Endoscopic or “Minimally Invasive” Craniosynostosis Repair
Originally repairs for craniosynostosis were done through a large open incision. Specifically in sagittal synostosis surgeons would remove a strip of bone from the top of the skull. This approach had generally poor long term results with regard to improving head shapes. The open technique was then modified to a greater remodeling procedure, more intrusive, but yielding better long term results. Now the open technique encompasses a greater remodeling of the skull and does yield fine results, but through a larger incision and longer hospital stays. The benefits of the open technique is that no helmet therapy is required post- operatively, it is safer to see the entire operative field and it yields excellent long-term results. The drawbacks of this technique are larger incisions in the hairline, longer operating time, increased need for blood transfusions and longer hospital stay.
With the introduction of Endoscopic Surgery or “Minimally Invasive” repairs an endoscope (small operating camera) is used through two small 5 cm (about 2 inches) incisions on the top of the head for reconstruction. This procedure also removes a portion of bone as in the past, but also allows the surgeon to do additional reconstruction. With both the neurosurgeon and the craniofacial surgeon, the bone cuts and remodeling are completed. This procedure takes about one hour as opposed to the open procedure which is closer to four hours.
The post operative course is usually 24 hours in the hospital as opposed to 3-4 days for the open procedure. Also, the blood transfusion rate for the minimally invasive approach is about 25-30 percent as opposed to 50-75 percent with open techniques. The difference in the post operative course is that those with the minimally invasive approach require helmet therapy. This is a banding device applied to the skull at about 3 weeks post-operation. This helps to remodel the bones for approximately 3-6 months.
What we have found in reviewing patient outcomes is for a child with mild to moderate synostosis the minimally invasive technique has had good results. For those children with more severe deformities or syndromes the open techniques still yields safer and better long term results.
Minimally invasive approaches for craniosynostosis have yielded good results for sagittal synostosis. The results for other forms of fusions, specifically coronal and metopic synostosis have been tried with poor results thus far. Even with molding helmets post-operatively, it is very difficult to change the forehead and the orbits. Our belief is that better results can be achieved through a combination of the minimally invasive approach with the use of a dissolvable distractor.
A distracting device is placed during surgery on the bone to slowly allow forward repositioning of the skull and/or orbits. An attached turning device is placed outside the scalp and allows the parent and/or surgeon to turn or “distract” the bone daily for approximately 1-1.5 mm. This is painless to the child, but allows the bone to move slowly forward until the surgeon feels there is adequate remodeling of both the skull, forehead and orbits. Once distraction is stopped, in approximately 1-2 weeks, the turning device is easily removed from the scalp in the office. Then the bone remains in its new position and is allowed to heal. The space created during distraction usually fills with bone in about 8 weeks. The tendency of the skull, forehead and orbits to remain in their new position is excellent. With this new technique there is no need for any post surgical helmet therapy. The distractor on the underlying bone dissolves in approximately 12 months.