Regression of cephalic index following endoscopic repair of sagittal synostosis

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Metrics used to quantify preoperative severity and postoperative outcomes for patients with sagittal synostosis include cephalic index (CI), the well-known standard, and the recently described adjusted cephalic index (aCI), which accounts for altered euryon location. This study tracks the time course of these measures following endoscopic repair with orthotic helmet therapy. The authors hypothesize that CI and aCI show significant regression following endoscope-assisted repair.


CT scans or 3D photographs of patients with nonsyndromic sagittal synostosis treated before 6 months of age by endoscope-assisted strip craniectomy and postoperative helmet therapy (n = 41) were reviewed retrospectively at three time points (preoperatively, 0–2 months after helmeting, and > 24 months postoperatively). The CI and aCI were measured at each time point.


Mean CI and aCI increased from 71.8 to 78.2 and 62.7 to 72.4, respectively, during helmet treatment (p < 0.001). At final follow-up, mean CI and aCI had regressed significantly from 78.2 to 76.5 and 72.4 to 69.7, respectively (p < 0.001). The CI regressed in 33 of 41 cases (80%) and aCI in 39 of 41 cases (95%). The authors observed a mean loss of 31% of improvement in aCI achieved through treatment. A strong, positive correlation existed between CI and aCI (R = 0.88).


Regression following endoscope-assisted strip craniectomy with postoperative helmet therapy commonly occurs in patients with sagittal synostosis. Future studies are required to determine whether duration of helmet therapy or modifications in helmet design affect regression.

ABBREVIATIONS aCI = adjusted CI; CI = cephalic index; ICC = intraclass correlation coefficient.

Article Information

Correspondence Kamlesh B. Patel: Washington University in St. Louis, MO.

INCLUDE WHEN CITING Published online October 5, 2018; DOI: 10.3171/2018.7.PEDS18195.

Disclosures Dr. Patel is a consultant for Stryker CMF and a paid speaker for Hanger Clinic. Dr. Naidoo is a paid speaker for Hanger Clinic and Orthomerica.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Vertex view of a scaphocephalic patient CT scan (left) and 3D photograph (right). Anteroposterior length (orange line) and traditional biparietal width (green line) are shown. Figure is available in color online only.

  • View in gallery

    Series of vertex and posterior views of 3D photographs of a patient with sagittal synostosis taken at specified time points: preoperative (A), initial postoperative (B), and final postoperative (C). Lumps are due to imperfect skullcap fit. Figure is available in color online only.

  • View in gallery

    Graphic representation of traditional and adjusted CIs at preoperative, initial follow-up, and final follow-up time points. The lower margin of the normocephalic range is indicated by the red line (75%). Mean traditional and adjusted CI values were significantly different between time points (p < 0.001). Figure is available in color online only.

  • View in gallery

    Graphic representation of postoperative changes in aCI over time at shorter intervals in 8 patients. Figure is available in color online only.



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