Endoscopic craniectomy for early surgical correction of sagittal craniosynostosis

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Object. The authors sought to minimize scalp incisions, blood loss, and operative time by using endoscopically assisted strip craniectomies and barrel-stave osteotomies to treat infants with sagittal suture synostosis.

Methods. Four patients, aged 2, 4, 9, and 12 weeks, who presented with scaphocephaly underwent endoscopic midline craniectomies through small midline scalp incisions. The mean operative time for the procedure was 1.68 hours (range 1.15–2.8 hours); the mean blood loss was 54.2 ml (range 12–150 ml). Three patients did not require blood transfusions and were discharged within 24 hours. Postoperatively, all patients were fitted with custom cranial molding helmets. Follow-up evaluation ranged between 8 and 15 months. All patients had successful correction of their scaphocephaly with no mortalities, morbidities, or complications.

Conclusions. The use of endoscopic techniques for early correction of sagittal synostosis is safe; decreases blood loss, operative time, and hospitalization costs; and provides excellent early surgical results.

Article Information

Address reprint requests to: David F. Jimenez, M.D., Division of Neurological Surgery, University of Missouri Hospital and Clinics, One Hospital Drive, Columbia, Missouri 65212. email: djimenez@surgery.missouri.edu.

© AANS, except where prohibited by US copyright law.



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    Composite drawing demonstrating endoscopic strip craniectomy. Two small incisions are placed medially over the anterior fontanelle and the lambda. The endoscope and dissector are inserted anteriorly followed by subgaleal and epidural dissection. After paramedian osteotomies have been completed, a midline strip of bone is removed. Barrel-stave osteotomies are then extended bilaterally and normocephaly is achieved with postoperative helmet-molding therapy.

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    Left: Endoscopic view of the subgaleal space after dissection with monopolar electrocautery. Right: Artist's rendition of the figure shown at left. A midline, superiorly located retractor elevates the scalp away from the cranium.

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    Left: Endoscopic visualization of the undersurface of the stenosed sagittal suture. Right: Artist's illustration of the figure shown at left. A midline, inferiorly placed probe is seen depressing the dura away from the overlying skull. Several small diploic veins are seen paramedian to the sagittal sinus.

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    Left: Endoscopic view of bone-cutting scissors being used to create a paramedian osteotomy. Right: Artist's rendition of the figure shown at left. The tip of the scissors are seen in the left lower quadrant. Cutting through the posterior edge of the anterior fontanelle, a retractor, elevating the scalp, is seen in the right upper corner.

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    Intraoperative photograph showing removal of the midline strip through the anterior incision. Wide strips can be removed through small incisions by bisecting the bone.

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    Left: Endoscopic view of the lateral edge of the strip craniectomy showing the barrel-stave osteotomies. Right: Artist's view of the figure shown at left. A retractor is seen in the right upper quadrant, elevating the scalp. The wedge-shaped osteotomies are seen in the lower half of the diagram along with the underlying dura.

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    Postoperative photograph of a patient in a polypropylene molding helmet. Anteroposterior growth is partially restricted while allowing increased bitemporal and biparietal expansion to achieve rapid normocephaly.

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    Left: Preoperative lateral view of a 4-week-old girl who was born with a prominent, palpable midline osseous ridge, marked bifrontal bosselation, occipital cupping, and significant scaphocephaly. Right: Lateral view of the same infant 7 months postoperatively.

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    Left: Preoperative aerial view of the patient shown in Fig. 7. Right: Postoperative view of the same patient demonstrating correction of scaphocephaly and bitemporal widening.

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    Graph displaying cephalic indices over time. The cephalic index is obtained by measuring the most lateral aspect of the head (euryon—euryon) and dividing this value by the greatest distance from the anterior (glabella) to posterior (opisthocranion) point. Low numbers indicate scaphocephaly, whereas high numbers indicate brachycephaly. All of our patients had low indices preoperatively and rapidly achieved and maintained normocephaly after treatment. The graph shows the upper and lower limits as well as the mean cephalic index (thick lines). Thin lines with various symbols indicate the individual patients.



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