Endoscopically Assisted Correctionof Sagittal CraniosynostosisLESLEY BROWN, RN; MARK R. PROCTOR, MD

www.aorn.org/CE

3.4

ABSTRACT

Craniosynostosis is premature fusion of one or more of the cranial sutures of an infant’sskull. Several sutures may be fused, alone or in combination. The endoscopically assistedapproach to correcting craniosynostosis is an alternative to more traditional techniques,such as open-strip craniectomy and the Pi procedure for infants younger than fourmonths of age and the cranial vault remodeling procedure for older children. Theendoscopic procedure is less invasive and decreases the time patients spend underanesthesia, the need for transfusions, and lengths of hospital stay. The endoscopic approachrelies on early diagnosis and surgery because the bones of very young infants are thin andpliable, which makes it easier to cut and remove the fused suture via a minimally invasiveapproach. After surgery, a cranial remolding helmet is used to direct skull growth. AORN J93 (May 2011) 566-579. © AORN, Inc, 2011. doi: 10.1016/j.aorn.2010.11.035

Key words: craniosynostosis, cranial sutures, open-strip craniectomy, Piprocedure, cranial vault remodeling procedure, endoscopically assisted stripcraniectomy

The newborn skull is composed of five mainbones, two frontal, one occipital, and twoparietal. Sutures (ie, flexible bands of con-

nective tissue) lie between these bones. The sutures1

allow an infant’s head to mold during the birthingprocess and are also growth plates that accommo-date the rapid brain growth that occurs in the firstyear of life. The infant’s skull has one metopic su-

ture, one sagittal suture, two coronal sutures, andtwo lambdoid sutures (Figure 1). The metopic sutureshould close when an infant is between three andnine months of age. The lambdoid, sagittal, and cor-onal sutures should close when an adult is between22 and 39 years of age.

During the first year of life, an infant’s head in-creases in circumference by approximately 9 cm inthe first six months and another 3 cm during thenext six months.2 Skull development is reliant onrapid brain growth, which causes the bones tospread apart at the cranial sutures. The normal skull-growth pattern occurs in a direction perpendicular tothe open sutures of the skull.

When a suture prematurely fuses, which resultsin growth arrest, the brain can no longer push thebones apart perpendicular to the suture. Rudolf

indicates that continuing education contacthours are available for this activity. Earn the con-tact hours by reading this article, reviewing thepurpose/goal and objectives, and completing theonline Examination and Learner Evaluation athttp://www.aorn.org/CE. The contact hours forthis article expire May 31, 2014.

doi: 10.1016/j.aorn.2010.11.035

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Ludwig Karl Virchow, a German physician in thelate 1800s, defined this phenomenon and statedthat “premature closure of [cranial] sutures pre-vent[s] growth perpendicular to the suture and[accompanies] compensatory growth at others.”3

This growth pattern leads to an abnormallyshaped skull. Infants with abnormal skull devel-opment secondary to craniosynostosis (ie, prema-ture ossification [fusion] of the skull and closureof cranial sutures) should be referred to a neuro-surgeon or craniofacial surgeon for diagnosis andtreatment. It is not uncommon for a parent, familymember, or pediatrician to notice that the infant’shead has an abnormal shape, and this leads to theeventual diagnosis.

The reason craniosynostosis occurs is unclearand possibly multifactorial, although geneticsseems to play a major role in this condition aswell as many syndromic craniosynostosis condi-tions (eg, Crouzon syndrome, Pfeiffer syn-drome, Apert syndrome).4,5 There may be afamilial pattern in craniosynostosis that is not aresult of a recognized syndrome. In 2007, Kohand Gries4 noted that 2% to 6% of infants withsagittal synostosis have family members withthe condition. Komotar et al5 noted that 70%to 90% of sagittal craniosynostosis occurs inmale infants.

