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The fundamental principle of closed endoscopic strip craniectomy is to operate on infants with craniosynostosis as soon as possible. The best results are obtained when the newborn is about 12 weeks old or younger. However, successful skull reshaping can be achieved after surgery in infants with the use of STARband family helmets.
Endoscopic strip craniectomy aims to relieve a suture that has closed early and to allows the newborn to restore his/her deformed skull and face to a normal shape with the help of a rapidly growing brain. The intended head shape is achieved in the months following the operation, with the newborn's continuous use of a custom-made STARband helmet.
Surgical intervention to treat craniosynostosis has been practiced since 1890. There have been some procedures that have been developed and promoted as a treatment for this condition since then. Nowadays, there are two major techniques that are globally accepted: Cranial Vault Reconstruction (CVR) and Endoscopic- Assisted Strip Craniectomy.
With traditional open CVR surgery, a large incision is made, generally from one ear to another. This way, the bones of the infant become largely accessible. The surgeon removes the fused suture and bones. After remodeling the bones manually, the surgeon attaches the bone pieces to the skull with surgical screws and plates.
The traditional operation (Cranial Vault Remolding) typically lasts 3-7 hours and usually requires 3-5 days of hospital stay. After the surgery, widespread swelling, and some pain and discomfort occur.
Although the results of traditional surgery have improved in time, patients are still exposed to excessive swelling, pain, blood loss, blood transfusion, and more complications in addition to a longer hospital stay.
Treatment options for craniosynostosis have only been developed since the last century. During early procedures, also called strip craniectomy; however, the skull was opened wide and only the bone in the closed suture line was removed. This was similar to today's endoscopy-supported closed surgery. The most important differences between present procedures and previous ones are that the incision to the closed suture area is much smaller with endoscopy and a helmet treatment is required postoperatively. With the technique used formerly, opened sutures were closed and there was not sufficient recovery seen in most of the patients. That situation led to the development of larger-scale (CVR / open surgery) operations. With those practices led by Dr. Tessier, the cranial bones located in a larger area were removed and remodeled to a normal skull shape. However, there are some complications with these operations. The most important one is to perform large-scale surgery which is extremely harsh on the newborn. Another one is the concern of the gradual decline in growth pattern, which reveals itself in time and leads to regression up to a certain point. Moreover, re-closure of the bones in the skull remains a problem.
Dr. Jimenez and Dr. Barone, who developed the endoscopic closed surgery in the 90s, described what they were doing as minimally invasive endoscopic surgery. These surgeons added two technologies to improve the outcome of conventional strip craniectomy, which are endoscopy and postoperative orthosis treatment (helmet). Much smaller incisions are made and there is much less blood loss. In addition, damage to tissue is extremely limited. Moreover, the membrane which protects the skull and allows for the regeneration of bones (dura mater and the periosteal layer), remains generally intact. After the surgery, orthosis (helmet) treatment ensures that the skull grows in the desired direction. The brain and skull growth directed by STARband helmet treatment prevents the rapid re-closure of the suture, which used to occur in the past. The work of these two surgeons has paved the way for a new era in surgeries for craniosynostosis. Today, almost every pediatric hospital in the United States performs less invasive endoscopic-assisted strip craniectomy. The top five pediatric hospitals in the United States:
offer families the endoscopic technique.
In contrast to the endoscopic strip craniectomy technique, open CVR surgeries are usually performed between 6-12 months. Therefore, many pediatricians have the habit of monitoring babies with head shape deformities for a period of time and, after a while directing them to neurosurgeons on a date close to the months mentioned above. Families may seek the help of a neurosurgeon on their own due the infant’s worsening head shape. Thus, the medical community needs to refer patients with cranial deformities to neurosurgeons sooner, preferably right after birth, so that less invasive methods such as closed endoscopic strip craniectomy surgery may be performed. In fact, surgeons performing surgery for craniosynostosis with the endoscopic method, encourage the referral of babies with suspected diagnosis as soon as possible. Early diagnosis and referral allow families to have the chance to choose endoscopic technique surgery. The bottom line is, delaying the referral to a neurosurgeon is an issue which requires a change in the referral model as well as raising the awareness of pediatricians.
The family should know that when the endoscopic technique is performed, the skull structure of their babies will gradually reform to a normal skull shape with the STARband treatment program after surgery. Also, most of the cases done with the endoscopic technique exhibit better correction as compared to open surgery. Families should be patient during this period of slow correction. For families who are concerned about this, open CVR surgery would be an alternative. With open CVR surgery since the skull is opened wide, immediate correction of the skull shape is achieved. However, the recovery process can be long and difficult since it is a more aggressive technique. The advantages of endoscopic closed surgery are: It is physically well tolerated/bearable by infants, it leaves exceedingly small and essentially undetectable surgical scars, and there is usually little blood loss.
