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(a and b) pre operative 3D fotogrammetry of a patient with synostosis of left coronal and bilateral lambdoid sutures. (c and d)12 months postoperative 3D fotogrammetry of same patient. The cranial axis has almost completely aligned with the facial axis and the shape of the forehead is almost symmetrical, with perfect rounding of the occipital area d c
Source publication
Background
Surgical methods to treat craniosynostosis have evolved from a simple strip craniectomy to a diverse spectrum of partial or complete cranial vault remodeling with excellent results but often with high comorbidity. Therefore, minimal invasive craniosynostosis surgery has been explored in the last few decades. The main goal of minimal inva...
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Introduction:
Endoscopic strip craniectomy with helmeting (ESCH) has been shown to be a safe and efficacious alternative to fronto-orbital remodeling (FOR) for selected children with craniosynostosis. In addition to clinical factors, there may be economic benefits from the use of ESCH instead of FOR.
Methods:
A retrospective review of 23 patient...
Citations
... The first operations for craniosynostosis date back to the 19th century [24,25], when the fused suture was removed without further reconstruction [24,26]. The outcome of these early suturectomies was unsatisfactory and associated with a high mortality rate [26,27], which led to the abandoning of this method [28]. In the following decades, various other surgical methods were no longer followed before being slowly re-established [27]. ...
... In the following decades, various other surgical methods were no longer followed before being slowly re-established [27]. In the 1940s, strip craniectomies were frequently performed [28], but led to numerous recurrences [26,27], especially in older children [28]. With significant improvements in anaesthetic procedures and blood transfusion in the 1950s, craniosynostosis surgery became much safer [28]. ...
... In the following decades, various other surgical methods were no longer followed before being slowly re-established [27]. In the 1940s, strip craniectomies were frequently performed [28], but led to numerous recurrences [26,27], especially in older children [28]. With significant improvements in anaesthetic procedures and blood transfusion in the 1950s, craniosynostosis surgery became much safer [28]. ...
Scaphocephaly is the most common type of craniosynostosis and various surgical techniques are used for treatment. Due to late postoperative changes of the head shape, long-term outcome data is important for evaluating any new surgical technique. At our institution, minimally invasive strip craniectomy without regular helmet therapy is the standard treatment in scaphocephalic patients. Between October 2021 and February 2023, we retrospectively examined the skull shape of patients who underwent minimally invasive strip craniectomy for scaphocephaly using a 3D surface scan technique. The cephalic index (CI), the need for helmet therapy and additional cosmetic outcome parameters were investigated. We included 70 patients (72.5% male). The mean follow-up time was 46 (10–125) months and the mean CI was 75.7 (66.7–85.2). In 58 patients, the final cosmetic result was rated as “excellent/good” (mean CI: 76.3; 70.4–85.0), in 11 as “intermediate” (mean CI: 73.3; 66.7–77.6), and in one case as “unsatisfactory” (CI 69.3). The presence of a suboccipital protrusion was associated with a “less than good” outcome. The CI correlated significantly with the overall outcome, the presence of frontal bossing, and the interval between scan and surgery (age at scan). Minimally invasive strip craniectomy is an elegant and safe method to correct scaphocephaly. Our data show good cosmetic results in the long term even without regular postoperative helmet therapy.
... (van der Meulen et al. 2009;Johnson and Wilkie 2011;Cornelissen et al. 2016;Tønne et al. 2020) CS is caused by early fusion of the sutures. While craniofacial surgeons have been developing various techniques to advance the treatment of this condition (David and Sheen 1990;Jimenez and Barone 1998;Rahimov et al. 2016;Delye et al. 2018;Breakey et al. 2021) molecular biologists have been unravelling its underlying genetics and have developed various mouse models presenting the condition. (Rice et al. 2003;Eswarakumar et al. 2004;Ishii et al. 2015;Flaherty et al. 2016;Katsianou et al. 2016;Merkuri and Fish 2019;Lee et al. 2019) The Crouzon mouse model, type Fgfr2 C342Y/+ , was developed in 2004, following the discovery of the genes responsible for early fusion of the coronal suture (joining the parietal and frontal bones) in humans. ...