The most common premature fusion is that ofthe sagittal suture, which results in a head shapeknown as scaphocephaly. In scaphocephaly, the

midline sagittal suture, which separates the twoparietal bones that meet at the top of the head,fuses. The parietal bones cannot be pushed apartby brain growth, therefore, lateral skull growth isrestricted, and an overgrowth occurs in an anterior-posterior direction. This results in a long, narrow-shaped head with frontal and occipital “bossing”or bulging and a palpable ridge along the infant’ssagittal suture (Figure 2).2 Typically, scaphoceph-aly is an isolated condition and not associatedwith a syndrome or a known genetic condition.6

For patients with sagittal craniosynostosis, theclinician makes a diagnosis based primarily onskull measurements and physical examination andby obtaining a family history. Computed tomogra-phies or radiographs are generally not necessarybut may be used to confirm the diagnosis. Basedon this information, the clinician can make a de-finitive diagnosis and counsel family membersabout treatment options.

COMPLICATIONS OFUNTREATED CRANIOSYNOSTOSISUntreated craniosynostosis may cause increasedintracranial pressure (ICP), delayed or bluntedcognitive and psychomotor development, andproblems with psychosocial development. In2006, Komotar et al5 reported that 20% of pa-tients with nonsyndromal, single-suture

Figure 1. Normal skull of the newborn.

Figure 2. Long narrowly shaped skull of an infantwith scaphocephaly.

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craniosynostosis and 60% of patients with syndro-mal craniosynostosis experience increased ICP,although the effects this might have on an infantare not completely understood. Clinical signs ofICP (eg, papilledema, irritability, vomiting, fonta-nelle bulging) are often not evident in infantswith craniosynostosis as a result of physiologicaladaptation.5 Numerous studies have examinedwhether nonsyndromal, single-suture craniosynos-tosis has an effect on cognitive and psychomotordevelopment.4 Study results are inconclusive, andno true randomized studies have been performedto evaluate the effects of surgery on the outcomeof cognitive development.4 In addition to con-cerns about the cognitive and psychomotor effectsof craniosynostosis, other concerns relate to thedevelopment of an abnormally shaped head,which could lead to psychosocial issues, poorself-esteem, and social development problems.

SURGICAL TREATMENT OPTIONSThe open-strip craniectomy (ie, surgical removal ofthe fused suture) was first performed in 1892 byAmerican surgeon L. C. Lane.3 Initially, this proce-dure was performed as life-saving surgery to relieveICP; however, later surgeons began to perform thisprocedure for a combination of more subtle braingrowth and cosmetic reasons.3 The open-strip crani-ectomy procedure requires an anesthetic time of twoto four hours and a large incision with a significantpossibility that the patient will need blood products.Most importantly, the results often are not optimalbecause suture refusion occurs before a significantshape change has taken place.

In 1978, John Jane, MD, and John Pershing,MD, developed the Pi procedure, which results inan immediate correction of the skull deformity(Figure 3).3 Unlike the open-strip craniectomyprocedure in which the fused suture is removed,during the Pi procedure, the surgeon makes sev-eral cranial bone cuts and removes and reposi-tions the bone, and the resulting gap is allowed toclose naturally. The results of this procedure aretypically better than those of the strip craniectomy,

but the procedure still requires opening the cranium,which often results in blood loss significant enoughto require a transfusion and hospital stays of two tofour days.

Cranial vault remodeling is a much more com-plex procedure that involves making a large inci-sion, removing and replacing the cranial bones, andimplanting plates. The procedure results in greaterblood loss that often requires blood transfusionand much longer anesthetic time and hospitaliza-tion. It generally is reserved for children olderthan eight months whose brains have significantlymatured in size.

ENDOSCOPICALLY ASSISTEDSTRIP CRANIECTOMYRecent child care recommendations have af-fected the development of infant skull defor-mities. Although the relationship between

Figure 3. Skull of an infant before (A) and immediatelyafter (B) bone repositioning during a Pi procedure.

