Pediatrician - Special Surgery Edition
October 9, 2015

In the past, children with prematurely fused skull sutures had just a single option available to them: an operation involving an ear-to-ear incision done when they’re 9 to 12 months old, the age when they’re more likely to withstand the procedure. Today, however, says pediatric neurosurgeon Edward Ahn, it’s possible using endoscopic techniques to perform the same procedure through a one-inch incision. The only real impediment to making sure children receive this significantly safer and less invasive option, says Ahn, is for prospective patients to be referred before they reach 3 months of age.

Developed in the early 2000s, the endoscopic version involves making a small incision where the skull bones are fused. By inserting an endoscope and tools, surgeons can excise the problematic bone section. Ahn and his colleagues recently introduced an ultrasonic bone cutter, which provides better protection against blood loss since many bleeds come from skull bones themselves. Minimizing blood loss—the riskiest part of the operation—is especially important because even a small amount of lost blood is proportionally large for these tiny patients.

Although the traditional operation usually necessitates blood transfusions for all patients, with the newer procedure only a fifth will require a transfusion. Additionally, patients who have the newer operation typically spend only a single night at the hospital, compared with up to a week for the traditional procedure.

On the day of discharge, patients who have the endoscopic surgery are fitted for a helmet, which they wear 23 hours a day for the next six to nine months, a treatment that molds the head into a natural shape as it grows. When children are finished with the helmet, Ahn says, they rarely need additional treatment. This period is pivotal to successful outcomes, he adds, and it’s why the endoscopic surgery is only available to patients no older than 3 months. After that, the head is less malleable, requiring patients to have the riskier open surgery.

Besides age, Ahn says, there are few factors that disqualify potential patients from the endoscopic technique. Although it’s been used most often to correct only fused sagittal sutures, he and other neurosurgeons are now using it for patients with more than one fused suture and even more complex craniofacial syndromes.

The endoscopic technique also offers cosmetic advantages, Ahn adds, making scars essentially invisible compared to the obvious marks left behind after a bilateral craniotomy. Often, parents bring their children back to visit, with their boys sporting short haircuts—something that would have been a rarity in the past.

“The biggest compliment to me,” says Ahn, “is when parents say their friends are amazed after they describe what their child went through as a baby, because they never would have known.