published studies.

Study Selection

Retrieved studies were systematically assessed using inclusion and exclusion criteria by 2 reviewers (H.Y. and T.J.A.). Inclusion criteria were 1) diagnosis of sagittal craniosynostosis by a plastic surgeon or neurosurgeon; 2) at least 50% of the patient population had isolated sagittal craniosynostosis; 3) cohorts were divided into open surgery and endoscopically assisted surgery; and 4) follow-up outcomes were measured at 12 months or more. Exclusion criteria for the meta-analysis included 1) lack of quantitative comparison between open surgery and endoscopically assisted surgery; 2) nonhuman subjects; 3) inclusion of patients with syndromic craniosynostosis; and 4) editorials, abstracts, review articles, case reports, and dissertations. When duplicate studies were found, only the most complete reports were included for quantitative assessment. Studies from the same institution and possibly the same cohort of patients were only included if different outcome variables were reported.

Data Extraction and Critical Appraisal

All data were extracted from article texts, tables, and figures. Each retrieved article was reviewed by 2 investigators independently (H.Y. and T.J.A.). Authors were contacted when there were missing or incomplete data. The quality of the methodology and the risk of bias across studies were assessed by 1 reviewer (H.Y.) using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies.43 Measured variables included selection bias, study design, confounders, blinding, data collection methods, and withdrawals and dropouts, as well as a global rating, and the tool rates each as “strong,” “moderate,” or “weak.”

Statistical Analysis

Pooled effects between groups were calculated as standardized mean difference (SMD) with 95% CIs. Interstudy heterogeneity was not applicable because there were only 2 studies for each outcome. We used both random and fixed effects models to estimate the overall effect. A p value < 0.05 was set for statistical significance. Analysis was performed on “Comprehensive Meta-analysis” software (version 3.3, BIOSTAT).

Results

Literature Search

The search strategy identified a total of 503 studies (Fig. 1). After removal of 187 duplicate studies, inclusion and exclusion criteria were applied to the titles of the remaining 316 articles. This yielded 28 studies that underwent full-text analysis, of which 15 did not meet the inclusion criteria of 1) having more than 50% of patients present with sagittal synostosis; and 2) reporting on quantitative results. Three of the studies had overlapping cohorts for which unique outcomes were not reported (Table 1). Of the 10 studies included in the qualitative analysis, only 3 reported appropriate data from nonoverlapping cohorts that could be used for meta-analysis.

FIG. 1.
FIG. 1.

PRISMA flowchart for systematic review.

TABLE 1.

Exclusion of eligible studies

Authors & YearExcludedExplanations & Comments
Abbott et al., 2012NoNA
Arts et al., 2018NoNA
Bonfield et al., 2016NoNA
Chan et al., 2013YesIncludes pts w/ syndromic craniosynostosis; pts w/ sagittal craniosynostosis represent 33% of cohort
Dvoracek et al., 2015YesOverlapping pt population suspected
Esparza & Hinojosa, 2008NoNA
Farber et al., 2017YesPts w/ metopic craniosynostosis only
Garber et al., 2017NoNA
Ghenbot et al., 2015NoNA
Ghosh et al., 2014YesOverlapping pt population suspected
Han et al., 2016NoOverlapping pt population confirmed; included for largest cohort size
Hashim et al., 2014YesAnalysis of neuropsychological outcomes only
Keshavarzi et al., 2009YesPts w/ metopic craniosynostosis only
Keshavarzi et al., 2010YesPts w/ sagittal craniosynostosis represent 45% of cohort
Kohan et al., 2008YesCase studies of twin pts
Le et al., 2014YesOverlapping pt population suspected
MacKinnon et al., 2009YesPts w/ unilat coronal craniosynostosis only; overlapping pt population & data suspected
MacKinnon et al., 2013YesPts w/ unilat coronal craniosynostosis only; overlapping pt population & data suspected
Nguyen et al., 2015YesPts w/ metopic craniosynostosis only
Nowaková et al., 2015YesTranslated from Czech; nonquantitative data
Rogers et al., 2015YesMeasured outcome is hand preference
Shah et al., 2011NoNA
Siu et al., 2014YesCase studies of 2 pts w/ unilat coronal craniosynostosis & Down syndrome
Tan et al., 2013YesPts w/ unilat coronal craniosynostosis only
Thompson et al., 2018NoNA
Vogel et al., 2014NoOverlapping pt population confirmed w/ authors; included for unique data
Yarbrough et al., 2014YesCase series of 5 pts w/ mixed suture types
Zubovic et al., 2015YesPts w/ unilat lambdoid craniosynostosis only
NA = not applicable; pts = patients.

Seven of the 28 full-text analysis studies originated from Washington University School of Medicine, with confirmed or potential overlapping cohorts. Therefore, for each key question only the study with the largest cohort was included in the literature review. This process resulted in 10 studies with unique cohorts for specific outcomes. There were 4 weak, 3 moderate, and 3 strong papers (Table 2).