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positioning and sudden infant death syndromewas suggested as early as the 1960s, it was notuntil decades later that the American Academyof Pediatrics made an official statement regard-ing sleep position for infants. The Back-to-Sleep program was formally adopted by theAmerican Academy of Pediatrics in 1992; todecrease the incidence of sudden infant deathsyndrome, the program recommends that infantssleep on their backs or sides.7 As a result,many children have developed sleep-related de-formational plagiocephaly (ie, an abnormallyshaped head caused by external forces appliedto the skull).8,9 This increased incidence of cra-nial flattening led to widespread use of helmetsto correct the condition, which gave clinicians ex-pertise in the use of cranial remolding helmets.8,9 Atthe same time, endoscopy has become more widelyused in many surgical specialties. The combinationof these two technologies has led to the develop-ment of the endoscopically assisted stripcraniectomy.

Endoscopically assisted strip craniectomies forcorrection of craniosynostosis have been performedat Children’s Hospital Boston (CHB), Massachu-setts, since 2004. This procedure is less invasivethan traditional surgeries, which decreases the timespent under anesthesia, the need for transfusions,and the lengths of hospital stay.10 This method oftreatment relies on early surgery because the correc-tion requires rapid brain growth to help recontourthe cranial bones. The optimal age for an infant toundergo this procedure is younger than threemonths. The bones of infants in this age group arevery thin and pliable, which makes it easier to cutand remove the fused suture. In addition, the rapidhead growth that occurs during the first year of lifeallows the orthosis (ie, the custom-made externalhelmet) to assist in molding skull growth in the de-sired direction. The infant may need to wear thehelmet from three to nine months after surgery, de-pending on the severity of his or her original cranio-synostosis. Overall, the results have been excellent,

and this procedure has become a valuable alternativeto traditional treatment options.

PREOPERATIVE CAREThe preoperative nurse reviews the preoperativelaboratory work and confirms that blood productsare available. The parents are given the opportunityto donate blood for directed donation to their child,provided their blood types are compatible. Bloodbank personnel place a unit of packed red bloodcells and a bottle of 25% albumin into a cooler anddeliver the cooler to the OR. The need to transfusethese patients is rare, but when a transfusion isneeded, it is imperative to have blood products im-mediately available.

On the day of surgery, the circulating nurse visitsthe patient and his or her family members in thepreoperative waiting area. The nurse identifies thepatient with two identifiers (eg, name, date of birth,medical record number), which the parent or legalguardian verifies. The nurse reviews the patient’smedical record and allows the family members timeto ask questions. After assessing the patient, the cir-culating nurse develops a nursing care plan specificto this patient (Table 1). The surgeon greets the pa-tient and family members, and marks the location ofthe surgical site with his or her initials. The anesthe-sia professional also speaks with the family at thistime, questioning the parents about the infant’s med-ical and surgical history, discussing the planned an-esthesia care, and verifying NPO status. Accordingto the NPO guidelines at CHB, infants in this agegroup are allowed

! solid food eight hours before surgery,! formula six hours before surgery or breast

milk four hours before surgery, and! clear liquids two hours before surgery.

The perioperative period is a very difficult timefor parents of infants younger than three monthsundergoing this procedure. Many parents have neverbeen away from their child. At CHB, the parents donot accompany the infant into the OR. Perioperativeteam members (ie, preoperative nurse, circulatingnurse, anesthesia professional, surgeon) attempt to

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TABLE 1. Nursing Care Plan for Infants Undergoing Endoscopically Assisted Correctionof Craniosynostosis

Diagnosis Nursing interventionInterim outcome

criteriaOutcomestatement

Risk for fluidvolume deficit

! Identifies factors associated with an increasedrisk for hemorrhage or fluid and electrolyteimbalance.

! Monitors physiological parameters (eg, decreasedblood pressure, increased heart rate).

! Implements hemostasis techniques.! Collaborates in fluid and electrolyte management

by! monitoring blood loss,! ensuring that blood products are present in the

OR, and! administering fluid and electrolyte and blood

product therapy as prescribed.! Evaluates response to administration of

fluids and electrolytes and blood producttherapy.

