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OBJECTIVEAt British Columbia Children's Hospital (BCCH), pediatric patients with nonsyndromic craniosynostosis are admitted directly to a standard surgical ward after craniosynostosis surgery. This study's purpose was to investigate the safety of direct ward admission and to examine the rate at which patients were transferred to the intensive care unit (ICU), the cause for the transfer, and any patient characteristics that indicate higher risk for ICU care.METHODSThe authors retrospectively reviewed medical records of pediatric patients who underwent single-suture or nonsyndromic craniosynostosis repair from 2011 to 2016 at BCCH. Destination of admission from the operating room (i.e., ward or ICU) and transfer to the ICU from the ward were evaluated. Patient characteristics and operative factors were recorded and analyzed.RESULTSOne hundred fourteen patients underwent surgery for single-suture or nonsyndromic craniosynostosis. Eighty surgeries were open procedures (cranial vault reconstruction, frontoorbital advancement, extended-strip craniectomy) and 34 were minimally invasive endoscope-assisted craniectomy (EAC). Sutures affected were sagittal in 66 cases (32 open, 34 EAC), coronal in 20 (15 unilateral, 5 bilateral), metopic in 23, and multisuture in 5. Only 5 patients who underwent open procedures (6%) were initially admitted to the ICU from the operating room; the reasons for direct admission were as follows: the suggestion of preoperative elevated intracranial pressure, pain control, older-age patients with large reconstruction sites, or a significant medical comorbidity. Overall, of the 107 patients admitted directly to the ward (75 who underwent an open surgery, 32 who underwent an EAC), none required ICU transfer.CONCLUSIONSOverall, the findings of this study suggest that patients with nonsyndromic craniosynostosis can be managed safely on the ward and do not require postoperative ICU admission. This could potentially increase cost savings and ICU resource utilization.

Introduction: Our center previously reported low transfusion rates for craniosynostosis surgery by two experienced neurosurgeons using standard intraoperative techniques and acceptance of low hemoglobin levels. This study evaluated whether low rates were maintained over the last 10 years and if a less experienced neurosurgeon, trained in and practicing in the same environment, could achieve similar outcomes., Methods: All craniosynostosis operations performed in children between 2004 and 2015 were reviewed retrospectively. Transfusion rates were calculated. Analyses examined the relationship of transfusion to craniosynostosis type, surgical procedure, redo operation, surgeon, and perioperative hemoglobin levels., Results: Two hundred eighteen patients were included: 71 open sagittal, 28 endoscopic-assisted sagittal, 32 unicoronal, 14 bicoronal, 42 metopic, and 31 multisuture. Median age at operation was 9.1 months. Overall transfusion rate was 24 %: 17 % open sagittal, 7 % endoscopic-assisted sagittal, 6 % unicoronal, 21 % bicoronal, 45 % metopic, and 45 % multisuture. The timing of transfusions were 75, 21, and 4 % for intraoperative, postoperative, and both, respectively. Patients not receiving transfusion had a mean lowest hemoglobin of 87 g/l (range 61-111) intraoperatively and 83 g/l (range 58-115) postoperatively. Mean lowest hemoglobin values were significantly lower in those necessitating intraoperative (75 g/l, range 54-102) or postoperative (59 g/l, range 51-71) transfusions. There was no significant difference in transfusion rate between less and more experienced surgeons. There were no cardiovascular complications or mortalities., Conclusion: In craniosynostosis surgery, reproducible, long-term low blood transfusion rates were able to be maintained at a single center by careful intraoperative technique and acceptance of low intraoperative and postoperative hemoglobin levels in hemodynamically stable patients. Furthermore, low rates were also achieved by an inexperienced neurosurgeon in the group. This suggests that these results may be achievable by other neurosurgeons, who follow a similar protocol.

Aims and Objectives: The significance of beaten copper appearance (BCA) on skull radiographs in children following surgery for isolated sagittal craniosynostosis has not been studied. This study was designed to look for any correlation between BCA and symptoms suggestive of intracranial hypertension in this group of patients., Materials and Methods: Forty-eight consecutive children, who were operated for isolated sagittal synostosis from 1987 to 2000 and had postoperative skull radiographs, were included. Patients were divided into: (a) BCA group (n = 20), consisting of children who had beaten copper appearance on skull radiographs at last follow up, and (b) Non-BCA group (n = 28), consisting of children who did not have this finding. Records were reviewed to look for symptoms suggestive of intracranial hypertension, such as headache, head banging, and irritability., Results: Median age at surgery was 4.8 months for BCA group and 4 months for the non-BCA group. Follow up ranged from 4 to 156 months with a mean of 36.2 months. Total of 28.6% (n = 6) of the children with follow up radiographs done at < or =18 months of age had BCA. The incidence of BCA increased to 83.3% in children with skull radiographs performed after 48 months of age. In 18 (90%) children, the BCA was 'diffuse' with 5 (25%) children having the maximum possible score of 8. In the BCA group, 45% (n = 9) had symptoms compared to 10.7% (n = 3) in the control group (p = 0.0068)., Conclusions: This study suggests a significant number of children with BCA on radiographs develop symptoms suggestive of raised ICP following surgical treatment in infancy and prolonged follow up may be warranted in this group of patients.

