Open Calvarial Vault Reconstruction for Sagittal Craniosynostosis after 1 Year of Age

Objective: Sagittal craniosynostosis remains the most common form of premature single-suture fusion. The primary goals of reconstruction are to relieve growth restriction and improve both biparietal narrowing and frontooccipital bossing. Surgical techniques to correct scaphocephaly have evolved from the strip craniectomy to cranial vault remodeling. Repair is technically more challenging in older patients due to thicker bone requiring more extensive remodeling and need to fill defects. The aim of our study is to assess the safety and efficacy of open repair in patients over 1 year of age.

Methods: Following IRB approval the authors performed a retrospective chart review of open repairs for nonsyndromic sagittal craniosynostosis between the years of 2004 and 2016 (N = 170). Inclusion criteria required primary calvarial vault reconstruction surgery performed after 1 year of age (N = 20). A combination of subtotal, posterior and clamshell techniques were used. The data associated with length of hospital stay, blood loss, transfusion rates, operative times, cephalic indices (CI), and complications were reviewed. Measurements were taken from available preoperative and 1-year postoperative 3D reconstructed CT scans. All scans were performed using a low-dose radiation protocol. SPSS (v.20 Chicago, IL) was used for statistical analysis. Significance was determined by a value of p = 0.05.

Results: The patients’ mean age (± SD) at surgery was 31 ± 17 months. Of the 20 patients, 10 (50%) were treated by subtotal calvarial vault reconstruction, 7 (35%) by clamshell and 3 (15%) by posterior vault only.

Perioperative data were as follows. Mean operative time was 265 ± 50 minutes; mean estimated blood loss was 328 ± 206 ml; and mean length of stay was 3.8 ± 0.8 days. 85% of patients required intraoperative transfusions while 40% required postoperative transfusions. Mean pre- and postoperative CI values were 67.8 ± 3.7 and 73.7 ± 4.5, respectively.

Within the first 30 postoperative days there were no readmissions, medical or surgical complications, additional surgery, or mortality.

Preoperative CIs for subtotal (69.2), clamshell (67.2) and posterior vault (64.7) were equivalent (p = 0.15). Postoperative Cis for the three techniques were 75.8, 72.0 and 70.4, respectively (p = 0.08). There is a trend towards less improvement in CI with increasing age at surgery.

Conclusions: Open calvarial vault reconstruction is a safe method to correct sagittal craniosynostosis in older children. Despite the safety profile, our series suggest that earlier intervention is better. As children age, the calvarium becomes more rigid and the rate of brain expansion is less, both of which make it difficult to attain ideal aesthetic outcomes (eg, CI>75). In subgroup analysis, subtotal resulted in the best results, followed by clamshell and posterior technique.