Optimal duration of postoperative helmet therapy following endoscopic strip craniectomy for sagittal craniosynostosis

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Many infants with sagittal craniosynostosis undergo effective surgical correction with endoscopic strip craniectomy (ESC) and postoperative helmet therapy (PHT). While PHT is essential to achieving optimal cosmesis following ESC, there has been little comprehensive analysis of the ideal PHT duration needed to attain this goal.


The authors retrospectively reviewed the charts of infants undergoing ESC and PHT for sagittal synostosis at our institution between 2008 and 2015. Data collected included age at surgery, follow-up duration, and PHT duration. Cephalic index (CI) was evaluated preoperatively (CIpre), at its peak level (CImax), at termination of helmet therapy (CIoff), and at last follow-up (CIfinal). A multivariate regression analysis was performed to determine factors influencing CIfinal.


Thirty-one patients (27 male, 4 female) were treated in the studied time period. The median age at surgery was 2.7 months (range 1.6 to 3.2) and the median duration of PHT was 10.4 months (range 8.4 to 14.4). The mean CImax was 0.83 (SD 0.01), which was attained an average of 8.4 months (SD 1.2) following PHT initiation. At last follow-up, there was an average retraction of CIfinal among all patients to 0.78 (SD 0.01). Longer helmet duration after achieving CImax did not correlate with higher CIfinal values. While CImax was a significant predictor of CIfinal, neither age at surgery nor CIpre were found to be predictive of final outcome.


Patients undergoing ESC and PHT for sagittal synostosis reach a peak CI around 7 to 9 months after surgery. PHT beyond CImax does not improve final anthropometric outcomes. CIfinal is significantly dependent on CImax, but not on age, nor CIpre. These results imply that helmet removal at CImax may be appropriate for ESC patients, while helmeting beyond the peak does not change final outcome.

ABBREVIATIONS CI = cephalic index; CIfinal = CI at last follow-up; CImax = maximum/peak CI achieved; CIoff = CI at helmet removal; CIpre = preoperative CI; ESC = endoscopic strip craniectomy; PHT = postoperative helmet therapy.

Article Information

Correspondence Edward S. Ahn: Mayo Clinic, Rochester, MN. ahn.edward@mayo.edu.

INCLUDE WHEN CITING Published online August 31, 2018; DOI: 10.3171/2018.5.PEDS184.

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

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Serial laser imaging during the post-ESC helmeting period in a patient with sagittal synostosis. Serial lateral 3D laser images (lower row), calculated axial cranial depictions (top row), and corresponding CI measurements obtained preoperatively (A), 3 months postoperatively (B), and 12 months postoperatively (C), showing a retraction in CI from 0.82 to 0.80 between 3 and 12 months, but an overall improvement in CI from 0.70 to 0.80 during the helmeting period. Figure is available in color online only.

  • View in gallery

    Cephalic index (CI) trends in 31 patients undergoing ESC and PHT for sagittal synostosis. The average trend in CI in patients treated with PHT after ESC for sagittal synostosis demonstrates a peak around 8 months, followed by a steady retraction to final CI measurement, ending in the normal range (red line). The average CI in more than 300 normal babies (solid green line) and 95% normal range (dashed green lines) are shown for comparison.17 Numbers listed at the top indicate time points for the average values across groups: 1, CIpre; 2, CImax; 3, CIoff; and 4, CIfinal. Figure is available in color online only.



Abbott MMRogers GFProctor MRBusa KMeara JG: Cost of treating sagittal synostosis in the first year of life. J Craniofac Surg 23:88932012


Agrawal DSteinbok PCochrane DD: Long-term anthropometric outcomes following surgery for isolated sagittal craniosynostosis. J Neurosurg 105 (5 Suppl):3573602006


Barone CMJimenez DF: Endoscopic craniectomy for early correction of craniosynostosis. Plast Reconstr Surg 104:196519751999


Berry-Candelario JRidgway EBGrondin RTRogers GFProctor MR: Endoscope-assisted strip craniectomy and postoperative helmet therapy for treatment of craniosynostosis. Neurosurg Focus 31(2):E52011


Borghi ASchievano SRodriguez Florez NMcNicholas RRodgers WPonniah A: Assessment of spring cranioplasty biomechanics in sagittal craniosynostosis patients. J Neurosurg Pediatr 20:4004092017


Dlouhy BJNguyen DCPatel KBHoben GMSkolnick GBNaidoo SD: Endoscope-assisted management of sagittal synostosis: wide vertex suturectomy and barrel stave osteotomies versus narrow vertex suturectomy. J Neurosurg Pediatr 25:6746782016


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


Goodrich JT: Single incision endoscope-assisted surgery for sagittal craniosynostosis. Childs Nerv Syst 33:782017


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


Iyer RRUribe-Cardenas RAhn ES: Single incision endoscope-assisted surgery for sagittal craniosynostosis. Childs Nerv Syst 33:152017


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


Jimenez DFBarone CMCartwright CCBaker L: Early management of craniosynostosis using endoscopic-assisted strip craniectomies and cranial orthotic molding therapy. Pediatrics 110:971042002


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


Johnson JOJimenez DFBarone CM: Blood loss after endoscopic strip craniectomy for craniosynostosis. J Neurosurg Anesthesiol 12:602000


Lauritzen CGDavis CIvarsson ASanger CHewitt TD: The evolving role of springs in craniofacial surgery: the first 100 clinical cases. Plast Reconstr Surg 121:5455542008


Murad GJClayman MSeagle MBWhite SPerkins LAPincus DW: Endoscopic-assisted repair of craniosynostosis. Neurosurg Focus 19(6):E62005


Pindrik JMolenda JUribe-Cardenas RDorafshar AHAhn ES: Normative ranges of anthropometric cranial indices and metopic suture closure during infancy. J Neurosurg Pediatr 25:6676732016


Ridgway EBBerry-Candelario JGrondin RTRogers GFProctor MR: The management of sagittal synostosis using endoscopic suturectomy and postoperative helmet therapy. J Neurosurg Pediatr 7:6206262011


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


Wilbrand JFWilbrand MMalik CYHowaldt HPStreckbein PSchaaf H: Complications in helmet therapy. J Craniomaxillofac Surg 40:3413462012


Wood BCAhn ESWang JYOh AKKeating RFRogers GF: Less is more: does the addition of barrel staves improve results in endoscopic strip craniectomy for sagittal craniosynostosis? J Neurosurg Pediatr 20:86902017




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