Nonendoscopic, minimally invasive calvarial vault remodeling without postoperative helmeting for sagittal synostosis
Authors: Mutchnick Ian S. , Maugans Todd A. 
Published: March 2012

Object
Multiple surgical procedures have been described for the management of isolated nonsyndromic sagittal synostosis. Minimally invasive techniques have been recently emphasized, but these techniques necessitate the use of an endoscope and postoperative helmeting. The authors assert that a safe and effective, more “minimalistic” approach is possible, avoiding the use of endoscopic visualization and routine postoperative application of a cranial orthosis.

Methods
A single-institution cohort analysis was performed on 18 cases involving infants treated for isolated nonsyndromic sagittal synostosis between 2008 and 2010 using a nonendoscopic, minimally invasive calvarial vault remodeling (CVR) procedure without postoperative helmeting. The surgical technique is described. Variables analyzed were: age at time of surgery, sex, estimated blood loss (EBL), operative time, intraoperative complications, postoperative complications, length of stay, pre- and postoperative cephalic index (CI), clinical impressions, and results of a 5-question nonstandardized questionnaire administered to patient caregivers regarding outcome.

Results
Eleven male and 7 female infants (mean age 2.3 months) were included in the study. The mean duration of follow-up was 16.4 months (range 6–38 months). The mean procedural time was 111 minutes (range 44–161 minutes). The mean length of stay was 2.3 days (range 2–3 days). The mean EBL in all 18 patients was 101.4 ml (range 30–475 ml). One patient had significant bone bleeding resulting in an EBL of 475 ml. Excluding this patient, the mean EBL was 79.4 ml (range 30–150 ml). There were no deaths or intraoperative complications; one patient had a superficial wound infection. The mean CI was 69 preoperatively versus 79 postoperatively, a statistically significant difference (p < 0.0001). Two patients were offered helmeting for suboptimal surgical outcome; one family declined and the single helmeted patient showed improvement at 2 months. No patient has undergone further surgery for correction of primary deformity, secondary deformities, or bony irregularities. Complete questionnaire data were available for 14 (78%) of the 18 patients; 86% of the respondents were pleased with the cosmetic outcome, 92% were happy to have avoided helmeting, 72% were doubtful that helmeting would have provided more significant correction, and 86% were doubtful that further surgery would be necessary. Small, palpable, aesthetically insignificant skull irregularities were reported by family members in 6 cases (43%).

Conclusions
The authors present a nonendoscopic, minimally invasive CVR procedure without postoperative helmeting. Their small series demonstrates this to be a safe and efficacious procedure for isolated nonsyndromic sagittal synostosis, with improvements in CI at a mean follow-up of 16.1 months, commensurate with other techniques, and with overall high family satisfaction. Use of a CVR cranial orthosis in a delayed fashion can be effective for the infrequent patient in whom this approach results in suboptimal correction.