Minimally Invasive Endoscopic Surgery for Infantile Craniosynostosis: A Longitudinal Cohort Study.

OBJECTIVE: To evaluate patient outcomes of minimally invasive endoscopic strip craniectomy (ESC) for craniosynostosis. STUDY DESIGN: This is a retrospective cohort analysis (2004-2018) of 500 consecutive infants with craniosynostosis treated by ESC with orthotic therapy at a single center. Operative outcomes included transfusions, complications, and reoperations as well as head circumference change based on World Health Organization percentiles. Multivariable logistic regression was used to identify risk factors associated with blood transfusion. Paired t tests were used for within-patient comparisons and Fisher exact test to compare syndromic and nonsyndromic subgroups. RESULTS: ESC was associated with low rates of blood transfusion (6.6%), complications (1.4%), and reoperations (3.0%). Risk factors for transfusion included syndromic craniosynostosis (P = .01) and multiple fused sutures (P = .02). Median surgical time was 47 minutes, and hospital length of stay 1 day. Transfusion and reoperation rates were higher among syndromic patients (both P < .001). Head circumference normalized by 12 months of age relative to World Health Organization criteria in infants with sagittal, coronal, and multisuture craniosynostosis (all P < .001). CONCLUSIONS: ESC is a safe, effective, and durable correction of infantile craniosynostosis. ESC can achieve head growth normalization with low risks of blood transfusion, complications, or reoperation. Early identification of craniosynostosis in the newborn period and prompt referral by pediatricians allows families the option of ESC vs larger and riskier open reconstruction procedures.

Trends in Ambulatory Care for Children with Concussion and Minor Head Injury from Eastern Massachusetts between 2007 and 2013.

OBJECTIVE: To characterize trends in health care utilization and costs for children diagnosed with concussion or minor head injury within a large pediatric primary-care association. STUDY DESIGN: We conducted a retrospective cohort analysis from 2007 through 2013 examining all outpatient medical claims related to concussion and minor head injury from 4 commercial insurance companies for children 6-21 years of age who were patients within a large pediatric independent practice association located throughout eastern Massachusetts. RESULTS: Health care visits for concussion and minor head injury increased more than 4-fold during the study period, with primary-care and specialty clinics experiencing the greatest increases in the rate of visits while emergency department visits increased comparatively less. These increases were accounted for by both the proportion of children diagnosed with concussion or minor head injury (1.3% of all children in 2007 vs 3.3% in 2013) and the number of encounters per diagnosed patient (1.0 encounters per patient in 2007 vs 1.7 in 2013). Although the overall population costs devoted to care for concussion or minor head injury increased 34%, the cost per individual diagnosed child decreased 31%. CONCLUSIONS: Over the past 7 years, health care encounters for children diagnosed with concussion or minor head injury increased substantially in eastern Massachusetts. Care for these injuries increasingly shifted from the emergency department to primary-care and specialty providers.

Pediatric traumatic brain injury and radiation risks: a clinical decision analysis.

OBJECTIVE: To determine the optimal imaging strategy for young children with minor head injury considering health-related quality of life and radiation risk. In children with minor head trauma, the risk of missing a clinically important traumatic brain injury (ciTBI) must be weighed against the risk of radiation-induced malignancy from computed tomography (CT) to assess impact on public health. STUDY DESIGN: We included children <2 years old with minor blunt head trauma defined by a Glasgow Coma Scale score of 14-15. We used decision analysis to model a CT-all versus no-CT strategy and assigned values to clinical outcomes based on a validated health-related quality of life scale: (1) baseline health; (2) non-ciTBI; (3) ciTBI without neurosurgery, death, or intubation; and (4) ciTBI with neurosurgery, death, or intubation >24 hours with probabilities from a prospective study of 10000 children. Sensitivity analysis determined the optimal management strategy over a range of ciTBI risk. RESULTS: The no-CT strategy resulted in less risk with the expected probability of a ciTBI of 0.9%. Sensitivity analysis for the probability of ciTBI identified 4.8% as the threshold above which CT all becomes the preferred strategy and shows that the threshold decreases with less radiation. The CT all strategy represents the preferred approach for children identified as high-risk. CONCLUSION: Among children <2 years old with minor head trauma, the no-CT strategy is preferable for those at low risk, reserving CT for children at higher risk.