Mark Proctor
56 statements · 1 topic · summaries given as host listed separately
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Open surgery is a mechanical operation where bones are repositioned and fixed, but those bones don't grow normally over time; results at end of surgery aren't completely predictive of outcomes 5 or 10 years later.
clinical ·
Craniosynostosis
Some endoscopic craniosynostosis patients could truly go home the same day, though Proctor has never been bold enough to do so; most stay overnight (often as 23-hour observation rather than formal admission).
clinical ·
Craniosynostosis
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Mark's statements about Craniosynostosis 56 statements
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Endoscopic Treatment of Craniosynostosis: Pediatric Endoscopic Neurosurgery 2018
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Humans have very rapid brain growth in the first year of life, slowing considerably over the second year; past 2 years of age sutures play a very small role in skull or brain growth.
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Virchow's law defines that skull growth is normally perpendicular to the sutures; if bone is closed, growth occurs parallel to sutures due to compensatory overgrowth in other areas.
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Synostosis affects about 1 in every 2000 live births, with sagittal being by far the most common in about half of children.
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In sagittal synostosis, the back of the head is the narrowest part (whereas normally it is the widest), with wide and bossed frontal region.
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In unilateral coronal synostosis, there is orbital dystopia where the orbit on the affected side is higher and shallower, and the nose deviates toward the affected side.
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Lambdoid synostosis is very rare, representing about 1 to 2% of all synostosis cases; Boston Children's sees about 100 new synostosis patients per year and averages 1 lambdoid case annually.
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In lambdoid synostosis, the mastoid should be low (extended) on the affected side, which helps distinguish it from deformational changes.
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Strip craniectomy results were poor historically, with about one-third of patients having bones fuse together before significant correction, leading to adoption of larger cranial vault reconstructions.
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David Jimenez and Constance Barone in the mid-1990s pioneered endoscopic synostosis surgery with smaller incisions, less blood loss, and adjuvant helmet therapy.
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Open surgery is a mechanical operation where bones are repositioned and fixed, but those bones don't grow normally over time; results at end of surgery aren't completely predictive of outcomes 5 or 10 years later.
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Endoscopic surgery is a release procedure that relies on brain growth to move bones out over time or requires adjuncts like springs, distractors, or helmets to direct growth.
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Conceptually, endoscopic surgery turns synostosis into a deformational problem by opening bones to make them malleable, then reshaping with a helmet.
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Laparoscopic cholecystectomy was first reported in 1987 by a team in France and met significant early skepticism before becoming standard of care.
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Only surgeons involved with open cholecystectomy and management of its potential complications should perform laparoscopic cholecystectomy (quote from historical article applied to craniosynostosis context).
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you 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.
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CDC parameters of care for synostosis (2010–2012) consider endoscopic surgery a viable treatment option but stress the need for a very experienced team.
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For sagittal synostosis endoscopic surgery, a 0-degree endoscope is used; Proctor avoids using high-quality neurosurgical scopes to prevent damage in this relatively blunt procedure.
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Meticulous technique is necessary to keep blood transfusion rates down in endoscopic craniosynostosis surgery.
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For sagittal synostosis, two incisions are made (anterior and posterior), burr holes created and expanded with Kerrison rongeurs to about a 2 cm gap.
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Recent studies from Hopkins, DC, and Saint Louis show that narrow (2 cm) bone strips are just as effective as wide (6 cm) strips; most centers now use narrow strips with no barrel staves.
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Helmets allow real-time adjustment (e.g., if top of head is getting flat, can adjust for more rounding), whereas springs or distractors cannot be adjusted.
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Endoscopic treatment leads to sustained changes in cranial index over time, with results very similar to open operation from a cranial index perspective (compared by multiple groups).
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In unilateral coronal synostosis treated endoscopically, neo-suture formation can occur, making it appear as if the patient never had a fused suture.
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3D photogrammetry studies show facial asymmetry improved significantly more in the endoscopic group than in the frontal orbital advancement group, likely due to early release.
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First 100 consecutive endoscopic cases (all synostosis types): mean surgical time 48 minutes, estimated blood loss 23 mL, 8 transfusions, median hospital stay 1 day.
