The Role of Preoperative Computed Tomography in Nonsyndromic Craniosynostosis

Abstract

Background: There is currently no consensus on the utility of preoperative computed tomography (CT) in nonsyndromic craniosynostosis. This systematic review and meta-analysis examines the evidence available on the necessity of preoperative CT for the treatment of nonsyndromic craniosynostosis. Methods: A comprehensive literature review of the National Library of Medicine (PubMed) database was performed. The following variables were analyzed: concordance of findings between clinical examinations and CT, incidental findings reported on imaging, and the effect of imaging on subsequent management. Concordance between clinical examination/CT and the presence of incidental findings were collected and displayed as descriptive data. The effect of imaging on subsequent diagnosis/management was analyzed by meta-analysis. Results: Eleven studies met the inclusion criteria for a total of 728 patients. Overall, physical examination concordance with CT diagnosis was 97.9% (371/379). Overall, incidental findings led to additional imaging/workup in 1.79% of cases (5/278). The results of the meta-analysis revealed that, in the absence of alternative imaging modalities, CT scans significantly altered diagnosis or led to additional investigations in 12 cases (4.8%, 95% confidence interval = 3%–8%). Preoperative CT scans led to additional investigations in 5 cases and detected incomplete/wrong diagnoses in 7 cases. Conclusions: The results of the present meta-analysis support the use of preoperative CT scans for nonsyndromic craniosynostosis in the absence of alternative imaging modalities. The results also suggest that in properly selected patients, alternative imaging modalities may be appropriate, potentially obviating the need for CT scans.

Challenging the Norm: Is Routine Use of Cranial CT in Evaluation of Craniosynostosis Necessary?

“…7 Another meta-analysis reveals that clinical examination has a 98% concordance with CT diagnosis in cases of nonsyndromic craniosynostosis, with preoperative CT scans altering diagnosis 5% of the time. 8 In the setting of lambdoid craniosynostosis, retrospective evidence suggests that preoperative imaging can be useful given the multiple radiographic abnormalities associated with isolated lambdoid craniosynostosis. 14 The highest-quality evidence comes from recent practice guidelines dictating that imaging should be reserved for cases of suspected craniosynostosis where the clinical examination is equivocal, and that for patients with plagiocephaly, CT scanning should only be used for the purpose of definitively ruling out craniosynostosis.…”

“…Evidence from a prospective multicenter study reveals that craniofacial surgeons are able to correctly diagnose single-suture craniosynostosis based on clinical examination alone with an accuracy exceeding 98% 7 . Another meta-analysis reveals that clinical examination has a 98% concordance with CT diagnosis in cases of nonsyndromic craniosynostosis, with preoperative CT scans altering diagnosis 5% of the time 8 . In the setting of lambdoid craniosynostosis, retrospective evidence suggests that preoperative imaging can be useful given the multiple radiographic abnormalities associated with isolated lambdoid craniosynostosis 14 .…”

“…2,3,5,6 In most craniofacial centers, the workup for suspected singlesuture craniosynostosis involves a cranial CT scan, despite data suggesting that routine CT scans may be unnecessary in the diagnosis of this disease. [7][8][9] Moreover, the risks associated with childhood radiation exposure are important factors to consider when ordering radiographic studies for craniosynostosis. These include radiation-induced cancer, cognitive effects, ocular damage, anaphylaxis, and renal injury from intravenous contrast, as well as complications of sedation such as apnea, laryngospasm, and the emergent need for cardiopulmonary resuscitation.…”

“…In most craniofacial centers, the workup for suspected single-suture craniosynostosis involves a cranial CT scan, despite data suggesting that routine CT scans may be unnecessary in the diagnosis of this disease 7–9 . Moreover, the risks associated with childhood radiation exposure are important factors to consider when ordering radiographic studies for craniosynostosis.…”

Computed Tomography in Patients With Craniosynostosis

“…Only 9.4% of surgeons do not obtain preoperative CTs, likely using physical examination alone to make the diagnosis. For some patients, this could result in unnecessary intervention, as the physical examination can at times be misleading 7 . Furthermore, 25.9% of craniofacial surgeons always order postoperative head CTs, usually to assess their outcomes, whereas almost half (47.1%) never order postoperative scans.…”