Examination of Necessary Duration of Helmet Therapy Post-Endoscopic Surgery for Infants with Sagittal Craniosynotosis 

Clinical Question

Background

Craniosynostosis is when one or more sutures of an infant’s skull are prematurely fused. Sagittal Craniosynostosis (SC) occurs when the sagittal suture that runs across the top of the skull is prematurely fused resulting in a narrow, elongated head shape. The premature fusion of the skull can result in abnormal growth patterns as the infant develops.¹ Untreated, it can cause increased intracranial pressure, inhibit brain growth, and cause an atypical cosmetic presentation of the skull.² As such, surgical treatment is typically used to separate the prematurely fused sutures. Infants who undergo endoscopic surgery to treat craniosynostosis typically are younger than 6 months old.³

Surgery is commonly followed by helmet therapy with a cranial remolding orthosis (CRO) to direct three-dimensional growth of the skull. A certified orthotist coordinates with the surgeon and pediatrician to achieve acceptable cranial presentation as bone growth and bone healing occurs. However, duration of CRO use varies and a consensus has yet to be reached as to the proper duration to ensure long-lasting anthropometric cranial proportions and minimal regression. The purpose of this CAT is to explore the duration necessary to provide infants with sagittal craniosynostosis acceptable anthropometric cranial proportions.

Search Strategy

Synthesis of Results

The four articles reviewed look at helmet therapy (HT) duration post-surgical intervention (see Evidence Table). Three articles included infants who underwent endoscopic strip craniectomy and one article included infants who underwent endoscopic assisted craniectomy. All the articles looked at infants who had sagittal craniosynostosis (SC). A total of 73 infants with SC were included in two retrospective studies, one retrospective review, and one computational modeling study. The computational study indicated greatest duration of HT examined (8 months) resulted in highest cephalic index (CI) of 86.2 which is indicative of successful HT since untreated SC is marked by a low CI.⁴ Both retrospective studies and the retrospective review indicated improvement of CI with HT; however, the study by Iyer, et al. included data from more time points with longer follow-up post-HT. The study found peak CI occurred at an average of 8.4 months of HT.⁵ No significant improvement in CI with extending HT beyond the peak CI was found.⁵

The study by Nguyen, et al. showed improvement of CI (71.3 → 75.6) after an average HT duration of 4.2 months.³ However, it only examined metrics pre- and post-HT and did not follow the participants to examine CI through full growth and development. The final article examined was a retrospective review that found peak CI of 81.3 after 5.2 months of HT.⁶ However, the review did not include follow-up post cessation of HT.