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Weight under 5 kg was a risk factor for transfusion; now waiting until over 5 kg for all patients, transfusion rates down to about 3%.
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Cost of endoscopic treatment is 40% of open operation; three studies (Boston, Saint Louis, Midwest US) show consistent results.
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Boston cost study included all hospital costs, home costs, and gas mileage for families traveling to orthotist appointments.
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In experienced centers, both open and endoscopic craniosynostosis surgery should be very safe procedures.
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Centers should have access to both minimally invasive and open techniques, and provide comprehensive care including surgery, neuropsych testing, and orthotist access.
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Endoscope exposure to dura during dissection is very brief (20–30 seconds on average for sagittal synostosis); light source typically used at 70–75% (not 100%).
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Endoscope appears to generate less heat than the drill; no injuries from scope heat have been observed.
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Ideal surgical age for endoscopic craniosynostosis is about 10 to 12 weeks (3 months), when brain growth is most rapid.
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Oldest patient treated endoscopically was 7 months of age (mild sagittal synostosis); result was reasonable but correction is less robust at older ages due to reduced brain growth.
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Would not offer endoscopic surgery past 6 months for severe deformity (e.g., cranial index 0.62); may extend to 5–6 months for milder cases (cranial index 0.7 or 0.72).
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Historical strip craniectomy had 20–30% rate of suture closing back before significant correction; current approach differs by using adjuvant therapy (helmets, springs, distractors) to direct growth.
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In helmeted sagittal synostosis, the goal is 2:1 growth ratio (width to length) during helmet course; starting cranial index 0.75 reaches about 0.8 after 6 months.
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Head circumference must be tracked closely during helmet therapy; do not want to see fall-off on growth curve; ideally should see a jump up with the operation.
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Early endoscopic cases used two large IVs and an arterial line (treated like open cases); current standard is two IVs only, no A-line, no Foley catheter.
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Some endoscopic craniosynostosis patients could truly go home the same day, though Proctor has never been bold enough to do so; most stay overnight (often as 23-hour observation rather than formal admission).
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Average sagittal synostosis case is so classic that most surgeons can diagnose without imaging; imaging obtained if any question exists to avoid operating on open suture or missing a fused suture.
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the second thing I'd rather not have happen is I told the family that everything was fine and the suture ended up being fused
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Well under 10–20% of craniosynostosis patients require imaging to make the diagnosis.
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For sagittal synostosis, plain X-ray may suffice instead of CT scan; unilateral coronal can almost always be diagnosed on exam (nasal deviation, eye height, ear position).
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Would never consider operating on lambdoid synostosis without a CT scan; it is a very difficult diagnosis to make clinically.
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Ultrasound is increasingly used to show open versus closed sutures without radiation exposure; literature on this is growing.
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MRI black-bone studies are a potential viable technique to show suture status and brain detail better than other modalities, though not yet adopted at Boston Children's.
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For metopic synostosis, helmet can be stopped as soon as desired shape is achieved (as short as 3 months); there is essentially no regression.
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For sagittal synostosis, there is definite regression; patients lose on average 0.02 cranial index between 1 and 2 years of age.
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Average helmet duration for sagittal synostosis is 7 months from surgery; Proctor pushes closer to 1 year unless cranial index exceeds 0.82.
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For unilateral coronal, there is no regression, but almost none are perfect at 1 year, so helmet is almost always continued to 1 year.
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Jimenez now standardly helmets sagittal synostosis patients for 18 months; Proctor thinks loss between 1 and 2 years is so small that helmet value after 1 year is very small.
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For coronal synostosis, bone removal is also about 1 to 2 centimeters, similar to sagittal.
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Summaries Mark gave as host · 1 summary
Recaps of other experts' statements, not Mark's own clinical position.
Summaries Mark gave as host · Craniosynostosis 1 summary
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Endoscopic Treatment of Craniosynostosis: Pediatric Endoscopic Neurosurgery 2018
Host summary
Mark Proctor summarizing a resource: only surgeons involved with open cholecystectomy and management of its potential complications should before this procedure
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