Chi David, Gibson Ella, Chiang Sarah N, Lee Koeun, Naidoo Sybill D, Lee Amy, Birgfeld Craig, Pollack Ian F, Goldstein Jesse, Golinko Michael, Bonfield Christopher M, Siddiqi Faizi A, Kestle John R W, Smyth Matthew D, Patel Kamlesh B
1Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.
2Department of Neurosurgery, Seattle Children's Hospital, University of Washington, Seattle, Washington.
J Neurosurg Pediatr. 2022 Aug 19;30(5):490-498. doi: 10.3171/2022.7.PEDS22139. Print 2022 Nov 1.
Surgical treatment of sagittal craniosynostosis is challenging in older patients. This study aimed to assess the effect of increasing age on open surgical technique selection and patient outcomes using the multi-institutional Synostosis Research Group (SynRG) collaboration.
Surgeons in SynRG were surveyed for key influences on their preferred open calvarial vault remodeling techniques at various patient ages: < 6, 6-12, and > 12 months. The SynRG database was then queried for open repairs of nonsyndromic sagittal craniosynostosis performed for patients older than 12 months of age. Perioperative measures, complications, and preoperative and postoperative cephalic indices were reviewed.
All surgeons preferred to treat patients at an earlier age, and most (89%) believed that less-optimal outcomes were achieved at ages older than 12 months. The modified pi procedure was the dominant technique in those younger than 12 months, while more involved open surgical techniques were performed for older patients, with a wide variety of open calvarial vault remodeling techniques used. Forty-four patients met inclusion criteria, with a mean (± SD) age at surgery of 29 ± 16 months. Eleven patients underwent parietal reshaping, 10 parietal-occipital switch, 9 clamshell craniotomy, 7 geometric parietal expansion, 6 modified pi procedure, and 1 parietal distraction. There were no readmissions, complications, or mortality within 30 days postoperatively. Patients' cephalic indices improved a mean of 6.4% ± 4.0%, with a mean postoperative cephalic index of 74.2% ± 4.9%. Differences in postoperative cephalic index (p < 0.04) and hospital length of stay (p = 0.01) were significant between technique cohorts. Post hoc Tukey-Kramer analysis identified the parietal reshaping technique as being significantly associated with a reduced hospital length of stay.
Patient age is an important driver in technique selection, with surgeons selecting a more involved calvarial vault remodeling technique in older children. A variety of surgical techniques were analyzed, with the parietal reshaping technique being significantly associated with reduced length of stay; however, multiple perioperative factors may be contributory and require further analysis. When performed at high-volume centers by experienced pediatric neurosurgeons and craniofacial surgeons, open calvarial vault techniques can be a safe method for treating sagittal craniosynostosis in older children.
矢状缝早闭的手术治疗对于年龄较大的患者具有挑战性。本研究旨在通过多机构颅缝早闭研究组（SynRG）合作，评估年龄增长对开放性手术技术选择和患者预后的影响。
对SynRG的外科医生进行调查，了解在不同患者年龄（<6个月、6 - 12个月和>12个月）时，哪些因素对他们首选的开放性颅骨穹窿重塑技术有关键影响。然后查询SynRG数据库，获取为年龄超过12个月的非综合征性矢状缝早闭患者进行开放性修复的相关信息。回顾围手术期指标、并发症以及术前和术后的头指数。
所有外科医生都倾向于在患者年龄较小的时候进行治疗，大多数（89%）认为12个月以上的患者预后较差。改良π手术是12个月以下患者的主要技术，而年龄较大的患者则采用更复杂的开放性手术技术，使用了多种开放性颅骨穹窿重塑技术。44例患者符合纳入标准，手术时的平均（±标准差）年龄为29±16个月。11例患者接受了顶骨重塑，10例接受了顶枕转换，9例接受了蛤壳状颅骨切开术，7例接受了几何顶骨扩张术，6例接受了改良π手术，1例接受了顶骨牵张术。术后30天内无再次入院、并发症或死亡病例。患者的头指数平均改善了6.4%±4.0%，术后平均头指数为74.2%±4.9%。不同技术组之间术后头指数（p<0.04）和住院时间（p = 0.01）的差异具有统计学意义。事后Tukey-Kramer分析确定顶骨重塑技术与缩短住院时间显著相关。
患者年龄是技术选择的重要驱动因素，外科医生会为年龄较大的儿童选择更复杂的颅骨穹窿重塑技术。分析了多种手术技术，顶骨重塑技术与缩短住院时间显著相关；然而，多个围手术期因素可能也起作用，需要进一步分析。当由经验丰富的儿科神经外科医生和颅面外科医生在大容量中心进行手术时，开放性颅骨穹窿技术可以是治疗年龄较大儿童矢状缝早闭的一种安全方法。
