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Delayed Multisutural Synostosis Following Endoscopic Suturectomy and Postoperative Helmet Therapy
Mitchel Seruya, MD1, Tina Sauerhammer, MD2, Alex Ropper, MD3, Albert Oh, MD2, Mark Proctor, MD3, Gary Rogers, MD, JD, MBA, MPH2.
1Georgetown University Hospital, Washington, DC, USA, 2Children's National Medical Center, Washington, DC, USA, 3Children's Hospital Boston, Boston, MA, USA.

BACKGROUND: Fusion of adjacent patent cranial sutures following operative treatment of craniosynostosis has been described in both open and endoscopic approaches. The etiopathogenesis and incidence of this process is unclear, but the impact on cranial growth and shape can necessitate reoperation. The purpose of this study was to explore the incidence of delayed multisutural synostosis following endoscopic suturectomy and helmet therapy (ES+HT).
METHODS: A retrospective review was performed of all infants with craniosynostosis who underwent ES+HT between 2004-2010. Patient demographics and type of affected suture(s) were recorded. All patients with documented post-operative multisutural synostosis were included. The temporal course and clinical nature of these cases were detailed.
RESULTS: 128 infants (85 male, 43 female) underwent endoscopic suturectomy with helmet therapy at a mean surgical age of 3.3 ± 2.1 months. Involved sutures included sagittal (N=62), unicoronal (N=24), metopic (N=19), atypical two sutures combination (N=10), bicoronal (N=9), and unilambdoidal (N=4). 6 patients (4.7%) had clinical and CT evidence of delayed multisutural synostosis. Preoperative diagnosis was sagittal (n=3; 4.8% of all sagittal patients); bilateral coronal (n=2; 22% of all bilateral coronal patients); and metopic with bilateral coronal synostosis (n=1, 10% of all atypical two suture combination patients). There were no patients with metopic, lambdoid, or unilateral coronal synostosis identified. Mean surgical age in this group was 1.9 ± 1.1 months and delayed fusion was confirmed by CT imaging at an average of 13.0 ± 5.8 months following suturectomy. Four of 6 infants (66.7%) were syndromic, consisting of Crouzon (n=2) and Saethre-Chotzen (n=2) syndrome. All patients were noted to have a decline in head circumference that prompted radiographic evaluation. CT consistently demonstrated signs suggestive of intracranial hypertension (e.g., endocortical erosion and loss of subdural space) and all patients underwent open cranial remodeling.
CONCLUSIONS: Delayed multisutural synostosis following ES+HT occurred in nearly 5% of patients and was associated with decreasing post-operative head circumference and radiographic evidence of intracranial hypertension. Infants with a syndromic diagnosis and bicoronal synostosis demonstrated the highest rates. Such populations should be carefully monitored if treated with this technique.


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