Object: A number of studies have shown good short-term cosmetic outcomes following surgery for isolated sagittal craniosynostosis. Whether the improvement in head shape persists in the longer- term is less clear. The aim of this study was to investigate the long-term anthropometric outcomes following surgery for isolated sagittal craniosynostosis., Methods: Records were retrospectively reviewed for children with isolated sagittal synostosis who underwent surgical revision between 1987 and 2000. Only children who underwent surgery before 8 months of age and for whom serial anthropometric data (skull width, skull length, and cephalic index) were available were included in the study. The operative procedure consisted of vertex and parietal craniectomies involving removal of the sagittal suture and a 1.5- to 2.5-cm piece of adjacent parietal bone on each side as well as bilateral parietal barrel-stave osteotomies. Ninety cases satisfied the eligibility criteria. The mean age of the patients at surgery was 5 months (range 1.9-7.5 months). The mean preoperative cephalic index was 66.78. The follow-up period ranged from 1.8 to 167 months (mean 39.6 months). In 24 cases, the follow-up period was longer than 36 months. Eighteen (75%) and five (20.8%) of these 24 cases were followed up for longer than 5 and 10 years, respectively. The mean increase in cephalic index at the last follow up was 8.69% (p < 0.0001). The maximum improvement in the cephalic index occurred within 6 months of surgery, at which point it had improved by a mean of 11.1% (p < 0.0001). The cephalic index remained increased throughout the follow-up period, with a mean change of -1.84% (standard deviation, 4.28%; 99% confidence interval -3.33 to -0.37%) from the first postoperative to the final measurement., Conclusions: Surgery for isolated sagittal craniosynostosis leads to a significant improvement in the cephalic index, which is most marked in the early postoperative period. Improvement in the cephalic index is still present after prolonged follow up.

Object: Data from animal studies have shown that in experimentally induced craniosynostosis, removal of the involved calvaria results in the formation of new calvaria with time, and sutures redevelop in their normal anatomical positions. However, the pattern of suture reformation following surgery in humans with craniosynostosis remains ill-defined. The aim of this study was to determine the pattern of postoperative suture reformation in children who have undergone surgery for isolated sagittal synostosis and assess possible factors related to suture reformation., Methods: Records were retrospectively reviewed for 42 consecutive infants who had surgery for isolated sagittal synostosis between 1987 and 2000 and for whom postoperative skull radiographs were available. The radiographs were evaluated for sagittal suture morphology and patency of the coronal and lambdoid sutures. Surgery involved at a minimum 1) a vertex craniectomy, characterized by removal of the sagittal suture and a 1.5- to 2.5-cm piece of adjacent parietal bone with the attached pericranium bilaterally, and 2) parietal osteotomies and/or craniectomies. The median age at surgery was 3.9 months (range 1.9-7.6 months). The mean duration of follow up was 32.2 months (range 6-144 months). The sagittal suture had reformed in only seven (16.7%) of the children at follow up. In the other 35 (83.3%), the craniectomized bone defects had reossified without any part of the sagittal suture being visible on the radiographs., Conclusions: There is a very low incidence of suture reformation in children after surgery for isolated sagittal craniosynostosis. Genetic predisposition, inclusion of undiagnosed syndromic patients, and current operative techniques may be some of the factors responsible for the low incidence of suture reformation seen in this series.

Aims and Objectives: Isolated sagittal synostosis can be diagnosed easily on clinical grounds. This study was designed to determine if children could be operated on based solely on a clinical diagnosis or whether such an approach would result in any potentially unnecessary surgeries., Materials and Methods: Records of 114 consecutive children operated on for isolated nonsyndromic sagittal synostosis over a 14-year period (1987-2000) were reviewed to see whether the clinical findings were in concordance with the intraoperative findings and histopathology of the sagittal suture., Results: The age at surgery ranged from 1.9 to 81.3 months (median 4.3 months). Preoperative skull radiographs were done in 78 children and computer tomography (CT) scans of the head in 12 children. One hundred percent of the skull radiographs and 83.3% of the CT scans were completed prior to referring the children to a pediatric neurosurgeon. CT scans confirmed the diagnosis in all patients in whom it was available. For the rest, pathology reports and/or operative records were available for 108 (94.7%) children and were confirmatory for sagittal craniosynostosis in all., Conclusions: Accurate diagnosis of isolated sagittal synostosis can be made clinically, and operative correction can proceed without a need for radiological investigations, unless the clinical features are not completely typical. This approach could result in significantly reduced radiation exposure for the developing brain and could provide economic benefits to health care providers.

