Eleven years of experience with endoscopic and open surgery for craniosynostosis and risk factors for undesirable outcome
Authors: Dabbagh Ohadi Mohammad Amin , Maroufi Seyed Farzad , Talebi Kahdouei Mohammadsadegh , Tayebi Meybodi Keyvan , Mirashrafhi Fatemeh , Nejat Farideh , Zeraati Hojjat , Habibi Zohreh 
Published: January 2025

OBJECTIVE
This study reports the authors’ experience with surgical interventions for nonsyndromic craniosynostosis. They assessed open surgery and minimally invasive endoscopic suturectomy in terms of periprocedural outcomes and related risk factors for postoperative complications and reoperation. This study aimed to provide insights toward surgical approach decisions and lay the groundwork for future prospective studies in this field.

METHODS
In this retrospective cohort study, the medical records of all patients with nonsyndromic craniosynostosis who underwent primary surgery at the authors’ center from 2014 to 2024 were analyzed. The authors assessed open surgery and endoscopic suturectomy based on anesthesia time, length of hospitalization, hematological parameters, postoperative blood transfusion volume, and changes in head circumference percentile (HCP). A subgroup analysis was conducted for patients younger than 6 months across different types of craniosynostosis. Further investigation was conducted to identify potential risk factors for postoperative complications and reoperation.

RESULTS
A total of 633 pediatric patients treated for nonsyndromic craniosynostosis were included in this study (281 with endoscopic suturectomy, 352 with open surgery). These data indicated a growing trend for endoscopic procedures. The authors’ center began performing endoscopic surgery in 2014, and by 2024, 75% of craniosynostosis patients underwent this procedure (p < 0.001). Patients in the endoscopic group experienced shorter anesthesia times (p < 0.001), reduced lengths of hospitalization (p < 0.001), and lower blood transfusion volumes (p < 0.001) compared with those in the open surgery group; however, blood transfusion volume differences were not significant in the subgroup analysis. The subgroup analysis revealed comparable HCP changes in sagittal (p = 0.4) and coronal (p = 0.85) craniosynostosis. In comparison, greater changes were noted after open surgery in cases of metopic (p = 0.03) and multisuture (p = 0.04) craniosynostosis. The rates of postoperative complications (endoscopic 6.4% and open 4.5%) and reoperation (endoscopic 4.6% and open 2.8%) were comparable between the two groups. In univariate analysis, higher weight (OR 1.07, p < 0.05) was identified as the only risk factor for postoperative complications, which can be attributed to delayed surgical intervention. Coronal (OR 8.38, p < 0.05) and multisuture (OR 23.66, p < 0.01) craniosynostoses were associated with higher reoperation rates, while adding barrel stave osteotomies was linked to a lower reoperation rate (OR 0.22, p < 0.05).

CONCLUSIONS
Endoscopic suturectomy is associated with acceptable periprocedural outcomes compared with open surgery, with comparable rates of complications and reoperation. These findings are supported by the subgroup analysis. However, further studies focusing on craniometric outcomes are needed, as surgical procedures have shown variable results across different types of craniosynostosis.