! The patient’s bloodpressure and pulseare within theexpected rangeand remain stablewith positionchange at the timeof transfer to thepostanesthesiacare unit (PACU)and dischargefrom the PACU.

! The patient’surinary output iswithin the expectedrange at dischargefrom the OR,procedure room, orPACU.

! The patient’s fluidvolume status andhematocrit arewithin acceptableparameters.

! The patient’s fluid,electrolyte, andacid-base balancesare maintained ator improved frombaseline levels.

Risk forperioperativepositioninginjury

! Identifies baseline tissue perfusion.! Identifies physical alterations that require additional

precautions for procedure-specific positioning byanticipating positioning equipment needed for thespecific operative procedure.

! Positions the patient by! using equipment within safe parameters,! coordinating patient positioning with team

members, and! monitoring the patient’s body alignment.

! Implements protective measures to prevent skin/tissue injury related to mechanical sources by

! protecting bony prominences and! protecting all body areas at risk for injury when

the patient is positioned in the prone positionon a headrest.

! Applies safety devices.! Evaluates tissue perfusion by

! assessing for signs and symptoms of skininjury related to positioning and

! evaluating postoperative neurologic status.

! The patient’spressure pointsdemonstratehyperemia for lessthan 30 minutes.

! The patient hasfull return ofmovement of theextremities at thetime of dischargefrom the OR orprocedure room.

! The patient’speripheral tissueperfusion isconsistent withpreoperative statusat discharge fromthe OR orprocedure room.

! The patient is freefrom signs andsymptoms ofinjury related topositioning.

! The patient hasskin perfusionconsistent with orimproved frombaseline levelsestablished beforesurgery.

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TABLE 1. (continued) Nursing Care Plan for Infants Undergoing Endoscopically AssistedCorrection of Craniosynostosis

Diagnosis Nursing interventionInterim outcome

criteriaOutcomestatement

Risk forimbalancedbodytemperature

! Assesses risk for inadvertent hypothermia.! Implements thermoregulation measures by

! increasing room temperature,! minimizing skin exposure,! selecting temperature-regulating devices

based on patient need, and! administering warmed fluids and solutions.

! Monitors body temperature.! Evaluates response to thermoregulation measures.

! The patient’stemperature is higherthan 36° C (98.6° F) atthe time of dischargefrom the operating orprocedure room.

! The patient is ator returning tonormothermia atthe conclusion ofthe immediatepostoperativeperiod.

Risk for infection ! Assesses susceptibility to infection.! Classifies the surgical wound.! Implements aseptic technique.! Performs skin preparation.! Monitors for signs and symptoms of infection.! Monitors the sterile field and maintains continuous

surveillance.! Protects from cross-contamination.! Minimizes the length of the surgical procedure by

planning care.! Initiates traffic control.! Administers prescribed prophylactic treatments.! Administers care to the wound site.! Evaluates factors associated with increased risk

for postoperative infection at the completion of theprocedure.

! The patient has a clean,primarily closed surgicalwound covered with adry, sterile dressing atdischarge from the OR.

! The patient is freefrom signs andsymptoms ofinfection.

Compromisedfamily coping

! Identifies psychosocial status.! Assesses coping mechanisms.! Identifies barriers to communication.! Determines knowledge level.! Identifies designated support person’s educational

needs.! Assesses readiness to learn.! Assesses coping mechanisms.! Includes designated support person in

perioperative teaching.! Elicits perceptions of surgery.! Explains the expected sequence of events.! Implements measures to provide psychological

support.! Provides status reports to the designated support

person.! Evaluates psychosocial response to the plan of care.! Evaluates response to instructions.

! The designated supportperson verbalizes thesequence of events toexpect before andimmediately aftersurgery.

! The designated supportperson states realisticexpectations regardingrecovery from theprocedure.

! The designated supportperson identifies signsand symptoms toreport to the surgeon orhealth care provider.

! The designated supportperson describes theprescribed postoperativeregimen accurately.