Aims and Objectives: Although syndromic craniosynostosis is one of the causes for early closure of the anterior fontanelle, there is no literature on the incidence and causes of fontanelle closure in isolated single-suture craniosynostosis. The objective of this study was to review the incidence of fontanelle closure by a wormian bone in isolated, nonsyndromic sagittal craniosynostosis., Materials and Methods: Intraoperative records of 100 consecutive children under 1 year of age, operated for isolated sagittal synostosis over a 14-year period (1987- 2000), were reviewed to identify the presence of a wormian bone closing the anterior fontanelle., Results: The median age at surgery was 4.2 months with a range of 1.9-11.7 months. Intraoperatively, a wormian bone was seen replacing the anterior fontanelle in 4 cases giving an incidence of 4%., Conclusions: A wormian bone can occupy the anterior fontanelle in children with isolated sagittal craniosynostosis giving the appearance of a 'closed fontanelle'., (Copyright 2006 S. Karger AG, Basel)

Objective: The current study was performed to determine the rate of allogeneic blood transfusion for coronal and metopic craniosynostosis surgery done by two experienced pediatric neurosurgeons and to identify factors associated with a need for transfusion., Methods: First operations for coronal and metopic craniosynostosis correction in children from 1996 to 2002 were reviewed retrospectively. For analysis, the primary endpoint was defined as either the receipt of a blood transfusion or a postoperative Hb level below 70 g/l, even if no blood was transfused. Univariate and multivariate analyses were done to examine the relationship of attaining the primary endpoint to extent of surgery, surgeons, surgery time, preoperative hemoglobin, craniosynostosis type, weight, and age., Results: Thirty-two patients were operated on: 17 with unicoronal; 9 with bicoronal, and 6 with metopic craniosynostosis. Median age at operation was 7.5 months. Blood transfusion rates were 0% for unicoronal, 44% for bicoronal, and 33% for metopic synostosis operations. Logistic regression revealed that the best predictor of having a postoperative hemoglobin level of <70 g/l or receiving a blood transfusion was the extent of surgery (beta=1.59, SE(beta)=0.57). The odds of reaching the primary endpoint for extensive surgery over basic surgery was 4.9 [95%CI=(1.6,15.0)]. Once extent of surgery was accounted for in the model, no other covariates significantly improved the model., Conclusions: Low transfusion rates were achieved in primary operations for coronal and metopic craniosynostosis using simple intraoperative techniques and by accepting a low postoperative hemoglobin level.

Object: As public concern about the risks of blood transfusions increased in the mid-1990s, avoidance of transfusions became a goal of surgery for sagittal synostosis. This study was performed to confirm a hypothesized reduction in transfusion rates in recent years and to identify factors associated with both the need for transfusion and low postoperative levels of hemoglobin., Methods: Sagittal synostosis operations performed in children between 1986 and 1999 were reviewed retrospectively. Patients underwent a minimum of vertex strip craniectomy and parietal craniectomies. There were 118 patients whose median age at surgery was 4.2 months. The primary end point for analysis was defined as either the receipt of a blood transfusion or a postoperative level of hemoglobin less than 70 g/L. Forty-two percent of patients (95% confidence interval [CI] 31-52%) treated before 1996 and 11% of patients (95% CI 0-23%) treated from 1996 onward received blood. The reduction in the blood transfusion rate in later years was, in part, related to the acceptance of a lower postoperative hemoglobin level, often below 70 g/L. A univariate analysis showed that the only patient or surgical factors that correlated with reaching the primary end point in a statistically significant manner were the year of surgery and the extent of surgery. A logistic regression of the age and weight of the child, length of surgery time (from skin opening to skin closure), preoperative hemoglobin level, extent of surgery, and surgeon against the primary end point revealed that the best predictor of the need for a blood transfusion or the presence of a postoperative hemoglobin level lower than 70 g/L was the extent of surgery (beta = 1.4, standard error of the beta statistic = 0.44). Once the extent of surgery was accounted for in the model, no other covariates significantly improved the model. Techniques implemented to minimize blood loss since 1995 included the following: use of the Colorado needle for scalp incision, selection of the Midas Rex craniotome for cranial cuts, and application of microfibrillar collagen. Postoperative hemoglobin was allowed to decrease to 60 g/L if the child was stable hemodynamically, before blood was administered. There were no cardiovascular, wound healing, or infectious complications, and no surgeries were repeated for cosmetic reasons., Conclusions: Low blood transfusion rates were achieved using simple intraoperative techniques and by accepting a low level of postoperative hemoglobin.