Surgical Management of Sagittal Synostosis: A Comparative Analysis of Strip Craniectomy and Calvarial Vault Remodeling

Abstract

Although surgical treatment of sagittal synostosis has become normative, the procedure of choice is still debated. This retrospective analysis, during a 10-year period (1986-1995) at Children’s Hospital Los Angeles, compares the more conservative strip craniectomy (SC) procedure with a more extensive occipital reduction-biparietal widening calvarial vault remodeling (CVR) technique for the management of sagittal synostosis. SC was performed in 72 patients (61%) and CVR in 46 (39%). Patients undergoing CVR were older (mean 5.3 vs. 3.0 months, p< 0.01), the procedure time longer (mean 126 min vs. 72 min, p < 0.01), intraoperative blood loss greater (mean 243 vs. 54 cm³, p < 0.01), and the frequency of intraoperative blood transfusion increased (100 vs. 38%, p < 0.01; mean volume 357 vs. 51 cm³, p < 0.01) compared to patients undergoing SC. No significant intraoperative complications occurred in either group. The total time of hospitalization was similar (mean 4.4 vs. 3.8 days, p = 0.02). No neurological, hematological, or transfusion-related complications or deaths were encountered in either group. Cosmetic outcomes were significantly better in the CVR group with 79% rated as excellent compared to 41% in the SC group (p < 0.01). Fifty-nine percent of the SC patients manifested bony defects at last follow-up visit. Two SC patients required reopera-tion for poor cosmetic outcomes; CVR was successfully employed in both cases. These findings demonstrate that CVR is superior to SC in providing immediate and lasting correction of calvarial deformities secondary to sagittal synostosis. The optimal age at time of surgery is <6 months; however, CVR can be utilized throughout infancy, while SC becomes progressively less effective after 6 months of age. No significant complications were observed in either group, despite the increased operative manipulation and greater incidence of blood transfusion in the CVR patients.

The incidence of raised intracranial pressure in nonsyndromic sagittal craniosynostosis following primary surgery

“…We accept that CR entails longer admissions and greater transfusion rates than MSC, 25 and is liable to a higher incidence of accidental vascular or dural breach, as is inevitable with the more extensive dissection that the procedure demands. However, we consider that it is undesirable to expose patients to a procedure, the MSC, which still has attendant risks, 25,27 is less effective at correcting the scaphocephalic deformity, and has a markedly higher reoperation rate, with the risks that that entails.…”

“…However, we consider that it is undesirable to expose patients to a procedure, the MSC, which still has attendant risks, 25,27 is less effective at correcting the scaphocephalic deformity, and has a markedly higher reoperation rate, with the risks that that entails. The significantly higher rate of raised ICP experienced by these patients postoperatively is a further cause of concern.…”

Correction of Sagittal Craniosynostosis Using a Novel Parietal Bone Fixation Technique: Results over a 10-Year Period

“…We have not performed this operation (or strip craniectomies) on patients younger than 3 months, preferring to allow those infants time to grow given the potential for significant blood loss. Postoperative cranial index measurements (82% excellent, 18% good and 0% poor results) compare favorably to those of accepted CVR techniques [11, 20]. Furthermore, these results are immediate, durable and do not require the use of a molding helmet or follow-up surgeries for device removal.…”

“…Serious debate remains regarding the most appropriate and effective corrective procedure. The use of strip craniectomies, while advocated by some authors in patients less than 3 months of age [8], is generally considered inferior to more extensive cranial remodeling procedures in terms of its immediate and long-term cosmetic outcomes [9,10,11]. These CVR techniques include: the π procedure, modified-π procedure, total vertex craniectomy, parietal flap cranioplasties and a variety of others [12,13,14,15,16,17].…”

Perioperative Management of Pediatric Patients with Craniosynostosis

“…Several investigators have found that spring-mediated cranioplasty required less blood product replacement than cranial vault remodeling and might provide the same cosmetic outcome as cranial vault remodeling [23][24][25]. However, other studies have shown that complex calvarial vault remodeling provides the better outcome, in comparison to less invasive procedures like synostectomy or strip craniectomy, for sagittal craniosynostosis repair [22,26].…”