! The designatedsupport persondemonstratesknowledge of theexpectedpsychosocialresponses to theprocedure.

! The designatedsupport persondemonstratesknowledge of theexpected responsesto the operative orinvasive procedure.

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reassure and comfort the parents as much as possi-ble and answer all of their questions. During sur-gery, the circulating nurse communicates with theliaison nurse who continually updates the familymembers during the procedure.

INTRAOPERATIVE CAREThere are many considerations in the managementof an infant undergoing surgery. Most impor-tantly, OR personnel must work as a team. Thesurgeons, anesthesia professional, nurses, andscrub personnel all have important roles in pro-viding safe, expert care and in ensuring the bestpossible outcome for the patient. The periopera-tive team must take a number of considerationsinto account when caring for infants this youngduring surgery, including managing the patient’sairway, managing fluid and blood loss, monitoringfor venous air embolus, positioning safely, andmaintaining body temperature.

Airway and Fluid ManagementThe anesthesia professional administers an inhala-tion anesthetic by mask for induction. After thepatient is anesthetized, an anesthesia professionalinserts an IV line. It is important to have ade-quate and secure venous access, which may beneeded for rapid fluid administration to managevolume loss or for blood product administrationto replace surgical blood loss, as well as for ad-ministration of standard intraoperative anestheticmedications. The anesthesia professional adminis-ters IV antibiotics within 30 minutes of the sur-geon making the initial incision. The surgeon pre-scribes two additional doses of antibiotics to beadministered after surgery. Initially, anesthesiaprofessionals at CHB prophylactically placed arte-rial lines in most patients for the unlikely eventthat heavy bleeding would be encountered. Surgi-cal results and patient outcomes at CHB havebeen very positive, however, so the surgeons andanesthesia professionals decided that routine arte-rial line placement is unnecessary.

After inserting an endotracheal (ET) tube, theanesthesia professional carefully secures the tubeto the patient’s face because the prone positionand the position of the OR bed (ie, turned 90 de-grees away from the anesthesia professional) pre-vent easy access to the ET tube during the sur-gery.11 Inadvertent extubation would be a seriousproblem because infants have very little respira-tory reserve, and it would be necessary to reposi-tion the patient for re-intubation.

Monitoring for and Treating VenousAir EmbolusThe anesthesia professional places a precordialDoppler (ie, an ultrasonic probe used to detect ve-nous air embolus) on the patient’s chest to the rightof the midline at the second or third intercostalspace. The Doppler produces characteristic soundswhen it detects air in the bloodstream. This is espe-cially important during this surgical procedure be-cause air can inadvertently enter the bloodstreamthrough apertures in the bone or a tear in a venoussinus or the dura. Typical patient positioning for thissurgery results in the surgical site being higher thanthe right atrium, which increases the risk for venousair embolus.11 The entire surgical team should re-main attentive to the sound of the Doppler and com-municate any noted changes. Other clinical signs,such as decreased end-tidal carbon dioxide levels,oxygen saturation levels, and blood pressure canpresent when a true air embolus occurs. Most often,there is no hemodynamic response when air soundsare heard via Doppler; however, when this occurs,the surgeon floods the surgical field with normalsaline solution to reduce bone, sinus, and dural ex-posure to air until the anesthesia professional hasruled out the presence of a venous air embolism.

PositioningPositioning is of crucial importance because ofthe delicate nature of an infant’s skin, the proneposition required for the surgery, and surgicalduration. When turning a patient to the proneposition, the surgical team pays careful attentionto the ET tube and IV lines to ensure that these

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are not accidentally dislodged. This procedurerequires the use of a special headrest that main-tains the infant’s head in a modified proneposition with significant extension (Figure 4).12 Ateam member who is familiar with this headrestshould be in charge of positioning and placementof the infant’s head to reduce complications. Be-fore surgery, the surgeon should evaluate the in-fant for cervical anomalies, especially if the infanthas syndrome-related synostosis.

