We think of open surgery as a mechanical operation... we take off the bones, we put them in the right place, we fix them in place. I wanna make it clear, that's not a panacea, right? When you take off all these bones and do all this, do all this work, those bones don't grow normally over time.
The scope nature of this case is, is not as sophisticated as a lot of the things you're gonna hear today. The scope is very good for the lighting, it's good for visualization, but there are people who do the same operation without use of the endoscope.
Endoscopic Treatment of Craniosynostosis: Pediatric Endoscopic Neurosurgery 2018
▶Ep 1 · 1:51
quoteWhy are we not like other animals that don't really suffer from synostosis? And, and truly the, the issue in, in humans as opposed to other animals is the, the very rapid growth of the brain in the first year of life.↗
▶Ep 1 · 1:56
clinicalHuman brain growth is very rapid in the first year of life, slows considerably over the second year, and past 2 years of age sutures play a very small role in skull or brain growth↗
▶Ep 1 · 2:27
clinicalVirchow's law defines that skull growth is normally perpendicular to sutures, and if bone is closed, growth occurs parallel to sutures due to compensatory overgrowth in other areas↗
▶Ep 1 · 2:54
epidemiologicalCraniosynostosis affects approximately 1 in 2000 live births with sagittal being the most common in about half of cases↗
▶Ep 1 · 3:56
clinicalIn sagittal synostosis, the back of the head is the narrowest part whereas normally it is the widest part↗
▶Ep 1 · 4:45
clinicalIn unilateral coronal synostosis, the nose always points up to the affected side↗
▶Ep 1 · 5:18
epidemiologicalLambdoid synostosis is very rare, representing about 1-2% of all synostosis cases, with approximately 1 case per year at a center seeing 100 new synostosis patients annually↗
▶Ep 1 · 6:24
clinicalHistorical strip craniectomy had poor results with about one-third of patients having bones fuse together before achieving correction↗
▶Ep 1 · 7:51
quoteWe think of open surgery as a mechanical operation... we take off the bones, we put them in the right place, we fix them in place. I wanna make it clear, that's not a panacea, right? When you take off all these bones and do all this, do all this work, those bones don't grow normally over time.↗
▶Ep 1 · 7:59
clinicalOpen cranial vault reconstruction does not result in bones growing normally over time; results at end of surgery are not completely predictive of appearance 5-10 years later↗
▶Ep 1 · 8:25
clinicalEndoscopic surgery is a release procedure that relies on brain growth to move bones out over time or requires adjuncts like springs or distractors↗
▶Ep 1 · 8:53
quoteConceptually, we're turning the synostosis into a deformational problem. We're, we're opening the bones so that they're malleable. And then we're reshaping it with with the helmet.↗
▶Ep 1 · 8:53
clinicalEndoscopic approach conceptually turns synostosis into a deformational problem by opening bones to make them malleable, then reshaping with helmet↗
▶Ep 1 · 9:22
opinionLaparoscopic cholecystectomy was initially met with significant skepticism in 1987 but became standard of care↗
▶Ep 1 · 9:49
quoteLaparoscopic cholecystectomy, passing fancy or legitimate treatment option.↗
▶Ep 1 · 10:47
guidelineOnly surgeons involved with open cholecystectomy and management of its complications should perform laparoscopic cholecystectomy↗
▶Ep 1 · 10:47
quoteOnly surgeons involved with open cholecystectomy and management of its potential complications should before this procedure.↗
▶Ep 1 · 10:56
quoteYou don't want to start to treat cranial synostosis in an endoscopic fashion if you don't really know how to treat cranial synostosis holistically, doing open procedures, etc.↗
▶Ep 1 · 11:11
guidelineCDC parameters of care (2010-2012) consider endoscopic surgery a viable treatment option but stress need for very experienced team↗
▶Ep 1 · 12:28
quoteThe scope nature of this case is, is not as sophisticated as a lot of the things you're gonna hear today. The scope is very good for the lighting, it's good for visualization, but there are people who do the same operation without use of the endoscope.↗
▶Ep 1 · 12:28
clinicalThe endoscope is used primarily for lighting and visualization; some surgeons perform the same operation without endoscope↗
▶Ep 1 · 12:46
clinicalA 0-degree endoscope is used, often not the high-quality neurosurgical scopes to avoid damage during this relatively blunt procedure↗
▶Ep 1 · 13:14
clinicalMeticulous technique is necessary to keep blood transfusion rates down↗
▶Ep 1 · 13:14
quoteI think really meticulous technique is necessary to keep the blood transfusion rates down.↗
▶Ep 1 · 13:33
clinicalFor sagittal synostosis, a 2 cm gap is the target width for bone removal↗
▶Ep 1 · 15:44
clinicalRecent studies from Hopkins, DC, and Saint Louis show narrow (2 cm) strips are just as effective as wide (6 cm) strips↗
