Update on Treatment of Sagittal Synostosis: What Can We Learn From the 16th Congress of the International Society of Craniofacial Surgery?
The optimal timing for surgery changes according to the aim of surgery: functional outcome benefits from early intervention, whereas volume benefits from later intervention. Full-scale intelligence quotient (IQ) and performance IQ are higher when surgery is performed early (Abstract 16; prospective cohort/91 patients).1 Motor scores and speech evaluation show dysfunction and even deterioration preoperatively, which improve after surgery (Abstract 17; prospective study/20 patients).2 In contrast, head circumference and intracranial volume after 2 years follow-up are significantly larger if the child is older than 6 months at time of surgery (Abstract 43; retrospective cohort/36 patients).3
The most frequently reported technique is the minimally invasive strip, supported either by helmet or by springs. Complete remodeling remains the treatment of first choice in some centers and remains the technique of choice for older patients.
Endoscopic-assisted suturectomy achieves a good Cephalic Index (CI). Additional barrel-staving does not further improve outcome (Abstract 55; retrospective cohort/73 patients).4 A 10-year follow-up on endoscopic repair and postoperative orthosis reports that 0.8% need reoperation due to increased intracranial pressure (ICP) (Abstract 56; retrospective cohort/250 patients).5
Spring-assisted surgery is on the rise. The GOSH group performs spring-assisted surgery in children with scaphocephaly aged <6 months showing improvement of scaphocephaly and favorable morbidity and mortality (Abstract 46; retrospective cohort/81 patients).6 Springs reduce operation time and blood loss, and achieve adequate skull expansion (Abstract 10; systematic review of 3 studies).7 The New Zealand program reports that 6% of their early patients required a second procedure due to insufficient bi-parietal widening (Abstract 68; retrospective cohort/54 patients).8
Cranial vault remodeling remains popular, especially for older patients (Abstract 62; technical report, Abstract 266; retrospective cohort/14 patients).9,10 Regional differences exist in the choice of technique. In the Australian Craniofacial Unit, the trend is toward extended craniectomy involving the frontal bone and lateral barrel-staving (Abstract 101; retrospective cohort/213 patients).11 Reports on distraction osteogenesis mainly come from Asia where it is considered an adjunct to total remodeling in older patients (Abstract 63; retrospective cohort/15 patients).12
Helmet, as adjunct to cranial remodeling or to spring-mediated surgery, either preoperatively or perioperatively, is reported to improve postoperative CI (Abstract 60; prospective cohort/49 patients, Abstract 59; retrospective cohort/27 patients).13,14 Preoperative helmet therapy does not seem to affect invasively measured ICP under general anesthesia prior to undergoing cranial vault remodeling (Abstract P-32; prospective cohort/25 patients).15 However, the effect of long-term use of a helmet on ICP and neurocognitive outcome remains to be established.
Of the few abstracts that present comparisons between techniques, none are randomized. Spring-assisted surgery and Pi-cranioplasty are compared with healthy controls with respect to intracranial volume, showing a significantly smaller intracranial volume after Pi-cranioplasty (Abstract 100; prospective cohort/103 patients).16 A meta-analysis reports a comparable CI for spring-assisted surgery and cranial vault remodeling, both being superior to strip craniectomy (Abstract 44; systematic review of 12 studies).17 In that same analysis, secondary outcomes (like blood loss and overall costs) are worse in cranial vault remodeling.17 Endoscopic strip craniectomy results in a better CI when compared to Pi-craniectomy (Abstract p-12; restrospective study/52 patients).18 Another study found comparable CI and volume after extended strip craniectomy with molding helmet and total cranial vault remodeling (Abstract 64; retrospective study/33 patients).19
Outcome parameters to quantify follow-up include IQ with language assessment,1 head circumference, CI, need for reoperation, the occurrence of raised ICP, and volume measurements (Abstract 8; observational study/506 patients, Abstract 14; MRI studies/16 patients).