Authors of section

Authors

Scott Bartlett, Michael Ehrenfeld, Gerson Mast, Adrian Sugar

Executive Editor

Edward Ellis III

General Editor

Daniel Buchbinder

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Early surgical treatment

1. Introduction

Premature closure of the sagittal suture results in scaphocephaly (dolichocephaly) or a boat shaped head. There may be a great deal of variability in the head shape, depending upon whether the closure started posteriorly or anteriorly and at what age. Consequently the occiput may be more affected than the frontal region, or vice versa. Commonly both are affected. The general goal of surgery is to shorten the skull in a sagittal plane and widen it in a coronal plane.

If the diagnosis is made within the first weeks or months of life, less invasive methods of treatment are gaining popularity. These include endoscopically assisted strip craniectomies with molding helmets, and spring assisted craniectomies. These are best performed by 6-12 weeks of age when the endoscopic approach is selected and 3-6 months of age when springs are utilized.

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2. Positioning and approach

The patient is positioned either supine or prone depending on the region most affected.

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The approaches to the endoscopic technique are short transverse incisions near the coronal and lambdoid sutures.

early surgical treatment

The approach for spring expansion is via a short lazy-S incision.

early surgical treatment

3. Osteotomies

Craniectomy with endoscopic approach

If the endoscopic approach has been selected, retractors and the endoscope are situated to allow removal of the fused sagittal suture in addition to a strip of bone parallel to the coronal suture and an additional strip parallel to the lambdoid suture.

The osteotomy is made using a craniotome or a heavy scissors. The bone is carefully separated from the dura and removed through the incision.

The wound is closed in layers with absorbable sutures.

A molding helmet is applied within the first weeks after surgery and is periodically adjusted to mold and shape the head as it grows (shorten anterior-posterior and expand transversely).

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Spring expansion

If the spring approach has been selected, a craniectomy (2 cm width) of the sagittal suture is performed, and 2 to 3 pre-bent springs of between 5 and 8 Newton's of force are placed.

sagittal synostosis

Note: Springs are made of stainless steel and are not commercially available. They are made with a wire bending device and their force is measured with a tensiometer.

early surgical treatment

Wound closure

The wound is closed in layers with absorbable sutures.

The springs are removed after 3-4 months.

4. Aftercare following endoscopic procedures

Postoperatively

A circumferential head dressing is utilized for 2-7 days depending on surgeon's preference. hours. Patients typically spend at least 1 day in an intensive care unit for neurological monitoring and are then discharged.

Medication

The following perioperative medications are controversial. There is little evidence to make strong recommendations for postoperative care.

  • Avoidance of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) for 7 days
  • Analgesia as necessary
  • Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.)

Postoperative imaging

Postoperative imaging is typically performed within the first several days after surgery to verify accuracy of surgery. Plain skull X-ray (AP and lateral) are taken immediately after surgery and periodically to assess the results of treatment.

Wound care

Remove sutures from skin after approximately 7-10 days if nonresorbable sutures have been used.
Apply ice packs for the first 12 postoperative hours as able although infants and young children do not tolerate this well (may be effective in a short term to minimize edema).
Avoid sun exposure and tanning to skin incisions for several months.

Diet

In children and infants age appropriate diets are then prescribed.

Follow-up

The patient is typically seen within the first weeks of surgery and then again after 6-8 weeks.