Operative Management of Non-Syndromic Sagittal Craniosynostosis: A Head-to-Head Meta-Analysis of Outcomes Comparing Three Techniques

Background

The treatment of sagittal craniosynostosis is currently evolving. Total vault remodeling (TVR) has been effective for correcting shape and expanding intracranial volume. However, treatment paradigms have shifted, emphasizing less-invasive procedures, including spring-assisted cranioplasty and strip craniectomy.  This study aimed to compare outcomes for TVR, spring-assisted cranioplasty, and strip craniectomy via systematic meta-analysis.

 

Methods

A literature search was conducted identifying all articles involving operative management of non-syndromic sagittal craniosynostosis. Comparison of 2 operative techniques was required for inclusion, and methodological quality was assessed via ASPS Levels of Evidence scale.  Three techniques were considered: TVR, strip craniectomy, and spring-assisted cranioplasty. Meta-analysis was conducted for change in cephalic index (CI), reported as weighted mean difference (WMD).  Pooled subgroup comparisons were performed for operative time, length of stay, blood loss, and total cost.

 

Results

13 studies were included, all cohorts providing level 3 evidence.  All studies involved TVR (n=187), 8 involved strip craniectomy (n=299), and 7 involved spring-assisted cranioplasty (n=158).  Average age for TVR was 8.4 months, compared to 4 months for craniectomy and 5 months for spring-cranioplasty; all groups were male-predominant.  Head-to-head comparison of change in CI demonstrated a greater, yet statistically insignificant change for TVR versus spring cranioplasty, WMD=0.94 [-0.23-2.11] (p=0.12, I²=55%).  In contrast, TVR showed a statistically greater change in CI versus strip craniectomy, WMD=1.47 [0.47-2.48] (p=0.004, I²=66%).  Post-operative cephalic index was correlated with follow-up for each technique, demonstrating that as follow-up increased, CI increased in the strip and spring cranioplasty groups and decreased in TVR groups.  Subgroup analysis showed longer operative time for TVR versus craniectomy/spring-cranioplasty (170.2 vs 97.2 min), higher blood loss (237.7 vs 47.3 mL), longer length of stay (5.13 vs 2.96 days), and higher total costs ($35,280 vs $13,147), all with p values<0.0001.

Conclusions

This study, the first meta-analysis comparing 3 primary operations for correcting sagittal craniosynostosis, demonstrates no difference in CI for TVR versus spring cranioplasty and a small but statistically greater improvement in CI favoring TVR to strip craniectomy.  Longer follow-up time was associated with decreasing CI for the TVR group and increasing CI for less invasive modalities, and secondary outcomes favored the less invasive procedures.  While definitive conclusions cannot be made, it appears that less invasive procedures are as efficacious as TVR but offer more favorable safety profiles.