Editorial: Endoscopy-assisted craniosynostosis

the effectiveness and the complications associated with the treatment of 139 patients with sagittal synostosis who had undergone endoscopy-assisted wide-vertex craniectomies and barrel stave osteotomies. These infants were treated with postoperative molding helmets for 1 year. They ranged in age from 2 weeks to 9 months. The authors report that visually the results were uniformly excellent and corroborate this by using cephalic index measurements. They also describe no significant complications, with the need for blood transfusion in only two patients intraoperatively and 12 patients overall. The indications for transfusion were a hematocrit of less than 19 and a pulse rate greater than 170. Most patients were discharged on the 1st postoperative day (132 patients [95%]). The authors further state that there were no dural tears and no intraparenchymal cerebral hemorrhages or air emboli. On the surface, this approach has a significant number of appealing features: a smaller or less conspicuous scar in childhood, shorter operating time, and overall low morbidity rate. Before one concludes that this is the optimal treatment of patients with sagittal synostosis, some additional factors need to be clarified. First, the authors state that there were no dural tears nor intracerebral hemorrhages. The authors did not, however, report a routine evaluation of the children’s skull and brain by using objective measures, such as computerized tomography (CT) scanning, in the immediate postoperative period to define this. The incidence of intracranial hemorrhage therefore cannot be stated based on the information provided because some of these complications may be “silent.” The endoscopic approach—which I have used, on occasion, with a rigid endoscope—as the authors have described, restricted visualization, particularly laterally, in the basal skull. In the abstract, the authors describe that they have performed temporal barrel stave osteotomies, which would require crossing a patent squamosal suture. In most children, this requires a significant depression of the surface contour of the dura and underlying brain because of the convex nature of the frontal, parietal, and temporal lobes. In the body of the text, however, the authors indicate that the barrel stave osteotomies come to the level of the squamosal suture, and it is unclear based on the abstract whether the craniotomies are beyond the suture. It is probable with the use of scissors, which the authors describe as their cutting instrument, that at some point either a significant depression of the brain and contusion of the brain surface or dural laceration and hemorrhage could occur. The third issue relates to the width of the craniectomy. The authors state that the mean width of the craniectomy defect is routinely 5.4 cm, with a skin incision line of 2 to 2.5 cm. This would mean that all the bone would have to be cut at least in half, if not thirds, to remove the bone segments. This would also indicate that the incision lines would tend to be more than 2.5 cm long (the photograph in Fig. 3F suggests that this scar may be longer than 2.5 cm, at least in some cases). Concern regarding the long-term consequences of a large defect over the sagittal sinus is also raised. In cases in which this amount of bone has been removed in my own practice, thinner or incomplete bone formation occurred years later. The vertex of the skull produces a less effective remineralization of the cranial defect compared with frontal and temporal regions. The authors do not describe the extent of remineralization of the defect area nor do they provide any CT scanning evidence of the thickness of regnerated bone in this region. This is important because one needs to judge whether the skull is going to be sufficiently thick and durable to allow for normal childhood activities and participation in sports later in life.