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BACKGROUND:
Calvarial vault remodeling (CVR) has been demonstrated as an effective method for correcting shape and increasing intracranial volume in non-syndromic sagittal craniosynostosis. However, the paradigm of treatment is shifting with an increasing emphasis on less invasive procedures such as strip suturectomy and spring-assisted cranioplasty (SAC). The purpose of this study was to compare outcomes for CVR, strip suturectomy, and SAC through a systematic meta-analysis.
METHODS:
A literature search was conducted to identify all articles involving operative management of non-syndromic sagittal craniosynostosis from 1990 to 2014. Studies were included if at least 2 operative techniques were compared and outcomes were reported by technique. Methodological quality was assessed via American Society of Plastic Surgeon’s Rating Scale. Three operative techniques were considered: CVR, strip suturectomy, and SAC. Head-to-head meta-analysis was conducted for the primary outcome, change in cephalic index, reported as weighted mean difference (WMD). Pooled subgroup analyses were performed for secondary outcomes including operative time, length of stay, estimated blood loss, total cost. Weighted t-tests were utilized to compare outcomes by operative technique.
RESULTS:
Of the initial 459 articles identified in the literature search, 13 were included in this meta-analysis, all of which were cohort studies providing level 3 evidence. All 13 studies involved CVR (187 patients), 8 involved sagittal suturectomy (299 patients), and 7 involved SAC (158 patients). Average age was greater for CVR (8.4 months) compared to either suturectomy (4.0 months) or SAC (5.0 months). All studies demonstrated a predominance of male patients. Head-to-head comparison of CVR versus SAC demonstrated a greater, yet statistically insignificant change in cephalic index post-operatively for CVR with a WMD = 0.94 (95% CI [-0.23, 2.11] p = 0.12, I2 = 55%). In contrast, CVR showed a statistically greater change in cephalic index versus strip suturectomy with WMD = 1.47 (95% CI [0.47, 2.48], p = 0.004, I2 = 66%). Post-operative cephalic index was correlated with reported study follow-up for each technique. As follow-up time increased, cephalic index increased in the suturectomy and SAC groups and decreased in CVR studies. Subgroup analysis demonstrated longer operative time for CVR versus suturectomy/SAC groups (170.2 min vs 97.2 min), as well as higher blood loss (237.7 mL vs 47.3 mL), longer length of stay (5.13 days vs 2.96 days), and higher total costs ($35,280 vs $13,147), all statistically significant with p values < 0.0001.
CONCLUSIONS:
This study represents the first meta-analysis comparing the three primary operative techniques for correcting sagittal craniosynostosis. Head-to-head analysis demonstrated no significant difference in cephalic index for CVR versus SAC. There was a small but statistically greater improvement in CI favoring CVR to strip suturectomy. Longer follow-up time was associated with a decrease in cephalic index for the CVR group and an increase in cephalic index for the less invasive modalities. Furthermore, all secondary outcome measures favored the less invasive groups. While definitive conclusions cannot be made, it appears that less invasive procedures are as efficacious as CVR but offer more favorable safety profiles.