Premature fusion of craniofacial joints, i.e. sutures, is a major clinical condition. This condition affects children and often requires numerous invasive surgeries to correct. Minimally invasive external loading of the skull has shown some success in achieving therapeutic effects in a mouse model of this condition, promising a new non-invasive treatment approach. However, our fundamental understanding of the level of deformation that such loading has induced across the sutures, leading to the effects observed is severely limited, yet crucial for its scalability. We carried out a series of multiscale characterisations of the loading effects on normal and craniosynostotic mice, in a series of in vivo and ex vivo studies. This involved developing a custom loading setup as well as software for its control and a novel in situ CT strain estimation approach following the principles of digital volume correlation. Our findings highlight that this treatment may disrupt bone formation across the sutures through plastic deformation of the treated suture. The level of permanent deformations observed across the coronal suture after loading corresponded well with the apparent strain that was estimated. This work provides invaluable insight into the level of mechanical forces that may prevent early fusion of cranial joints during the minimally invasive treatment cycle and will help the clinical translation of the treatment approach to humans.
... For example, osteotomy combined with long-standing helmet therapy achieves satisfactory shape correction but also requires consistent compliance. 3,4 Other dynamic procedures for correcting UCS are based on osteotomies and fronto-orbital distractors. [5][6][7] Spring-mediated distraction for craniosynostosis was first described by Uejima 8 Springs have been further developed and are now widely used for isolated sagittal synostosis; 9,10 however, their application for UCS is limited, and there are no reports available in the literature. ...
Objective
Surgical correction of unicoronal synostosis (UCS) entails extensive cranioplasties which do not address facial scoliosis. This paper presents the first results with springs that motivated the shift from extensive cranioplasties to dynamic techniques for surgical correction of UCS.
Methods
Two cases of UCS were operated with a linear osteotomy combined with springs. The deviation in facial symmetry (orbital dystopia angle) and skull base angles were measured on pre and postoperative computed tomography scans until 3 years of age.
Results
The facial scoliosis was corrected. At spring removal, the orbital dystopia angle had gone from a 9.2 to 13.2-degree deviation preoperatively to a 0.5 to 0.9-degree overcorrection compared with the ideal 0-degree deviation. Also, the skull base deviation improved.
Conclusion
Linear osteotomy combined with springs corrects the facial scoliosis in UCS. These cases indicate that dynamic methods may be beneficial for improving the results of surgical correction of UCS.
... Currently, HT, for an average duration of 12 months, is considered critical in the management of multisuture synostoses and is generally well-tolerated [38,40]. Delye et al. confirmed our complementary approach by reporting that when a newborn is diagnosed with non-syndromic craniosynostosis before the age of 3 months, EAS with molded HT offers a reasonable alternative to conventional open reconstruction [41]. Furthermore, in syndromic craniosynostosis, they believe it may also be an effective adjuvant therapy to mitigate the impact of the deformity until the child is older when definitive reconstructive surgery may be done [41]. ...
... Delye et al. confirmed our complementary approach by reporting that when a newborn is diagnosed with non-syndromic craniosynostosis before the age of 3 months, EAS with molded HT offers a reasonable alternative to conventional open reconstruction [41]. Furthermore, in syndromic craniosynostosis, they believe it may also be an effective adjuvant therapy to mitigate the impact of the deformity until the child is older when definitive reconstructive surgery may be done [41]. ...
To present the outcomes and adverse events associated with the endoscopic-assisted, minimally invasive suturectomy in patients with multisuture synostosis. This retrospective cohort study included children < 65 days of age who underwent endoscopic-assisted suturectomy (EAS) for multisuture craniosynostosis at a single tertiary referral center from 2013 to 2021. The primary outcome was calvarial expansion, and the secondary outcome was adverse events. The pre- and post-operative 3-dimensional brain computed tomography (CT) scan was used to calculate the intracranial volume and cephalic index. During a period of 2 years, 10 infants (10–64 days) diagnosed with multisuture synostosis underwent single-stage EAS of every affected suture in our center. The coronal suture was the most prevalent involved suture among our cases. The mean age and weight of the patients were 39 ± 17.5 days and 4.39 ± 0.8 kg, respectively. The surgical procedure took 42 ± 17.4 min of time and caused 46 ± 25.4 mL of bleeding on average. Ninety percent of the operations were considered successful (n = 9) regarding calvarial expansion. There were two complications, one requiring an open vault surgery and one repairing a leptomeningeal cyst. In the eight patients who did not necessitate further interventions, the mean pre-operative intracranial volume was 643.3 ± 189.4 cm³. The follow-up results within the average of 38.9 months after surgery showed that as age increases, the intracranial volume also increased significantly (R: 0.6, P < 0.0001), which suggests continued skull growth in patients who underwent EAS. With the low rate of intra- or post-operative complications and promising results on revising the restricted skull sutures, EAS seems both a safe and effective therapeutic modality in patients with multisuture synostosis, especially if completed in the first months after birth.
