This series of consecutive patients undergoing surgical treatment for isolated sagittal synostosis demonstrates a modification of the Melbourne method for total calvarial vault remodeling that addresses the phenotypic characteristics of the deformity. In our series, all patients experienced both subjective and objective improvement in head shape and cranial index over the course of our clinical follow-up. Through modification and simplification of previously published methods of vault remodeling, this technique attempts to minimize intraoperative blood loss, operative time, and length of hospital stay, while providing comparable clinical benefits.
The ideal technique for correction of severe scaphocephaly addresses all phenotypic aspects of the deformity. The Melbourne method of calvarial vault remodeling improved upon earlier technical approaches by addressing all the cranial dimensions. Its authors report excellent outcomes, with improved CI, decreased head circumference, and increased intracranial volume.17 Occipital elevation, barrel staving frontal and occipital regions, and switching parietal bone flaps to expand biparietal distance achieves normalization of head shape, does not sacrifice intracranial volume, and anticipates fourth dimensional volume changes.15 , 17 However, the operation is largely reliant on heterotopic bony relationships, especially in the movement and repositioning of the parietal plates. The interchange of parietal bone grafts to increase biparietal width and the anterior relocation of the occipital graft to decrease head length inevitably lead to longer operative times, larger volume intraoperative blood loss, and subsequent transfusion requirements.
The modification described in our case series maintains the original goals of the Melbourne method, while leveraging homeotopic relationships between most of the bone grafts. By utilizing a coronal strip of bone at the maximal biparietal width to raise and expand the deformed occiput, the current modification restricts larger bony movements to the occipital region alone. Parietal plate barrel staving in either the coronal or sagittal plane allows us to achieve comparable width expansion to the original Melbourne method without the need to interchange large parietal bone grafts. Accordingly, our current modifications permit shorter operative times and lower transfusion requirements compared with the original descriptions of the Melbourne method. The average operative time for our modification at 181 minutes compares favorably with the original reports from the Melbourne method of 285 minutes.15
The mitigation of intraoperative blood loss holds particular importance for patients undergoing operations for craniosynostosis, as some studies estimate blood loss to be 40% of total blood volume in total vault reconstruction.21 , 22 High volume blood loss and allogenic blood transfusions are both independently associated with adverse events including severe hypotension, metabolic acidosis, air embolism, cardiac arrest, death, postoperative ventilation, coagulopathies, transfusion-related immunologic reactions, and infections.23–31 Furthermore, intraoperative transfusion greater than 60 mL/kg of packed erythrocytes in craniosynostosis cases has been demonstrated to be an independent predictor for postoperative cardiorespiratory and hematological events requiring intensive care unit admission.29 Additional ongoing blood loss may persist from bone edges for 2–3 days postoperatively. Decreasing the number of cut bone edges and large graft movement allows our modification of the Melbourne method to address concerns about sequelae from large volume transfusion requirements by minimizing blood loss in the perioperative period. The intraoperative transfusion requirement in our study was 232 mL (23 mL/kg; range, 18–38 mL/kg), and no transfusion-related morbidity was noted in this series. By comparison, the average blood transfusion requirement for patients in the original Melbourne method was 460 mL.15
Objective assessment of vault remodeling techniques has commonly focused on serial measurements of the CI to quantify the severity of sagittal synostosis and its subsequent correction. Despite other more advanced modalities to evaluate head shape, CI remains the most easily measured and universally reported value as a surgical outcome.32 Children with scaphocephaly have an average CI of 60–67%, whereas the nonsynostotic patient population has CIs that range from 76% to 78%.33 , 34 In our cohort, the mean CI increased from 67.3% to 74.1%, with an overall mean increase of 10.3%. These changes are concordant with other published reports of CI changes following vault remodeling.11 The original Melbourne method provides a mean CI increase of 11.1% postoperatively. Recently, some authors have begun to challenge the validity of CI measures in patients with sagittal synostosis, suggesting the anterocaudal displacement of the euryon in this patient population affects CI measurements.35 , 36 Although imperfect, we used CI as an outcome measure in our series for its ease of calculation and its ability to provide meaningful comparison to published reports following different methods of vault remodeling.
Our patient series is small, with relatively short follow-up, but the results are promising. Although these early data suggest CI improvement, some studies suggest that vault remodeling may not provide long-term improvement in head shape.37 , 38 Furthermore, our study population is slightly older than some other reported series, with an average age of 17 months. An older age at operation may affect our long-term results compared with those of a younger population with perhaps a greater capacity for bony remodeling. Although CI is the most accessible outcome measure following vault remodeling, its use in our study may not accurately reflect postoperative morphologic changes. Others have evaluated 3-dimensional computed tomography data in evaluating outcomes after treatment for craniosynostosis,39 , 40 and future long-term assessment with CT volumetric analysis combined with neurocognitive evaluation may provide more detailed and representative information on the 3- and 4-dimensional effects of this novel technique.
A modification of the Melbourne method for total calvarial vault reconstruction attempts to address each of the phenotypic aspects of severe scaphocephaly associated with isolated sagittal synostosis and maintains a homeotopic relationship across the calvaria. By focusing on a simpler geometric design and minimizing large bone movements, this procedure is associated with shorter operative times, lower blood loss, and lower transfusion requirements. Long-term follow-up will elucidate the stability of morphologic changes in head shape associated with this operation.
The authors thank Elizabeth C. Meara for her original illustrations of their modified methods of calvarial vault remodeling.
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