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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Figures

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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.

References

1.

Albright AL: Operative normalization of the skull shape in sagittal synostosis. Neurosurgery 17:3293311985Albright AL: Operative normalization of the skull shape in sagittal synostosis. Neurosurgery 17:

2.

Epstein NEpstein FNewman G: Total vertex craniectomy for the treatment of scaphocephaly. Childs Brain 9:3093161982Childs Brain 9:

3.

Flotz ELLoeser JD: Craniosynostosis. J Neurosurgery 43:48571975J Neurosurgery 43:

4.

Greene CS JrWinston KR: Treatment of scaphocephaly with sagittal craniectomy and biparietal morcellation. Neurosurgery 23:1962021988Neurosurgery 23:

5.

Ingraham FDAlexander EJ JrMatson DD: Clinical studies in craniosynostosis. Analysis of fifty cases and description of a method of surgical treatment. Surgery 24:5185411948Surgery 24:

6.

Jane JAEdgerton MJFutrell JWet al: Immediate correction of sagittal synostosis. J Neurosurgery 49:7057101978J Neurosurgery 49:

7.

Lane LC: Pioneer craniectomy for relief of mental imbecility due to premature sutural closure and microcephalus. JAMA 18:49501892Lane LC: Pioneer craniectomy for relief of mental imbecility due to premature sutural closure and microcephalus. JAMA 18:

8.

Lannelongue M: De la craniectomie dans la microcéphalie. Compt Rend Seances Acad Sci 50:138213851890Lannelongue M: De la craniectomie dans la microcéphalie. Compt Rend Seances Acad Sci 50:

9.

Marchac DRenier D: Craniofacial Surgery for Craniosynostosis. Boston: Little Brown19828792Craniofacial Surgery for Craniosynostosis.

10.

O'Brien MOJohnson M: CraniosynostosisYoumans JR (ed): Neurological Surgery. Philadelphia: WB Saunders199021328Neurological Surgery.

11.

Olds MVStorrs BWalker ML: Surgical treatment of sagittal synostosis. Neurosurgery 18:3453471986Neurosurgery 18:

12.

Rougerie JDerome PAnquez L: Craniosténosis et dysmorphies cranio-faciales. Principes d'une nouvelle technique de traitement et ses résultats. Neurochirurgie 18:4294401972Neurochirurgie 18:

13.

Shilito J JrMatson DD: Craniostynostosis: a review of 519 surgical patients. Pediatrics 41:8298531968Pediatrics 41:

14.

Stein CSchut L: Management of scaphocephaly. Surg Neurol 7:1531551977Surg Neurol 7:

15.

Venes JLSayers MP: Sagittal synostectomy. Technical note. J Neurosurg 44:3903921976J Neurosurg 44:

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