Endoscopic assisted sagittal strip craniectomy with barrel stave osteotomies in sphinx position

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Author: Kumar Patel
Published:
Specialties: Craniofacial and Pediatric Plastic Surgery, Pediatric Surgery, Plastic Surgery
Schools:
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Basic Info

Contributors: Rongsheng Cai and Roop Gill.

Endoscopic assisted sagittal strip craniectomy with barrel stave osteotomies to treat sagittal suture craniosynostosis.

Advanced

Procedure

Endoscopic assisted sagittal strip craniectomy with barrel stave osteotomies in sphinx position

Indications

Sagittal craniosynostosis that presents with scaphocephaly (elongated head shape) with possible headaches, visual changes, seizures, hydrocephalus, increased intracranial pressure, or other evidence of symptoms that may be related to the skull being too small for the brain to adequately grow. A CT scan confirms craniosynostosis, and endoscopic surgery is ideally performed prior to the age of 6 months when the bone is still not fully calcified

Contraindications

Absence of symptoms or increased intra-cranial pressure and acceptable head shape. Relative contraindication: patient older than 6 months.

Instrumentation

Setup

Endoscope tower and scope setup, intubation with oral ray secured down the midline and secured to chin, 2 large bore IVs, arterial line, foley cath, sphinx pillow / positioning (hip abduction pillow modified as shown in the video), padding to avoid pressure, bone-wax and thrombin available, blood & FFP available

Preoperative Workup

History & physical, CBC, basic metabolic panel, PT/PTT, INR, anesthesiology evaluation for ASA class, low dose radiation 3D CT 1mm cuts head-to-hyoid

Anatomy and Landmarks

2 curvilinear incisions posterior to the anterior fontanelle and anterior to the posterior fontanelle. Scalp anatomy: skin, subcutaneous tissue, galea, periosteum, skull bone. Incision down to bone through periosteum must be mindful of any thin bone or cranial defects where dura is exposed. Identify cranial sutures: coronal and sagittal at the fontanelles. The major cerebral sinuses must be avoided and the dura carefully dissected free of the cranial sutures where it tends to be more adherent.

Advantages/Disadvantages

a. Advantages: Minimally invasive, minimal blood loss, smaller incision, shorter operative time.
b. Disadvantages: incomplete release of suture and barrel staves may limit skull remodeling, requires patient compliance with helmet therapy, not suitable for older children.

Complications/Risks

Bleeding, infection, damage to dura mater leading to CSF leak, bone fragments, premature re-fusion of suture or full thickness skull voids (incomplete re-ossification of removed segments)

Disclosure of Conflicts

Bleeding, infection, damage to dura mater leading to CSF leak, bone fragments, premature re-fusion of suture or full thickness skull voids (incomplete re-ossification of removed segments)

Acknowledgements

Jessica Boswell, John Weight

References

a.Kung, Theodore A., Christian J. Vercler, Karin M. Muraszko, and Steven R. Buchman. "Endoscopic Strip Craniectomy for Craniosynostosis." Journal of Craniofacial Surgery 27.2 (2016): 293-98. Web.
b.Nguyen, Dennis C., Kamlesh B. Patel, Albert S. Woo, Alex A. Kane, and Matthew D. Smyth. "Endoscopic-assisted Treatment of Sagittal Craniosynostosis and Calcified Cephalohematoma." The Journal of Craniofacial Surgery (2014): 1. Web.

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