TABLE 2.

Results of quality assessment of methodology

Authors & YearSelection BiasStudy DesignConfoundersBlindingData Collection MethodsAnalysesGlobal Rating
Abbott et al., 2012ModerateModerateWeakModerateModerateWeakWeak
Arts et al., 2018StrongModerateModerateModerateModerateModerateStrong
Bonfield et al., 2016StrongModerateWeakModerateModerateWeakWeak
Esparza & Hinojosa, 2008StrongWeakWeakModerateModerateWeakWeak
Garber et al., 2017StrongModerateModerateModerateModerateStrongStrong
Ghenbot et al., 2015ModerateModerateWeakModerateModerateWeakWeak
Han et al., 2016StrongModerateWeakModerateModerateModerateModerate
Shah et al., 2011StrongModerateWeakModerateModerateModerateModerate
Thompson et al., 2018StrongModerateStrongModerateModerateStrongStrong
Vogel et al., 2014StrongModerateWeakModerateModerateModerateModerate

Cohort Description

Patient demographic characteristics are outlined in Table 3. The cohort size of the meta-analysis was 688 patients, with 303 (44%) children undergoing endoscope-assisted craniosynostosis surgery and 385 (56%) children undergoing open repair for craniosynostosis. The age of the endoscopic cohort was younger than that of the open cohort (median 2.9, mean 3.4 months, and median 5.6, mean 15.5 months, respectively).

TABLE 3.

Demographic characteristics of patients in literature review studies

Authors & YearCity & State or CountryEPHPP RatingStudy DesignNo. of Pts% Pts w/ Sagittal CraniosynostosisNo. of Pts TreatedMean or [Median] Age (mos)*% MaleFU (mos)
EndoOpenEndoOpenEndoOpenEndoOpen      
Abbott et al., 2012Boston, MAWeakR OS201001010[3.0][13.1]70604.222.2
Arts et al., 2018Nijmegen, NetherlandsStrongR OS9310063304.0 ± 1.010 ± 8.9NR1212
Bonfield et al., 2016Vancouver, BC, CanadaWeakR OS991002871[3.8][4.8]NRNR
Esparza & Hinojosa, 2008Madrid, SpainWeakR OS155100391164.16.9NRNR
Garber et al., 2017Salt Lake City, UTStrongR OS300100100200[2.9][5.6]757651.695.4
Ghenbot et al., 2015St. Louis, MOWeakR OS271001215NRNRNR
Han et al., 2016St. Louis, MOModerateR OS29557.61401553.4 ± 1.215.5 ± 16.5NR25.237.4
Shah et al., 2011St. Louis, MOModerateP OS8910047423.66.868421325
Thompson et al., 2018Multicenter, USAStrongR OS93361.8311622[3][5]7065NR
Vogel et al., 2014St. Louis, MOModerateR OS4210021213.1 ± 0.26.8 ± 0.4NRNR
Endo = endoscope-assisted surgery; FU = follow-up; NR = not recorded; OS = observational study; P = prospective; R = retrospective.

The means are reported ± SD when the original study included the SD.

Study included in meta-analysis.

In the literature review, the reported age of the patients in the endoscopic and open cohorts ranged from 2.911 to 4.18 months and 4.84 to 15.516 months, respectively. The proportion of male patients in the studies treated by endoscopic and open procedures ranged from 68% to 75% and 42% to 76%, respectively. The follow-up ranged from 4.2 months to 95.4 months.

Perioperative Outcomes

Estimated Blood Loss

Endoscope-assisted craniosynostosis surgery has a significantly lower estimated blood loss compared to open craniotomies, based on 3 studies (SMD −1.57 ml/kg, 95% CI −1.75 to −1.39; p < 0.001) (Fig. 2A). From the literature review, Abbott et al.1 similarly reported medians of 4.1 ml/kg and 59.4 ml/kg when comparing endoscopic to open procedures.

FIG. 2.
FIG. 2.

Meta-analysis of perioperative measures. Std diff in means = SMDs. Figure is available in color online only.

Length of Stay

Endoscope-assisted craniosynostosis surgery has a significantly shorter LOS compared to open craniotomies, based on 2 studies (SMD −1.66 days, 95% CI −1.86 to −1.46; p < 0.001) (Fig. 2B). Thompson et al.44 conducted a multicenter retrospective study analyzing 933 propensity score–matched children and reported a median LOS of 2 and 4 days for endoscopic and open surgery, respectively. Abbott et al.1 also described a shorter LOS for endoscopic surgery compared to open surgery, with medians of 1 day and 3 days, respectively. A Spanish study8 measured mean time of hospitalization as a consequence of postoperative complications and found that endoscopic osteotomies (11.2 days) resulted in shorter stays compared to open sagittal suturectomy, open sagittal suturectomy with frontal dismantling, and total cranial vault remodeling (12.4, 11.5, and 16.2 days, respectively).

