Background: Suturectomy was largely replaced during the last four decades by more extensive, but predictable, cranial remodeling procedures proposed by Tessier. More recently, technical innovations (i.e., use of endoscope and post-operative orthotic reshaping) have led to a resurgence of suturectomy.
Objectives: Document a single-center experience using endoscope-assisted strip craniectomy (EASC) and post-operative molding helmet therapy (HT) to treat all major forms of craniosynostosis.
Methods: All cases of craniosynostosis treated by EASC+ HT were reviewed. The clinical records were evaluated with regard to type of fusion,age at operation, duration of procedure, need for transfusion, complications and the need for further surgery.
Results: 103 patients underwent EASC for craniosynostosis by the senior author. Mean age at surgery was 3.01 months (range=1.03-7.87, sd=1.41). Mean duration of surgery was 47.78 minutes (range=26.0-86.0, sd=10.17). Four (3.8%) patients received blood transfusions. Complications include one stitch abscess with no serious morbidities or death. Depending on type of synostosis the helmet was discontinued once the desired phenotype was obtained or when the infant was one year of age. There were two patients in whom the removed suture refused and three patients went on to fuse other sutures, all of whom experienced poor cranial growth and required subsequent cranial vault remodeling. Patient outcomes were fair to excellent and varied by fusion type. Sagittal synostosis (n=57): uniformly excellent cosmetic correction; 15% improvement in cranial index (mean preoperative CI =0.69, mean postoperative CI=0.79). This change was maintained at 1 year F/U. Unilateral coronal synostosis (n=19): excellent correction of nasal root deviation, orbital dystopia; reduced associated ophthalmologic findings (i.e., astigmatism and ocular torticollis) compared to patients treated with FOA; good to excellent improvement of forehead symmetry. Bilateral coronal synostosis (n=8): turribrachycephaly well-corrected; forehead projection improved but less dramatically than FOA. Moderate reduction of cranial index (preoperative CI 0.94 vs. postoperative CI 0.86). Metopic synostosis (n=10): variable results, ranging from fair to excellent. Correction of superior-lateral orbital rim retrusion was not consistent. Lamdoid synostosis (n=3): excellent reduction of the windswept appearance and occipital asymmetry. Complex multiple suture synostosis (n=6): Good to excellent results depending on sutures involved. On average, head circumference was maintained or improved post-operatively in all groups.
Conclusion: EASC+HT safely and effectively treats single and multiple suture synostosis in infants. The results rival those of larger open cranial expansion techniques. Outcome depends largely on the type of suture involved, and early age and consistent post-operative helmet therapy were felt critical. Failure of shape to improve or a sustained drop in head circumference percentile should alert the physician to the possibility of re-fusion or fusion of additional sutures.