... Currently, HT, for an average duration of 12 months, is considered critical in the management of multisuture synostoses and is generally well-tolerated [38,40]. Delye et al. confirmed our complementary approach by reporting that when a newborn is diagnosed with non-syndromic craniosynostosis before the age of 3 months, EAS with molded HT offers a reasonable alternative to conventional open reconstruction [41]. Furthermore, in syndromic craniosynostosis, they believe it may also be an effective adjuvant therapy to mitigate the impact of the deformity until the child is older when definitive reconstructive surgery may be done [41]. ...
... Delye et al. confirmed our complementary approach by reporting that when a newborn is diagnosed with non-syndromic craniosynostosis before the age of 3 months, EAS with molded HT offers a reasonable alternative to conventional open reconstruction [41]. Furthermore, in syndromic craniosynostosis, they believe it may also be an effective adjuvant therapy to mitigate the impact of the deformity until the child is older when definitive reconstructive surgery may be done [41]. ...
OBJECTIVE: To present the outcomes and adverse events associated with the endoscopic assisted, minimally invasive suturectomy in patients with multisuture synostosis.
MATERIAL AND METHODS: This retrospective cohort study included children <65 days of age who underwent endoscopic-assisted suturectomy (EAS) for multi-suture craniosynostosis at a single tertiary referral center between 2013 – 2021. The primary outcome was calvarial expansion and secondary outcome was adverse events. The pre-and post-operative 3-dimensional brain computed tomography scan (CT) was used to calculate the intracranial volume and cephalic index.
RESULTS: During a period of eight years, 10 infants (10 – 64 days) with a diagnosis of multisuture synostosis underwent single stage EAS of every affected suture in our center. The coronal suture was the most prevalent involved suture among our cases. The mean age and weight of the patients were 39 ± 17.5 days, and 4.39 ± 0.8 Kg respectively. The surgical procedure took 42 ± 17.4 minutes of time and led to 46 ± 25.4 mL of bleeding on average. Ninety percent of the operations were considered successful (n=9) in terms of calvarial expansion. There were two complications, one who required an open vault surgery, and one repair of leptomeningeal cyst. In the eight patients who did not necessitate further interventions; the mean pre-operative intracranial volume was 643.3 ± 189.4 cm3. The follow-up results within the 1.2 ± 0.8 years after surgery showed that as age increases, the intracranial volume also increased significantly (R: 0.6, P < 0.0001), which suggests continued skull growth in patients who underwent EAS.
CONCLUSION: With the low rate of either intra- or post-operative complications and also promising results on revising the restricted skull sutures, EAS seems both a safe and effective therapeutic modality in patients with multisuture synostosis, especially if completed in the first months after birth.
... 4 The existing body of research suggests that minimally invasive suturectomy accompanied by a postoperative cranial remolding orthosis (CRO) has proven safe and successful in treating patients with craniosynostosis, resulting in positive outcomes and improvements in cranial deformity and symmetr. [9][10][11] Less blood transfusions, reduced surgery time, and lesser hospitalization days are advantages of minimally invasive suturectomy. 12 This procedure creates a wide sutural excision in conjunction with lateral osteotomies so that future growth of the cranium occurs in all the three dimensions. ...
Key Clinical Message
Minimally invasive suturectomy has been reported to significantly decrease the economic cost of treating infants with craniosynostosis. Nonetheless, treatment should be accompanied by a cranial remolding orthosis to maintain the constant correction and reshaping of the skull throughout the infant's development.