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In contrast to the reconstruction of the skull during surgery with the open technique, the endoscopic technique relies on the development of the brain and skull to achieve a normal skull shape. This is because the brain grows rapidly during the first 12 months of life. Therefore, endoscopic surgery should be performed in the early months, ideally before 3 months of age. When the babies reach their 6th month, the benefit of the endoscopic technique decreases, especially since the brain, which is the driving force of growth, grows more slowly.
In order to obtain the expected skull shape and ensure the success of the operation, STARband helmet treatment should be started right after minimally invasive endoscopic surgery. The ideal orthosis (helmet) should lead growth towards the deformed areas, which occurred due to early closing of the sutures. There should be space surrounding the deformed areas enabling the head to achieve symmetry and proportion. The helmet is custom-made to allow for growth in the direction of the deformation during helmet treatment. It should be noted that the helmet needs to be made specifically so that there will not be any restriction in the growth of the brain and skull. The advantage of the STARband helmet program is, it uses STARscanner 3D scans to modify the direction of skull growth into those desired areas over time. It is of utmost importance that the helmet be worn for 23 hours by the patient in order to achieve the desired outcome of the treatment. In addition, frequent follow ups should be conducted by a cranial specialist every 2-4 weeks in order to monitor and make necessary adjustments to the helmet. The average duration of helmet treatment is between 6-9 months.
When endoscopic surgery for craniosynostosis was first performed in early ‘90s, many surgeons were concerned about complications during surgery. These surgeons felt, for a variety of reasons, that open skull CVR surgery was the best way to address craniosynostosis. However, after more than 20 years of experience, it is now obvious that endoscopic surgery is much less risky as compared to CVR surgery. Overall, the endoscopic technique is known to be as safe as and even more reliable than open CVR surgery. Studies have shown that with the endoscopic technique, the operation time is much shorter (only up to 45 minutes), there is little blood loss, and blood transfusions are much less necessary. If the patient does not have any specific medical conditions, patients are discharged the next day after surgery without any intensive care.
A major concern in all surgeries in infants is the effect of anesthesia. These concerns stem from the duration of time spent under anesthesia and the young age of the patients. In a recent study, it was observed that for every 30 minutes spent under anesthesia, the cognitive development of children who had undergone open CVR surgery for a single closed suture decreased significantly. In terms of cognitive developmental outcomes, the endoscopic technique is more favorable since the operation takes only 30-45 minutes compared to 3-4 hours for CVR surgery.
Endoscopic strip craniectomy, to treat craniosynostosis, caused some concerns among surgeons when it was first introduced by Dr. Jimenez in early ‘90s. These concerns were valid because in the past, strip craniectomy operations were not successful enough. Therefore, aggressive open surgery was started. However, with advances in modern technology, the current endoscope assisted operation has quite a different philosophy than the previous strip craniectomy. First, the endoscopic craniectomy operation is performed in a way that is minimally invasive. In this new method, the normal brain and periphery of the bone membrane are protected. Second, given what past generations have learned, it is clearly not possible to obtain results only by opening the suture. Therefore, the STARband helmet treatment is an important aspect of the treatment after surgery in order to achieve the expected results. The endoscopic technique has come a long way since it was first introduced. Currently, there are many clinical experiences, data, published articles, and research on the endoscopic technique. It is widely accepted all over the world now, and most importantly, it is proven to be effective. Families also prefer endoscopic strip craniectomy as a treatment method as it provides a less stressful experience.
Mark. R. Proctor. Endoscopic craniosynostosis repair. Submitted Jun 25, 2014. Accepted for publication Jul 07, 2014. doi: 10.3978/j.issn.2224-4336.2014.07.03 View this article at: http://dx.doi.org/10.3978/j.issn.2224-4336.2014.07.03
Candelario et al. Endoscope-assisted strip craniectomy and postoperative helmet therapy for treatment of craniosynostosis Neurosurgical Focus Volume 31 (2011): Issue 2 (Aug 2011) DOI link: https://doi.org/10.3171/2011.6.FOCUS1198
David F. Jimenez M.D. and Constance M. Barone M.D. Endoscope-assisted strip craniectomy and postoperative helmet therapy for treatment of craniosynostosis J Neurosurg: Pediatrics / Volume 12 / September 2013J Neurosurg Pediatrics 12:207–219, 2013 DOI link: https://doi.org/10.3171/2013.4.PEDS11191
Adnan DAĞÇINAR What is the Place of Endoscopy in Craniosynostosis Surgery? Türk Nöroşir Derg 27(3):353-356, 2017. http://norosirurji.dergisi.org/pdf/pdf_TND_1306.pdf