Operating Times

Endoscope-assisted craniosynostosis surgery had a significantly lower operating time compared to open craniotomies, based on 2 studies (SMD −1.68 days, 95% CI −1.87 to −1.48; p < 0.001) (Fig. 2C). Likewise, Thompson et al.44 and Abbott et al.1 reported medians of 1.16 and 2 hours for endoscopic procedures and 2.16 and 6 hours for open procedures.

Transfusions

Six studies1,2,4,11,16,44 reported a lower need for intraoperative and postoperative transfusions for patients undergoing endoscopic procedures compared to open cranial surgery. Endoscopic procedures showed a transfusion rate ranging from 0%1 to 26%2,44 of patients and open procedures ranged from 16%44 to 100%1 (Table 4).

TABLE 4.

Transfusion rates between endoscopic and open treatments of sagittal craniosynostosis

Authors & YearTreatmentTransfusion (%)
EndoOpen  
Abbott et al., 2012pRBC0*100*
Platelets020 
FFP020 
Cryoprecipitate010 
Albumin30*90* 
Arts et al., 2018pRBC2681
Bonfield et al., 20167.117.0
Garber et al., 2017Endo vs CVR13*83*
Endo vs SSC1323 
Han et al., 2016Intraop pRBC5.0*96.1*
Postop pRBC5.0*39.4* 
Thompson et al., 2018RBC blood products26*81*
Coagulation products3*16* 
CVR = total cranial vault reconstruction; FFP = fresh frozen plasma; pRBC = packed red blood cells; SSC = open sagittal strip craniectomy.

p < 0.05.

Complications

Eight studies1,2,4,8,11,16,39,44 reported on complications of open and endoscopic treatment of sagittal synostosis (Table 5). These studies all used different metrics to analyze rates of complications at various time points, including during the operation, during the hospital stay, and at various lengths of follow-up. Although statistical analysis was not reported, 6 studies reported equal or lower rates of complications for endoscopically treated patients. Han et al. observed complication rates at 4 time points and found no statistical difference between endoscopic and open surgery (range, p = 0.140 to p = 0.921). Most notably, 3 studies2,8,11 reported a lower reoperation rate for endoscopic techniques compared to open surgery.

TABLE 5.

Complications in patients with sagittal craniosynostosis undergoing endoscopic and open surgery

Authors & YearNo. of PtsComplicationEndoscopicOpen
EndoOpen%No. of Pts%No. of Pts  
Abbott et al., 20121010Postop emergency visits0.0030.03
Arts et al., 20186330Intraop complications1.613.31
Postop complications4.733.31   
Reoperation1.613.31   
Bonfield et al., 20162871Cardiovascular or wound healing0.000.00
Esparza & Hinojosa, 200839116Reoperation2.619.511
Wound infection2.610.00   
Subgaleal hematoma0.005.26   
Infected hematoma0.003.44   
Dural tear0.000.81   
Craniolacunae0.002.63   
Plate scarring0.001.72   
Postop hyperthermia10.3415.518   
Infection*1.742.316   
Garber et al., 2017100200Revision surgery1.017.014
Han et al., 2016140155Surgical complications2.131.32
Intraop durotomies3.657.812   
Postop complications3.654.57   
Readmit <30 days1.421.32   
Shah et al., 20114742Wound revision2.112.41
Thompson et al., 2018311622Hypotension requiring pressors38423
Venous air embolism1415   
Hypothermia, temp <35°C227026160   
Postop intubation261060   
Cardiac arrest000.21   

Bacterial and/or viral infection sites include the urinary tract, respiratory system, ophthalmic system, and/or central and mechanical intravenous lines.

Possible overlapping cohorts.

Cosmetic Outcomes

Two studies from different patient populations compared postoperative cranial index, both of which showed no statistical difference. Abbott et al.1 reported a postoperative cranial index of 0.77 and 0.75 for endoscopic and open procedures, respectively, with no significant difference. Likewise, Shah et al.39 also demonstrated a cranial index of 0.76 and 0.77 (p = 0.346) for endoscopic and open procedures. Finally, Ghenbot et al.12 looked at cranial vault volume, showing no significant difference for the endoscopic and open cohorts (p = 0.31), although the patients in this cohort were probably also all analyzed by Shah et al.39

Cost of Treatment

Three studies looked at the cost of craniosynostosis treatment. Abbott et al.1 and Vogel et al.45 analyzed the total cost of treating craniosynostosis, including the medical cost of hospital and physician fees, orthotic cost of helmet fittings, and indirect patient costs of travel and lost work days. The median (range) of the endoscopic and open surgery cost was $23,377 ($20,987–$24,977) and $55,121 ($44,690–$86,313), respectively,1 and the reported mean cost of endoscopic and open surgery was $37,356 and $56,990, respectively.45 Looking solely at medical costs,11 endoscopic procedures again were found to be cheaper ($21,203) than open procedures ($32,806).

