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A New Metric for Craniosynostosis Surgery Selection
Ethan D. Paliwoda
*1, Sawyer Farmer
2, Jai Patel
3, Aidan O'Brien
1, Saud Rehman
3, Tarun Prabhala
2, Michael Mellace
3, Ishan Patel
1, Mason Horne
1, Lauren Angnardo
1, Amanda Awad
1, Christina Rudolph
1, Travis Bevington
3, Matthew A. Adamo
2, Stephanie Bray
11Division of Plastic Surgery, Department of Surgery, Albany Medical Center, Albany, NY; 2Department of Neurosurgery, Albany Medical Center, Albany, NY; 3Department of Radiology, Albany, NY
Background: Surgical management of single-suture craniosynostosis relies on chronological age to guide selection between endoscopic strip craniectomy and open cranial vault remodeling, with six months serving as the conventional threshold. The relationship between preoperative CT-derived calvarial thickness, suture subtype, and surgical approach were assessed along with whether it may be used adjunctively alongside age to assess surgical candidacy.
Methods: This retrospective cohort study included 76 patients with isolated single-suture craniosynostosis who underwent preoperative CT at a tertiary pediatric center between 2013 and 2025. Calvarial thickness was measured at 15 anatomic sites using preoperative imaging. Comparisons were made across suture subtypes and surgical approach groups, and regression models were constructed with global calvarial thickness as the dependent variable.
Results: Endoscopic-treated sagittal-fused patients were significantly younger at imaging (1.7 vs 5.6 months, p<0.001) yet demonstrated paradoxically greater global calvarial thickness than open-treated counterparts (3.2 vs. 2.8 mm, p=0.027). Every open-treated sagittal patient's global thickness fell within the endoscopic distribution. Perioperative outcomes favored endoscopic sagittal repair across both thin (≤3.2 mm) and thick (>3.2 mm) global calvarial strata. Surgical approach was an independent predictor of calvarial thickness after multivariable adjustment (B=+0.52mm, p=0.017), but age at CT and cephalic index were not. In contrast, endoscopic coronal (2.0 vs 2.6 mm, p=0.045) and metopic (2.1 vs 2.7 mm, p=0.063) patients exhibited lower thickness than open-treated peers.
Conclusions: In sagittal craniosynostosis, preoperative calvarial thickness should be considered alongside chronological age in endoscopic candidacy determination, particularly in older infants for whom open surgery poses elevated risk.
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