... 15,16 and ESC is preferably performed early in life while the bone is still capable of being molded. 19,20 A modification of FOAR is the calvarial switch (CS), which takes advantage of a suitably rounded calvarial bone flap for corrections of the forehead. 21 Although CS can result in a significantly more symmetric forehead relative to FOAR, both methods are limited to the supraorbital level and do not involve correction of the orbits themselves or the facial skeleton below the orbits. ...
Objectives:
Unilateral coronal synostosis (UCS) results in a surgically demanding deformation, as the deformity is asymmetric in the calvarium but also presents with facial scoliosis and orbital dystopia. Traditional cranioplasties correct the forehead but have little effect on the face and orbits. Here, we describe a consecutive series of patients operated for UCS with osteotomy of the fused suture combined with distraction osteogenesis (FOD).
Methods:
Fourteen patients [mean age: 8.0 months (range: 4.3-16.6 months)] were included in this study. We measured and compared the orbital dystopia angle (ODA), anterior cranial fossa deviation (ACFD), and anterior cranial fossa cant (ACFC) between results from preoperative computed tomography and those at distractor removal.
Results:
Blood loss was 6.1 mL/kg (range: 2.0-15.2 mL/kg), and length of stay was 4.4 days (range: 3.0-6.0 days). We observed significant improvements in the ODA from [median (95% confidence interval)] -9.8° (-12.6° to -7.0°) to -1.1° (-3.7° to -1.5°) (p<0.001), ACFD from 12.9° (9.2-16.6°) to 4.7° (1.5-7.9°) (p<0.001), and ACFC from 2.5° (1.5-3.5°) to 1.7° (0.0-3.4) (p=0.003).
Conclusions:
The results showed that osteotomy combined with a distractor for UCS straightened the face and relieved orbital dystopia by affecting the nose angle relative to the orbits, correcting the deviation of the cranial base in the anterior fossa, and lowering the orbit on the affected side. Furthermore, this technique demonstrated a favorable morbidity profile with low perioperative bleeding and a short inpatient period, suggesting its potential to improve the surgical treatment of UCS.
... Our surgical techniques for MIS was similar to the same studies that were all aiming to release a fused suture with a small incision. 1,[14][15][16] For sagittal craniosynostosis, the procedure was conducted while the patient was lying with the head extended in a prone position. After skin preparation with povidone-iodine and drape, two transverse incisions were made with 3 cm length at 1 cm rear the anterior fontanelle and 1 cm in front of the lambdoid suture. ...
... Premature closure of skull sutures and subsequent skull deformity is mainly caused by compensatory overgrowth in the area of adjacent sutures. 15 For this reason, immediately after the diagnosis of craniosynostosis, the patient undergoes surgery to prevent further progression of cranial deformity. This study was set out with the aim of assessing the effect of MIS and postoperative CRO treatment on cranial symmetry of infants with craniosynostosis. ...
... The outcome of MIS is thoroughly tied to the use of CRO. 5 However, some authors considered this part of treatment as the main handicap or complication of treatment. 15 In this study, using a very light custom-made CRO (about 150 g), the complication was low. We measured the complications associated with CRO using a survey in VAS format. ...
Objective
To investigate the effectiveness of minimally invasive suturectomy (MIS) with cranial remolding orthosis (CRO) for treatment of patients with single-suture craniosynostosis.
Methods
In this multicenter prospective study, all patients included underwent MIS followed by postoperative CRO. The values of the cephalic index (CI) and cranial vault asymmetry index (CVAI) were measured and recorded before the surgery, at initiation of CRO, and at the cessation of CRO. The total cranial volume (TV), anterior hemisphere cranial volume (AV), and AV to TV were also acquired with a non-contact optical scanner. All patients were followed up at least until the end of the twelfth month of age.
Results
A total of 38 patients were included. The average operative time including anesthesia was 95.38 minutes. The average length of hospital admission was 2.5 days. There was a statistically significant difference in CI values for the patients with sagittal craniosynostosis (p < 0.05). The improvement in CVAI values were statistically significant in all three groups of participants (p < 0.001). The AV and TV from initiation to cessation of CRO treatment were statistically significant in all three groups of participants (p < 0.001). Regarding the AV to TV ratio, there was a significant difference from initiation to the cessation of CRO treatment in sagittal and metopic groups of participants (p < 0.05). The average daily hours of CRO wearing was 18.54 hours.