Discussion

In this meta-analysis and literature review, we found that surgical treatment of sagittal synostosis by endoscope-assisted surgery was associated with shorter operating room times, shorter LOS, reduced rates of transfusion, and similar cosmetic results at last follow-up (as measured by cranial index), compared with open surgery. Important differences highlighted include the age at time of surgery, which was consistently younger for children undergoing endoscopic repair. The study by Esparza and Hinojosa8 shows the differences between North American and European treatment; despite the difficulty in performing a direct comparison, the inclusion of this study highlights how different healthcare systems will have an impact on treatment options. Although a myriad of techniques for both open and endoscopic repair have been reported, rendering comparisons difficult, our meta-analysis provides the most comprehensive synthesis of the available literature pertaining to the surgical treatment of sagittal synostosis with open and endoscopic methods.

Perioperative Outcomes

Endoscopic treatment of craniosynostosis has significantly less estimated blood loss than open surgery.1,2,11,16 Consequently, the rate of transfusion has been found to be less for endoscopically treated patients.1,2,4,11,16,44 Bonfield et al.4 summarized 37 published studies that have investigated blood transfusion rates in craniofacial procedures, although they did not report any studies that directly compared endoscopic to open procedures. Although blood transfusion safety has improved over time, infants have a greater incidence of adverse outcomes than adults (37 vs 13 cases per 100,000 red blood cells transfused, respectively).15,27 This is most often due to complications such as transfusion-related acute lung injury (TRALI) and transfusion-related circulatory overload (TACO). Therefore, it is important to minimize the need for transfusion when performing surgery on infants. In their multicenter study of 31 institutions, Thompson et al.44 regretted the documented inaccuracies of blood loss estimates and sought alternatives to study this important metric.

The length of operating time and LOS for endoscopically treated patients was significantly shorter with endoscope-assisted correction of sagittal synostosis, as seen in 5 studies.1,8,11,16,44 Although the American studies show LOS means ranging from 1 to 4 days, Esparza and Hinojosa8 admit that their mean time of 11.9 days is unacceptable; their longer hospital stays seen in sagittal expansive osteotomies (12.4 days) and sagittal holocranial dismantling (16.2 days) are related to postoperative complications. This further suggests that the less invasive endoscopic techniques may reduce operating time and hospital stay.

Complications

Eight studies1,2,4,8,11,16,39,44 seem to support an equivalent or decreased complication rate for endoscopically assisted surgeries compared to open surgery. Future research should document the most common or most severe complications at each stage of treatment to provide the opportunity for analysis across studies. None of the included studies reported a higher incidence of injury to the sagittal sinus due to endoscopic surgery compared to open surgery. Because it is a novel technique, endoscopic surgery encompasses a large variability in outcomes and complications between different surgeons and procedures.

Cosmetic Outcomes

It has not yet been clearly defined how to best measure the postoperative aesthetic improvements after craniosynstosis surgery. The average cranial index (i.e., maximal cranial width/length) of children younger than 3 years of age was measured at 0.815.31 In children with sagittal synostosis, the cranial index is as low as 0.65.14,35 Our study shows that both endoscopic and open corrections, with cranial index ranging from 0.75 to 0.77, are able to achieve comparable postoperative results.1,39 Ghenbot et al.12 analyzed cranial vault volume in addition to cranial index and found no difference in cranial vault volume, assuaging the concern that molding helmet therapy would lead to volume restriction. Future studies evaluating these techniques must take into account variability in outcomes among children as well as other measures of cosmesis, including parent or patient impression and satisfaction.

Cost of Treatment

In 3 different populations,1,11,45 the cost of endoscopic treatment with helmet therapy follow-up was found to be lower than the cost of open surgery, with differences ranging from $11,603 to $31,744. The difference is mostly attributable to the more invasive and extensive nature of open cranial surgery, often requiring ICU observation, transfusions, or a higher rate of revision. The costs of helmets were reported in all included studies; however, there are several indirect costs and also additional time needed for postoperative helmet servicing that have not been measured in the published literature. Furthermore, there may be unaccounted obstacles and unknown patient or parent impressions of helmet usage that have not been studied. The long-term efficacy and costs require ongoing research.

Strengths and Limitations

Strengths of this study include an extensive search of the current literature, strict adherence to PRISMA guidelines, and quality of evidence analysis by EPHPP protocol. Currently, there exists no randomized controlled trial comparing the surgical approaches of endoscopic and open sagittal suture repair. Given the data suggesting absence of equipoise between the two techniques, it is unlikely that such a trial would be conducted. Ultimately, the findings of this meta-analysis require confirmation by larger, multicenter studies with extended follow-up.

