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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). — Mark Proctor, Endoscopic Treatment of Craniosynostosis: Pediatric Endoscopic Neurosurgery 2018 · 23:34
Endoscopic Treatment of Craniosynostosis: Pediatric Endoscopic Neurosurgery 2018
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As a part of the Pediatric Endoscopic Neurosurgery 2018 Course, Dr. Mark Proctor discusses endoscopic treatment of craniosynostosis. He reviews types of craniosynostosis, compares open versus endoscopic surgery, and demonstrates surgical te
video34:23 · Sep 2018
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Craniosynostosis affects approximately 1 in 2000–2500 live births, with sagittal representing roughly half of cases [e381-c3, e13573-c1]. Virchow's law remains foundational: skull growth occurs perpendicular to patent sutures, with compensatory parallel growth when sutures fuse prematurely . Brain growth is most rapid in the first year—doubling skull volume—then slows considerably; after age 2, sutures contribute minimally to cranial expansion [e381-c1, e13573-c42]. Surgical timing exploits this growth momentum: the 6-month mark captures substantial first-year growth potential, making 6–12 months the optimal window for open vault remodeling [e13573-c44, e13573-c51]. Endoscopic suturectomy with adjunctive helmet therapy (ideal age ~3 months) achieves cranial index outcomes comparable to open surgery, with 40% cost reduction, shorter hospital stays (median 1 day), and mean blood loss of 23 mL in experienced hands [e381-c21, e381-c25, e381-c27]. Narrow (2 cm) strip craniectomies are now standard, as effective as wide strips [e381-c17, e381-c18]. Elevated intracranial pressure occurs in only 5–20% of single-suture cases and does not manifest before age 1 [e13573-c36, e13573-c38]. Subtle developmental delays affect 30–50% of patients but do not correlate with surgical technique or timing [e13573-c40, e13573-c41]. Ultrasound is preferred for diagnosis under 6 months; CT remains the gold standard but is often unnecessary when clinical findings are classic [e13573-c25, e13573-c29].
- Endoscopic suturectomy with helmet achieves cranial index outcomes equivalent to open surgery at 40% cost, with shorter stays and lower blood loss in experienced centers.
- Narrow (2 cm) strip craniectomies are as effective as wide strips; helmet therapy allows real-time adjustment unlike springs or distractors.
Expert statements from the recordings in this collection.
Endoscopic Treatment of Craniosynostosis: Pediatric Endoscopic Neurosurgery 2018
Human skull is made up of 5 major bones separated by growth plates called sutures.
Mark Proctor1:25
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.
Mark Proctor1:56
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.
Mark Proctor2:27
Synostosis affects about 1 in every 2000 live births, with sagittal being by far the most common in about half of children.
Mark Proctor2:54
In sagittal synostosis, the back of the head is the narrowest part (whereas normally it is the widest), with wide and bossed frontal region.
Mark Proctor3:56
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.
Mark Proctor4:27
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.
Mark Proctor5:20
In lambdoid synostosis, the mastoid should be low (extended) on the affected side, which helps distinguish it from deformational changes.
Mark Proctor5:37
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.
Mark Proctor6:14
David Jimenez and Constance Barone in the mid-1990s pioneered endoscopic synostosis surgery with smaller incisions, less blood loss, and adjuvant helmet therapy.
Mark Proctor6:46
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.
Mark Proctor7:51
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.
Mark Proctor8:25
Conceptually, endoscopic surgery turns synostosis into a deformational problem by opening bones to make them malleable, then reshaping with a helmet.
Mark Proctor8:53
Laparoscopic cholecystectomy was first reported in 1987 by a team in France and met significant early skepticism before becoming standard of care.
Mark Proctor9:22
Only surgeons involved with open cholecystectomy and management of its potential complications should perform laparoscopic cholecystectomy (quote from historical article applied to craniosynostosis context).
CDC parameters of care for synostosis (2010–2012) consider endoscopic surgery a viable treatment option but stress the need for a very experienced team.
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.
Mark Proctor12:46
Meticulous technique is necessary to keep blood transfusion rates down in endoscopic craniosynostosis surgery.
Mark Proctor13:14
For sagittal synostosis, two incisions are made (anterior and posterior), burr holes created and expanded with Kerrison rongeurs to about a 2 cm gap.
Mark Proctor13:22
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.
Mark Proctor15:44
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.
Mark Proctor16:51
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).
Mark Proctor17:14
In unilateral coronal synostosis treated endoscopically, neo-suture formation can occur, making it appear as if the patient never had a fused suture.
Mark Proctor17:51
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.
Mark Proctor18:20
Astigmatism improved much better with endoscopic surgery compared to open surgery.
Mark Proctor18:39
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.
Mark Proctor18:55
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%.
Mark Proctor19:08
Cost of endoscopic treatment is 40% of open operation; three studies (Boston, Saint Louis, Midwest US) show consistent results.
Mark Proctor19:25
Boston cost study included all hospital costs, home costs, and gas mileage for families traveling to orthotist appointments.
Mark Proctor19:43
In experienced centers, both open and endoscopic craniosynostosis surgery should be very safe procedures.