Conclusions
The findings of this investigation complement those of earlier studies and showed that MIS with CRO treatment is a good strategy with satisfactory results for patients with single-suture craniosynostosis.
... There is a large body of evidence found in the literature that this treatment modality for craniosynostosis achieves good results, both financially and cosmetically [10][11][12]. However, it remains unclear as to what degree the early re-opening of the suture (i.e., suturectomy) or the postoperative helmet therapy affects the morphological or functional changes across the skull and brain. ...
... The EAC technique, as performed at the Radboudumc Centre of Expertise Craniofacial anomalies (Radboudumc Nijmegen, The Netherlands), was replicated across the 3D model under the surgical teams' guidance and the detailed report of Delye et al. [10]. Figure 1E depicts the replicated craniotomies performed across the 3D model. ...
... Helmet therapy after EAC has been reported to be a cost-effective method of correction while achieving the overall surgical goals for sagittal craniosynostosis. The technique adopted here is reported by Delye et al. [10], where 10-month postoperative helmeting is the standard practice. Such reports detail overall improvement to the cephalic shape postoperative. ...
Purpose
The aim of this study was to investigate the biomechanics of endoscopically assisted strip craniectomy treatment for the management of sagittal craniosynostosis while undergoing three different durations of postoperative helmet therapy using a computational approach.
Methods
A previously developed 3D model of a 4-month-old sagittal craniosynostosis patient was used. The strip craniectomy incisions were replicated across the segmented parietal bones. Areas across the calvarial were selected and constrained to represent the helmet placement after surgery. Skull growth was modelled and three variations of helmet therapy were investigated, where the timings of helmet removal alternated between 2, 5, and 8 months after surgery.
Results
The predicted outcomes suggest that the prolonging of helmet placement has perhaps a beneficial impact on the postoperative long-term morphology of the skull. No considerable difference was found on the pattern of contact pressure at the interface of growing intracranial volume and the skull between the considered helmeting durations.
Conclusion
Although the validation of these simulations could not be performed, these simulations showed that the duration of helmet therapy after endoscopically assisted strip craniectomy influenced the cephalic index at 36 months. Further studies require to validate these preliminary findings yet this study can lay the foundations for further studies to advance our fundamental understanding of mechanics of helmet therapy.
... [5] At initial adoption of this technique, the procedure was only done on patients with cognitive deficits and was met with poor outcomes, presumed to be secondary to late intervention as well as intervention on microcephaly rather than true synostosis. [6] The intervention was met with harsh criticism due to the high rates of mortality and was subsequently abandoned prior to the turn of the century. [7] The technique of strip craniectomy remerged in the 1920s when Faber and Towne identified early intervention as the key to success. ...
... In their 2010 review, the authors stated that the "bilateral barrel stave osteotomies allow for immediate increase in euryoneuryon distance" and thus CI. [16] This technique has been adopted by others for the potentially better CI achieved in single-suture craniosynostosis, particularly sagittal synostosis, as a result of the wedge osteotomies made posterior to the coronal sutures and anterior to the lambdoid sutures, which allow for increase in biparietal width. [6] Helmet therapy was started by postoperative day 5 and restricted growth in the A-P direction, allowing bitemporal-biparietal expansion to occur. Optimal correction of head shape was typically achieved within 6 weeks of surgery, and helmets were used for 12 months to ensure maintenance of head shape. ...
Over the past 30 years, advances in endoscopic technology and advancing interest in the benefits of minimally invasive approaches for craniofacial surgery have resulted in these techniques becoming a part of the standard of care in the treatment of craniosynostosis. In this review, we discuss the evolution and adoption of endoscopic-assisted strip craniectomy procedures. In addition to reviewing the studies describing various nuances and modifications to minimally invasive strip craniectomy, attention to comparisons in outcomes between traditional or open cranial vault reconstructions and endoscopic-assisted techniques is highlighted for different craniosynostosis diagnoses.