Only 3 studies met PRISMA criteria for full meta-analysis; this low number indicates the need for future studies. The studies included in this review consisted mostly of moderate and weak observational studies. One must also consider the selection bias due to preference of surgeons or institutions and shifts of practice over time. There have yet to be any studies that examine patient or parent satisfaction, or the required duration and comfort of helmet usage. It is also evident that there is a tradeoff between the potential benefits of endoscopic repair and the disadvantage of the length of time spent in a helmet. These compromises are mediated by parental preferences, which are difficult to capture in current literature. Future studies aimed at assessing “value-based medicine” by using methodologies such as decision-tree analyses may elucidate the benefit of endoscopic repair.

Furthermore, there is still a lack of understanding regarding the variability of endoscopic outcomes and, therefore, longer follow-up and further analyses are indicated. The current meta-analysis was additionally limited by the heterogeneity of suture types in some studies.16 Given the clinical and surgical heterogeneity that we have identified, it is of value to conduct future observational studies that separate different entities and account for patient and surgical variability. Given the dearth of data available for meta-analysis, interstudy heterogeneity could not be calculated.

Conclusions

Endoscope-assisted correction of sagittal synostosis has some benefits over open surgical repair. Endoscopic procedures are associated with lower estimated blood loss, operating time, days in hospital, and transfusion rates. Current evidence in the literature comparing endoscopic and open sagittal craniosynostosis repair is mostly of weak to moderate quality—only 3 papers were found to be strong. Although these early studies suggest several benefits of endoscopic procedures, consideration is needed for each individual family to understand the usage of helmets and unknown long-term outcomes. Future large prospective registries or randomized controlled trials are required to validate the findings of this study.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Yan, Ibrahim. Acquisition of data: Yan, Abel, Anderson. Analysis and interpretation of data: Yan, Abel. Drafting the article: Yan, Abel, Ibrahim. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Yan. Statistical analysis: Alotaibi. Administrative/technical/material support: Ibrahim. Study supervision: Yan, Ibrahim.

Supplemental Information

Companion Papers

Yan H, Abel TJ, Alotaibi NM, Anderson M, Niazi TN, Weil AG, et al: A systematic review of endoscopic versus open treatment of craniosynostosis. Part 2: the nonsagittal single sutures. DOI: 10.3171/2018.4.PEDS17730.

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    • Export Citation
  • 12

    Ghenbot RGPatel KBSkolnick GBNaidoo SDSmyth MDWoo AS: Effects of open and endoscopic surgery on skull growth and calvarial vault volumes in sagittal synostosis. J Craniofac Surg 26:1611642015

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

    Ghosh TDSkolnick GNguyen DCSun HPatel KSmyth MD: Calvarial thickness and diploic space development in children with sagittal synostosis as assessed by computed tomography. J Craniofac Surg 25:105010552014

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

    Gociman BMarengo JYing JKestle JRSiddiqi F: Minimally invasive strip craniectomy for sagittal synostosis. J Craniofac Surg 23:8258282012

  • 15

    Goodnough LT: Risks of blood transfusion. Anesthesiol Clin North America 23:241252v2005

  • 16

    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
  • 17

    Hashim PWPatel AYang JFTravieso RTerner JLosee JE: The effects of whole-vault cranioplasty versus strip craniectomy on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg 134:4915012014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Jimenez DFBarone CM: Endoscopic craniectomy for early surgical correction of sagittal craniosynostosis. J Neurosurg 88:77811998

  • 19

    Jimenez DFBarone CMMcGee MECartwright CCBaker CL: Endoscopy-assisted wide-vertex craniectomy, barrel stave osteotomies, and postoperative helmet molding therapy in the management of sagittal suture craniosynostosis. J Neurosurg 100 (5 Suppl Pediatrics):4074172004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Kapp-Simon KASpeltz MLCunningham MLPatel PKTomita T: Neurodevelopment of children with single suture craniosynostosis: a review. Childs Nerv Syst 23:2692812007

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

    Keshavarzi SHayden MGBen-Haim SMeltzer HSCohen SRLevy ML: Variations of endoscopic and open repair of metopic craniosynostosis. J Craniofac Surg 20:143914442009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Keshavarzi SMeltzer HCohen SRBreithaupt ABen-Haim SNewman CB: The risk of growing skull fractures in craniofacial patients. Pediatr Neurosurg 46:1931982010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Kohan EWexler ACahan LKawamoto HKKatchikian HBradley JP: Sagittal synostotic twins: reverse pi procedure for scaphocephaly correction gives superior result compared to endoscopic repair followed by helmet therapy. J Craniofac Surg 19:145314582008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Kolar JC: An epidemiological study of nonsyndromal craniosynostoses. J Craniofac Surg 22:47492011

  • 25

    Lane LC: Pioneer craniectomy for relief of mental imbecility due to premature sutural closure and microcephalus. JAMA 267:2301992

