Springs Produce Favorable Morphological Outcomes Relative to H-craniectomy According to a Two-center Comparison of Matched Cases.

BACKGROUND: Sagittal synostosis is the most common type of premature suture closure, and many surgical techniques are used to correct scaphocephalic skull shape. Given the rarity of direct comparisons of different surgical techniques for correcting craniosynostosis, this study compared outcomes of craniotomy combined with springs and H-craniectomy for non-syndromic sagittal synostosis. METHODS: Comparisons were performed using available pre- and postoperative imaging and follow-up data from the two craniofacial national referral centers in Sweden, which perform two different surgical techniques: craniotomy combined with springs (Gothenburg) and H-craniectomy (Renier's technique; Uppsala). The study included 23 pairs of patients matched for sex, preoperative cephalic index (CI), and age. CI, total intracranial volume (ICV), and partial ICV were measured before surgery and at 3 years of age, with volume measurements compared against those of pre- and postoperative controls. Perioperative data included operation time, blood loss, volume of transfused blood, and length of hospital stay. RESULTS: Craniotomy combined with springs resulted in less bleeding and lower transfusion rates than H-craniectomy. Although the spring technique requires two operations, the mean total operation time was similar for both methods. Of the three complications that occurred in the group treated with springs, two were spring-related. Importantly, the compiled analysis of changes in CI and partial volume distribution revealed that craniotomy combined with springs resulted in superior morphological correction. CONCLUSIONS: The findings showed that craniotomy combined with springs normalized cranial morphology to a greater extent than H-craniectomy based on changes in CI and total and partial ICVs over time.

Persistent discrepancies in orbital morphology after surgical treatment of unicoronal craniosynostosis: a critical image-based analysis.

OBJECTIVE: Unicoronal craniosynostosis (UCS) is characterized by complex orbital deformity and is typically treated by asymmetrical fronto-orbital remodeling (FOR) during the 1st year of life. The aim of this study was to elucidate to what extent orbital morphology is corrected by surgical treatment. METHODS: The extent to which orbital morphology was corrected by surgical treatment was tested by analysis of differences in volume and shape between synostotic, nonsynostotic, and control orbits at two time points. In total, 147 orbits were analyzed from patient CT images obtained preoperatively (mean age 9.3 months), at follow-up (mean age 3.0 years), and in matched controls. Semiautomatic segmentation software was used to determine orbital volume. For analysis of orbital shape and asymmetry, geometrical models, signed distance maps, principal modes of variation, and three objective parameters (mean absolute distance, Hausdorff distance, and dice similarity coefficient) were generated by statistical shape modeling. RESULTS: Orbital volumes on both the synostotic and nonsynostotic sides were significantly smaller at follow-up than volumes in controls and significantly smaller both preoperatively and at follow-up than orbital volumes on the nonsynostotic side. Significant differences in shape were identified globally and locally, both preoperatively and at 3 years of age. Compared with controls, deviations were mostly found on the synostotic side at both time points. Asymmetry between synostotic and nonsynostotic sides was significantly decreased at follow-up, but not compared with the inherent asymmetry of controls. On a group level, the preoperative synostotic orbit was mainly expanded in the anterosuperior and anteroinferior regions and smallest on the temporal side. At follow-up, the mean synostotic orbit was still larger superiorly but also expanded in the anteroinferior temporal region. Overall, the morphology of nonsynostotic orbits was more similar to that of controls than to synostotic orbits. However, the individual variation in orbital shape was greatest for nonsynostotic orbits at follow-up. CONCLUSIONS: In this study, the authors presented what is, to their knowledge, the first objective automatic 3D bony evaluation of orbital shape in UCS, defining in greater detail than has been done previously how synostotic orbits differ from nonsynostotic and control orbits, and how orbital shape changes from 9.3 months of age preoperatively to 3 years of age at the postoperative follow-up. Despite surgical treatment, both local and global deviations in shape persist. These findings may have implications for future directions in the development of surgical treatment. Future studies connecting orbital morphology to ophthalmic disorders, aesthetics, and genetics could provide further insight to enable better outcomes in UCS.

Does Coronal Suturectomies and Occipital Barrel Staves Make a Difference in Early Reconstruction for Sagittal Craniosynostosis?

BACKGROUND: Various surgical methods are used for early treatment of nonsyndromic sagittal craniosynostosis. The craniofacial centers in Uppsala and Helsinki fundamentally both use the H-Craniectomy: Renier's technique. However, the Helsinki group systematically adds coronal suturectomies to prevent secondary coronal synostosis and posterior barrel staves to address posterior bulleting. The effects of these additions in early treatment of sagittal craniosynostosis are currently unknown. METHODS: Thirty-six patients from Uppsala and 27 patients from Helsinki were included in the study. Clinical data and computed tomography scans were retrieved for all patients. RESULTS: The Helsinki patients had a smaller preoperative Cranial index (CI) (65 vs 72) and a smaller preoperative width (10.1 vs 11.2). There was no difference in postoperative CI, corresponding to a difference in change in CI. Regression analysis indicated that the larger change in CI in the Helsinki group was mainly due to a lower preoperative CI allowing for a larger normalization. The Helsinki patients had less growth in length (1.5 vs 2.1 cm) and more growth in width (2.3 vs 1.9 cm). There were no differences in head circumference or surgical complications. Secondary coronal synostosis was present in 43% of the Uppsala group at 3 years of age, while calvarial defects located at sites of previous coronal suturectomies and posterior barrel staving were seen in the Helsinki group 1 year postoperatively. CONCLUSIONS: Lower preoperative CI appears to be the main factor in determining the amount of normalization in CI. Prophylactic coronal suturectomies do not seem to benefit preservation of coronal growth function since the modification correlates to less sagittal growth and more growth in width.

Secondary Coronal Synostosis After Early Surgery for Sagittal Craniosynostosis: Implications for Cranial Growth.

ABSTRACT: Secondary Coronal Synostosis (SCS) in patients operated for non-syndromic Sagittal Craniosynostosis is a postoperative phenomenon with unclear implications. The aim of this study was to investigate whether SCS is a negative or a benign occurrence in the postoperative course. The authors hypothesized that SCS is related to reduced cranial growth and intracranial hypertension. Thirty-one patients operated for SC at an early age with the H-craniectomy technique were included in the study. Associations between SCS and cranial shape, growth, and signs of intracranial hypertension were analyzed. Intracranial volume distribution was assessed by measuring partial intracranial volumes defined by skull base landmarks. A total of 12/31 patients developed SCS during the postoperative course. The presence of SCS was associated with a higher prevalence of gyral impressions and a larger normalization of Cranial Index due to less growth in the anteroposterior plane. The SCS group had a smaller postoperative intracranial volume due to less posterior intracranial volume as well as less growth in head circumference. Whether this is a growth restriction caused by the SCS or a secondary effect of less primary brain growth remains to be determined. However, the correlation between SCS, less cranial growth and gyral impressions does imply that SCS should be taken into consideration during clinical follow-up as a potentially adverse event.