We read with interest the article by Hashim et al. in which the neuropsychological outcomes of patients treated for sagittal synostosis using strip craniectomy or whole vault cranioplasty were compared.1 The authors report better overall neurocognitive parameters in patients following the more extensive remodeling procedure and found that this difference was consistent in all age groups. We agree with the authors that early release of craniosynostosis is preferred for most children with this condition, but the less invasive technique highlighted in this article is significantly more invasive than the simple suturectomy technique advocated by many authors.2
Their “strip craniectomy” technique includes biparietal wedge-shaped osteotomies, manual outfracturing of the parietal bones, and placement of a “cinching suture,” consistent with an endoscopically assisted pi procedure. The cinching suture applies posterior cerebral compression to reduce sagittal length and increase parietal width in infants with sagittal synostosis, and contravenes one of the principal goals of all craniosynostosis procedures—to increase intracranial volume. If the authors’ purpose in designing this study was to condemn the use of this particular endoscopic technique and its parent, the pi procedure, we are in full agreement. However, this should not be confused with a true strip craniectomy procedure, such as the one long advocated by our group, in which only the restrictive suture is removed to allow cerebral expansion. Indeed, our studies have confirmed a sustained jump in head circumference percentile of 15 percent following this limited release.2
We are also concerned that the more invasive endoscopic technique described in this report obligatorily increases operative duration and exposure to general anesthesia, and may have an adverse effect on adjacent patent sutures and subsequent cranial growth. There is a growing body of literature that suggests prolonged exposure to certain inhalational anesthetic agents can induce neuroapoptosis and developmental delay in young children.3 The authors report better cognitive outcomes with earlier release (i.e., the benefit of early release trumps any detrimental impact of anesthesia on neurocognitive development), but the absence of a control group makes it impossible to isolate the possible anesthetic effects for either procedure. In addition, more extensive operations may induce premature fusion of previously uninvolved sutures and affect subsequent cranial growth.4 This has been reported to occur in most patients following pi procedures,4 but is very uncommon following simple suturectomy.5
We applaud the authors for a well-conducted and very meaningful study. Unfortunately, in a world that prefers its information in Twitter-like sound bites, it is unlikely that anyone will take the time to contemplate the technical and physiologic distinction between the endoscopically assisted pi procedure admonished in this report, and the simple suturectomy technique that we have reported on with such great success.2 Before categorically abandoning these techniques, we encourage the authors to collaborate with our group and repeat this study using a different comparison group: a true simple suturectomy with postoperative helmet therapy. Based on our experience with over 300 patients, we are optimistic that the outcome will be considerably different.
The authors have no financial interest to declare in relation to the content of this communication.
Benjamin C. Wood, M.D.
Division of Plastic Surgery
Children’s National Medical Center
Mark R. Proctor, M.D.
Department of Neurological Surgery
Children’s Hospital Boston
Gary F. Rogers, M.D., J.D., M.B.A.
Division of Plastic Surgery
Children’s National Medical Center
1. Hashim PW, Patel A, Yang JF, et al. The effects of whole-vault cranioplasty versus strip craniectomy on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg. 2014;134:491–501
2. Ridgway EB, Berry-Candelario J, Grondin RT, et al. The management of sagittal synostosis using endoscopic suturectomy and postoperative helmet therapy. J Neurosurg Pediatr. 2011;7:620–626
3. Sinner B, Becke K, Engelhard K.. General anaesthetics and the developing brain: An overview. Anaesthesia. 2014;69:1009–1022
4. Kuang AA, Jenq T, Didier R, et al. Benign radiographic coronal synostosis after sagittal synostosis repair. J Craniofac Surg. 2013;24:937–940
5. Sauerhammer TM, Seruya M, Ropper AE, et al. Craniectomy gap patency and neosuture formation following endoscopic suturectomy for unilateral coronal craniosynostosis. Plast Reconstr Surg. 2014;134:81e–91e
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