  • 26

    Lannelongue OM: De la craniectomie chez les microcéphales, chez les enfants arriérés et chez les jeunes sujets présentants, avec ou sans crises épileptiformes, de troubles moteurs ou psychiques. Congr Franc de Chir Paris 5:73811891

    • Search Google Scholar
    • Export Citation
  • 27

    Lavoie J: Blood transfusion risks and alternative strategies in pediatric patients. Paediatr Anaesth 21:14242011

  • 28

    Le MBPatel KSkolnick GNaidoo SSmyth MKane A: Assessing long-term outcomes of open and endoscopic sagittal synostosis reconstruction using three-dimensional photography. J Craniofac Surg 25:5735762014

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

    Lee HQHutson JMWray ACLo PAChong DKHolmes AD: Changing epidemiology of nonsyndromic craniosynostosis and revisiting the risk factors. J Craniofac Surg 23:124512512012

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

    Liberati AAltman DGTetzlaff JMulrow CGøtzsche PCIoannidis JP: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6:e10001002009

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

    Likus WBajor GGruszczyńska KBaron JMarkowski JMachnikowska-Sokołowska M: Cephalic index in the first three years of life: study of children with normal brain development based on computed tomography. Sci World J 2014:5028362014

    • Search Google Scholar
    • Export Citation
  • 32

    MacKinnon SProctor MRRogers GFMeara JGWhitecross SDagi LR: Improving ophthalmic outcomes in children with unilateral coronal synostosis by treatment with endoscopic strip craniectomy and helmet therapy rather than fronto-orbital advancement. J AAPOS 17:2592652013

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

    MacKinnon SRogers GFGregas MProctor MRMulliken JBDagi LR: Treatment of unilateral coronal synostosis by endoscopic strip craniectomy or fronto-orbital advancement: ophthalmologic findings. J AAPOS 13:1551602009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Mehta VABettegowda CJallo GIAhn ES: The evolution of surgical management for craniosynostosis. Neurosurg Focus 29(6):E52010

  • 35

    Murray DJKelleher MOMcGillivary AAllcutt DEarley MJ: Sagittal synostosis: a review of 53 cases of sagittal suturectomy in one unit. J Plast Reconstr Aesthet Surg 60:9919972007

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

    Nguyen DCPatel KBSkolnick GBNaidoo SDHuang AHSmyth MD: Are endoscopic and open treatments of metopic synostosis equivalent in treating trigonocephaly and hypotelorism? J Craniofac Surg 26:1291342015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Nowaková MKordoš PHladík MMedřická HRosický JKaleta E: Endoskopické operační řešení kraniosynostóz z pohledu dětského intenzivisty. Přehledové články 16:3083112015

    • Search Google Scholar
    • Export Citation
  • 38

    Rogers GFWood BCAmdur RLJeelani YReddy SProctor MR: Treatment type is associated with population hand preferences in patients with unilateral coronal synostosis: implications for functional cerebral lateralization. Plast Reconstr Surg 136:782e788e2015

    • Search Google Scholar
    • Export Citation
  • 39

    Shah MNKane AAPetersen JDWoo ASNaidoo SDSmyth MD: Endoscopically assisted versus open repair of sagittal craniosynostosis: the St. Louis Children’s Hospital experience. J Neurosurg Pediatr 8:1651702011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 40

    Shamseer LMoher DClarke MGhersi DLiberati APetticrew M: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 350:g76472015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Siu ARogers GFMyseros JSKhalsa SSKeating RFMagge SN: Unilateral coronal craniosynostosis and Down syndrome. J Neurosurg Pediatr 13:5685712014

  • 42

    Tan SPProctor MRMulliken JBRogers GF: Early frontofacial symmetry after correction of unilateral coronal synostosis: frontoorbital advancement vs endoscopic strip craniectomy and helmet therapy. J Craniofac Surg 24:119011942013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Thomas BHCiliska DDobbins MMicucci S: A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews Evid Based Nurs 1:1761842004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Thompson DRZurakowski DHaberkern CMStricker PAMeier PMBannister C: Endoscopic versus open repair for craniosynostosis in infants using propensity score matching to compare outcomes: a multicenter study from the Pediatric Craniofacial Collaborative Group. Anesth Analg 126:9689752018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 45

    Vogel TWWoo ASKane AAPatel KBNaidoo SDSmyth MD: A comparison of costs associated with endoscope-assisted craniectomy versus open cranial vault repair for infants with sagittal synostosis. J Neurosurg Pediatr 13:3243312014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Yarbrough CKSmyth MDHolekamp TFRanalli NJHuang AHPatel KB: Delayed synostoses of uninvolved sutures after surgical treatment of nonsyndromic craniosynostosis. J Craniofac Surg 25:1191232014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Zubovic EWoo ASSkolnick GBNaidoo SDSmyth MDPatel KB: Cranial base and posterior cranial vault asymmetry after open and endoscopic repair of isolated lambdoid craniosynostosis. J Craniofac Surg 26:156815732015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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Article Information

Contributor Notes

Correspondence Han Yan: The Hospital for Sick Children, Toronto, ON, Canada. hhan.yan@mail.utoronto.ca.INCLUDE WHEN CITING Published online July 6, 2018; DOI: 10.3171/2018.4.PEDS17729.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Headings
Figures
  • View in gallery

    PRISMA flowchart for systematic review.

