A multi-institutional survey on calvarial vault remodeling techniques for sagittal synostosis and outcomes analysis for patients treated at 12 months and older

Abstract

OBJECTIVE Surgical treatment of sagittal craniosynostosis is challenging in older patients. This study aimed to assess the effect of increasing age on open surgical technique selection and patient outcomes using the multi-institutional Synostosis Research Group (SynRG) collaboration. METHODS Surgeons in SynRG were surveyed for key influences on their preferred open calvarial vault remodeling techniques at various patient ages: < 6, 6–12, and > 12 months. The SynRG database was then queried for open repairs of nonsyndromic sagittal craniosynostosis performed for patients older than 12 months of age. Perioperative measures, complications, and preoperative and postoperative cephalic indices were reviewed. RESULTS All surgeons preferred to treat patients at an earlier age, and most (89%) believed that less-optimal outcomes were achieved at ages older than 12 months. The modified pi procedure was the dominant technique in those younger than 12 months, while more involved open surgical techniques were performed for older patients, with a wide variety of open calvarial vault remodeling techniques used. Forty-four patients met inclusion criteria, with a mean (± SD) age at surgery of 29 ± 16 months. Eleven patients underwent parietal reshaping, 10 parietal-occipital switch, 9 clamshell craniotomy, 7 geometric parietal expansion, 6 modified pi procedure, and 1 parietal distraction. There were no readmissions, complications, or mortality within 30 days postoperatively. Patients’ cephalic indices improved a mean of 6.4% ± 4.0%, with a mean postoperative cephalic index of 74.2% ± 4.9%. Differences in postoperative cephalic index (p < 0.04) and hospital length of stay (p = 0.01) were significant between technique cohorts. Post hoc Tukey-Kramer analysis identified the parietal reshaping technique as being significantly associated with a reduced hospital length of stay. CONCLUSIONS Patient age is an important driver in technique selection, with surgeons selecting a more involved calvarial vault remodeling technique in older children. A variety of surgical techniques were analyzed, with the parietal reshaping technique being significantly associated with reduced length of stay; however, multiple perioperative factors may be contributory and require further analysis. When performed at high-volume centers by experienced pediatric neurosurgeons and craniofacial surgeons, open calvarial vault techniques can be a safe method for treating sagittal craniosynostosis in older children.

Sagittal Craniosynostosis: Treatment and Outcomes According to Age at Intervention

“…A total of 49 manuscripts with 3316 patients were included in this study. Articles were categorized based on the average age at intervention; 0 to 6, older than 6 to 12, and older than 12 months 3,7–53 . Fifteen of the manuscripts included more than 1 age group, thus they are mentioned in different cohorts 10,11,13,23,30–32,40,43,45,49,50,52,54 .…”

“…Fifteen of the manuscripts included more than 1 age group, thus they are mentioned in different cohorts 10,11,13,23,30–32,40,43,45,49,50,52,54 . From the 49 articles, 36 (n=2141) included patients 0 to 6 months old, 15 (n=669) discussed patients older than 6 to 12 months old, and 9 (n=506) evaluated patients older than 12 months old 3,7–53 . Follow-up ranged from 12 to 144 months 3,7–53 .…”

“…From the 49 articles, 36 (n=2141) included patients 0 to 6 months old, 15 (n=669) discussed patients older than 6 to 12 months old, and 9 (n=506) evaluated patients older than 12 months old 3,7–53 . Follow-up ranged from 12 to 144 months 3,7–53 . Over 8 different types of open surgical techniques were identified and up to 5 different minimally invasive procedures were described 10,11,13,23,30–32,40,43,45,49,50,52,54 …”

“…Minimally invasive procedures were exclusively seen in the youngest cohort (0–6 mo) 3,7–53 . Four studies compared different surgical approaches (open versus minimally invasive) within the same age group (0–6 mo) 30,32,41,54 .…”

“…Four studies compared different surgical approaches (open versus minimally invasive) within the same age group (0–6 mo) 30,32,41,54 . Patients in the more than 6- to 12-month-old cohort and more than 12-month-old cohort underwent open surgical interventions only 10–16,19,21–23,26,27,31,33,34,40,43,45,49–52 . Twelve manuscripts compared different surgical techniques within different age groups 10,13,14,23,31,41,43,45,49,50,52 …”