▶Ep 1 · 15:59
clinicalMost centers have moved to narrow strip with no barrel staves on the side↗
▶Ep 1 · 16:51
clinicalHelmet allows real-time adjustment; if top of head gets flat and needs more rounding, helmet can be adjusted, unlike springs or distractors↗
▶Ep 1 · 16:51
quoteThe helmet lets you adjust in real time, right? If you're, let's say, the top of the head is getting a little flat, you want a little bit more rounding, you can adjust the helmet, or a springer distractor, you can't do that with.↗
▶Ep 1 · 17:18
clinicalEndoscopic results are very similar to open operation from cranial index perspective↗
▶Ep 1 · 17:35
clinicalHead growth is very good and sustained over time with endoscopic approach↗
▶Ep 1 · 18:20
clinicalFacial asymmetry improved significantly more in endoscopic group than frontal orbital group, attributed to early release↗
▶Ep 1 · 18:39
clinicalAstigmatism improved much better with endoscopic surgery compared to open surgery↗
▶Ep 1 · 18:55
clinicalIn first 100 consecutive cases: mean surgical time 48 minutes, estimated blood loss 23 mL, 8 transfusions, median hospital stay 1 day↗
▶Ep 1 · 19:08
clinicalWeight under 5 kg was identified as risk factor for transfusion; now wait until over 5 kg and transfusion rates are down to about 3%↗
▶Ep 1 · 19:25
clinicalCost of endoscopic treatment is 40% of open operation, confirmed by three independent studies↗
▶Ep 1 · 19:43
clinicalCost analysis included all hospital costs, home costs, and gas mileage for families traveling to orthotist↗
▶Ep 1 · 22:37
clinicalIdeal age for surgery is about 3 months (10-12 weeks)↗
▶Ep 1 · 23:13
clinicalOldest patient treated endoscopically was 7 months with mild sagittal synostosis; result was reasonable but less correction expected at that age↗
▶Ep 1 · 23:34
opinionWould not offer endoscopic treatment past 6 months for cranial index of 0.62, but reasonable to push to 5-6 months if starting cranial index is 0.7 or 0.72↗
▶Ep 1 · 24:45
clinicalWithout adjuvant treatment, would see similar 20-30% rate of suture closing back before significant correction↗
▶Ep 1 · 25:28
clinicalFor sagittal synostosis, helmet prevents front-to-back growth and promotes lateral growth; shooting for 2:1 growth ratio of width to length during helmet therapy↗
▶Ep 1 · 26:13
clinicalStarting with cranial index of 0.75, after 6 months of helmet therapy expect to reach about 0.8↗
▶Ep 1 · 26:35
clinicalVery important to track head circumference; do not want to stop growth or see fall-off on growth curve; ideally see slight jump up with operation↗
▶Ep 1 · 27:49
clinicalStandard now is two IVs, no arterial line, no Foley catheter for endoscopic cases↗
▶Ep 1 · 28:16
opinionSome endoscopic patients could potentially go home same day, though speaker has not attempted this; many kept as 23-hour observations rather than formal admissions↗
▶Ep 1 · 28:16
quoteYou know, honestly, Mark, some of these patients truly could go home the same day. I've never been bold enough to, to do that.↗
▶Ep 1 · 30:11
clinicalWell under 10-20% of patients require imaging to make diagnosis; average sagittal synostosis case is so classic that most can diagnose without imaging↗
▶Ep 1 · 30:21
clinicalFor sagittal synostosis, may consider just X-ray instead of CT scan as diagnosis is clear-cut↗
▶Ep 1 · 30:30
clinicalUnilateral coronal can almost always be diagnosed on exam based on nasal deviation, height of eye, and ear position; rarely recommend scans↗
▶Ep 1 · 30:40
opinionWould never consider going surgically into lambdoid without CT scan; very difficult diagnosis to make↗
▶Ep 1 · 30:53
clinicalUltrasound literature is emerging showing ability to demonstrate open versus closed suture without radiation exposure↗
▶Ep 1 · 31:05
clinicalBlack bone MRI studies are potential viable alternative for showing suture status and brain detail without radiation↗
▶Ep 1 · 32:03
clinicalFor metopic synostosis, essentially no regression once desired shape is achieved; can stop helmet as soon as 3 months if correction obtained↗
▶Ep 1 · 32:27
clinicalFor sagittal synostosis, definite regression occurs; patients lose average of 0.02 cranial index between 1 and 2 years of age↗
▶Ep 1 · 32:57
clinicalAverage length of time in helmet for sagittal synostosis is 7 months from surgery↗
▶Ep 1 · 33:05
clinicalFor sagittal cases, push closer to one year in helmet unless cranial index exceeds 0.82↗
▶Ep 1 · 33:23
clinicalFor unilateral coronal, no regression but almost none are perfect at one year, so almost always go to one year of helmeting↗
▶Ep 1 · 33:32
opinionSome surgeons (Jimenez) now standardly do 18 months of helmet for sagittal, but loss between 1-2 years is so small that helmet value is very small in that period↗
▶Ep 1 · 33:57
clinicalFor coronal synostosis, also remove about 1-2 cm of bone, similar to sagittal; this is fairly standard among surgeons performing this operation↗