  • View in gallery

    Meta-analysis of perioperative measures. Std diff in means = SMDs. Figure is available in color online only.

References
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    Chan JWStewart CLStalder MWSt Hilaire HMcBride LMoses MH: Endoscope-assisted versus open repair of craniosynostosis: a comparison of perioperative cost and risk. J Craniofac Surg 24:1701742013

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    • PubMed
    • Search Google Scholar
    • Export Citation
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    Di Rocco FArnaud ERenier D: Evolution in the frequency of nonsyndromic craniosynostosis. J Neurosurg Pediatr 4:21252009

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    Dvoracek LASkolnick GBNguyen DCNaidoo SDSmyth MDWoo AS: Comparison of traditional versus normative cephalic index in patients with sagittal synostosis: measure of scaphocephaly and postoperative outcome. Plast Reconstr Surg 136:5415482015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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    Esparza JHinojosa J: Complications in the surgical treatment of craniosynostosis and craniofacial syndromes: apropos of 306 transcranial procedures. Childs Nerv Syst 24:142114302008

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    Farber SJNguyen DCSkolnick GBNaidoo SDSmyth MDPatel KB: Anthropometric outcome measures in patients with metopic craniosynostosis. J Craniofac Surg 28:7137162017

    • Crossref
    • PubMed
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    • Export Citation
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    Fearon JAMcLaughlin EBKolar JC: Sagittal craniosynostosis: surgical outcomes and long-term growth. Plast Reconstr Surg 117:5325412006

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    Garber STKarsy MKestle JRWSiddiqi FSpanos SPRiva-Cambrin J: comparing outcomes and cost of 3 surgical treatments for sagittal synostosis: a retrospective study including procedure-related cost analysis. Neurosurgery 81:6806872017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Ghenbot RGPatel KBSkolnick GBNaidoo SDSmyth MDWoo AS: Effects of open and endoscopic surgery on skull growth and calvarial vault volumes in sagittal synostosis. J Craniofac Surg 26:1611642015

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

    Ghosh TDSkolnick GNguyen DCSun HPatel KSmyth MD: Calvarial thickness and diploic space development in children with sagittal synostosis as assessed by computed tomography. J Craniofac Surg 25:105010552014

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

    Gociman BMarengo JYing JKestle JRSiddiqi F: Minimally invasive strip craniectomy for sagittal synostosis. J Craniofac Surg 23:8258282012

  • 15

    Goodnough LT: Risks of blood transfusion. Anesthesiol Clin North America 23:241252v2005

  • 16

    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
  • 17

    Hashim PWPatel AYang JFTravieso RTerner JLosee JE: The effects of whole-vault cranioplasty versus strip craniectomy on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg 134:4915012014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Jimenez DFBarone CM: Endoscopic craniectomy for early surgical correction of sagittal craniosynostosis. J Neurosurg 88:77811998

  • 19

    Jimenez DFBarone CMMcGee MECartwright CCBaker CL: Endoscopy-assisted wide-vertex craniectomy, barrel stave osteotomies, and postoperative helmet molding therapy in the management of sagittal suture craniosynostosis. J Neurosurg 100 (5 Suppl Pediatrics):4074172004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Kapp-Simon KASpeltz MLCunningham MLPatel PKTomita T: Neurodevelopment of children with single suture craniosynostosis: a review. Childs Nerv Syst 23:2692812007

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

    Keshavarzi SHayden MGBen-Haim SMeltzer HSCohen SRLevy ML: Variations of endoscopic and open repair of metopic craniosynostosis. J Craniofac Surg 20:143914442009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Keshavarzi SMeltzer HCohen SRBreithaupt ABen-Haim SNewman CB: The risk of growing skull fractures in craniofacial patients. Pediatr Neurosurg 46:1931982010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Kohan EWexler ACahan LKawamoto HKKatchikian HBradley JP: Sagittal synostotic twins: reverse pi procedure for scaphocephaly correction gives superior result compared to endoscopic repair followed by helmet therapy. J Craniofac Surg 19:145314582008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Kolar JC: An epidemiological study of nonsyndromal craniosynostoses. J Craniofac Surg 22:47492011

  • 25

    Lane LC: Pioneer craniectomy for relief of mental imbecility due to premature sutural closure and microcephalus. JAMA 267:2301992

  • 26

    Lannelongue OM: De la craniectomie chez les microcéphales, chez les enfants arriérés et chez les jeunes sujets présentants, avec ou sans crises épileptiformes, de troubles moteurs ou psychiques. Congr Franc de Chir Paris 5:73811891

    • Search Google Scholar
    • Export Citation
  • 27

    Lavoie J: Blood transfusion risks and alternative strategies in pediatric patients. Paediatr Anaesth 21:14242011

  • 28

    Le MBPatel KSkolnick GNaidoo SSmyth MKane A: Assessing long-term outcomes of open and endoscopic sagittal synostosis reconstruction using three-dimensional photography. J Craniofac Surg 25:5735762014

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

    Lee HQHutson JMWray ACLo PAChong DKHolmes AD: Changing epidemiology of nonsyndromic craniosynostosis and revisiting the risk factors. J Craniofac Surg 23:124512512012

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

    Liberati AAltman DGTetzlaff JMulrow CGøtzsche PCIoannidis JP: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6:e10001002009

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

    Likus WBajor GGruszczyńska KBaron JMarkowski JMachnikowska-Sokołowska M: Cephalic index in the first three years of life: study of children with normal brain development based on computed tomography. Sci World J 2014:5028362014

    • Search Google Scholar
    • Export Citation
  • 32

    MacKinnon SProctor MRRogers GFMeara JGWhitecross SDagi LR: Improving ophthalmic outcomes in children with unilateral coronal synostosis by treatment with endoscopic strip craniectomy and helmet therapy rather than fronto-orbital advancement. J AAPOS 17:2592652013

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

    MacKinnon SRogers GFGregas MProctor MRMulliken JBDagi LR: Treatment of unilateral coronal synostosis by endoscopic strip craniectomy or fronto-orbital advancement: ophthalmologic findings. J AAPOS 13:1551602009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Mehta VABettegowda CJallo GIAhn ES: The evolution of surgical management for craniosynostosis. Neurosurg Focus 29(6):E52010

  • 35

    Murray DJKelleher MOMcGillivary AAllcutt DEarley MJ: Sagittal synostosis: a review of 53 cases of sagittal suturectomy in one unit. J Plast Reconstr Aesthet Surg 60:9919972007

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

    Nguyen DCPatel KBSkolnick GBNaidoo SDHuang AHSmyth MD: Are endoscopic and open treatments of metopic synostosis equivalent in treating trigonocephaly and hypotelorism? J Craniofac Surg 26:1291342015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Nowaková MKordoš PHladík MMedřická HRosický JKaleta E: Endoskopické operační řešení kraniosynostóz z pohledu dětského intenzivisty. Přehledové články 16:3083112015

    • Search Google Scholar
    • Export Citation
  • 38

    Rogers GFWood BCAmdur RLJeelani YReddy SProctor MR: Treatment type is associated with population hand preferences in patients with unilateral coronal synostosis: implications for functional cerebral lateralization. Plast Reconstr Surg 136:782e788e2015

    • Search Google Scholar
    • Export Citation
  • 39

    Shah MNKane AAPetersen JDWoo ASNaidoo SDSmyth MD: Endoscopically assisted versus open repair of sagittal craniosynostosis: the St. Louis Children’s Hospital experience. J Neurosurg Pediatr 8:1651702011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 40

    Shamseer LMoher DClarke MGhersi DLiberati APetticrew M: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 350:g76472015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Siu ARogers GFMyseros JSKhalsa SSKeating RFMagge SN: Unilateral coronal craniosynostosis and Down syndrome. J Neurosurg Pediatr 13:5685712014

  • 42

    Tan SPProctor MRMulliken JBRogers GF: Early frontofacial symmetry after correction of unilateral coronal synostosis: frontoorbital advancement vs endoscopic strip craniectomy and helmet therapy. J Craniofac Surg 24:119011942013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Thomas BHCiliska DDobbins MMicucci S: A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews Evid Based Nurs 1:1761842004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Thompson DRZurakowski DHaberkern CMStricker PAMeier PMBannister C: Endoscopic versus open repair for craniosynostosis in infants using propensity score matching to compare outcomes: a multicenter study from the Pediatric Craniofacial Collaborative Group. Anesth Analg 126:9689752018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 45

    Vogel TWWoo ASKane AAPatel KBNaidoo SDSmyth MD: A comparison of costs associated with endoscope-assisted craniectomy versus open cranial vault repair for infants with sagittal synostosis. J Neurosurg Pediatr 13:3243312014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Yarbrough CKSmyth MDHolekamp TFRanalli NJHuang AHPatel KB: Delayed synostoses of uninvolved sutures after surgical treatment of nonsyndromic craniosynostosis. J Craniofac Surg 25:1191232014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Zubovic EWoo ASSkolnick GBNaidoo SDSmyth MDPatel KB: Cranial base and posterior cranial vault asymmetry after open and endoscopic repair of isolated lambdoid craniosynostosis. J Craniofac Surg 26:156815732015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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