The areas of the headrest that are in contactwith the patient’s head are U-shaped gel rings

that cup around the patient’s ears and small gelpads that support the chin. Care must be taken toprevent corneal abrasions or pressure on the eyesor ears. The eyes are held closed with latex-free eyecoverings. The anesthesia professional does notuse ophthalmic lubricant because this can cause theprotective eye coverings to fall off. Surgical teammembers place the patient prone while maintainingthe patient’s proper body alignment with his or her

! chest and abdomen on gel rolls,! knees on gel pads,! lower legs elevated enough to ensure that the

toes are free from pressure or contact with themattress, and

! both arms at the patient’s sides supported byblankets and foam.

The circulating nurse places the electrosurgical unitgrounding pad on the patient’s back and places asafety strap over the patient to prevent movement.

Maintaining NormothermiaMaintenance of body temperature is particularlyimportant when caring for infants because they losebody temperature very rapidly when exposed to am-bient air. While the team prepares the patient forsurgery, the circulating nurse places warm blanketson the OR bed and over the patient to help preventonset of hypothermia. After the patient is positioned,the nurse places a forced-air temperature-regulatingblanket on the patient from the neck down. Thisprovides a flow of warm air over the patientthroughout the procedure.

Prepping and DrapingThe surgeon prepares the surgical site by confirmingthe proposed location of the incisions with the infor-mation on the surgical consent (Figure 5). The sur-geon preps the surgical site with povidone-iodinescrub and alcohol and paints it with povidone-iodinesolution. While the prep solution dries, the circulat-ing nurse inspects the area around the surgical siteto ensure that prep solutions have not dripped ontothe patient’s face or pooled under the patient. Thesurgical team members then drape the patient, after

Figure 4. The infant is positioned in the neurosurgicalheadrest with the ears protected by horseshoe-shaped gel padding (A) and the eyes closed andprotected with latex-free eye coverings (B).

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which they assemble the surgical field. At this time,the entire surgical team stops and performs a verbaltime out to confirm the correct patient, procedure,site, and position. Each member of the team thenidentifies himself or herself for the record.

THE SURGICAL PROCEDUREThe scrub person stands at the patient’s headwith the Mayo stand and the back table posi-tioned to his or her right and positions the drillnear the sterile field for easy access for the sur-geon. The scrub person sets up the Mayo standwith all essential instruments because there isvery little room for retrieving supplies at the pa-tient’s head. The routine Mayo stand setup in-cludes a towel that holds each size of compressedrayon cotton pledgets or strips as well as two 1/2-inch by 4-inch strips and 3/4-inch squares of ab-sorbable gelatin sponge soaked in thrombin. If adural tear occurs near the sagittal sinus or an em-

issary vein, then the surgeon uses compressedrayon cotton pledgets or strips, and gelatin spongesvery rapidly to cover the tear and apply pressure tothat area. The scrub person also places toothed Ad-son forceps, bayonet forceps, Penfield and Woodsonelevators, two Senn retractors, two straight hemo-stats, a Cushing periosteal elevator, and a small cu-rette on the Mayo stand. The scrub person placesTessier bone-cutting scissors, 3-mm and 4-mm Ker-rison rongeurs, a large Lexel rongeur, and curvedMayo scissors on the back table (Figures 6 and 7).

The surgeon injects 0.25% bupivacaine with1:200,000 epinephrine locally at the site of theincisions for the hemostatic effect of the epineph-rine. The surgeon uses a #15 knife blade to makea 2-cm incision in a medial-to-lateral directionover the midline of the skull just behind the coro-nal suture and at the location of the lambdoidsuture. This allows access to the sagittal sutureboth proximally and distally.

By using a needle tip on the electrosurgicalunit handpiece, the surgeon opens the tissue downto the periosteum and removes the periosteumfrom the bone with a periosteal elevator. The sur-geon makes a burr hole with a 5-mm acorn burr,being especially careful not to tear the dura. Thesurgeon inserts a Woodson elevator into the burrhole and moves it circumferentially to free the durafrom the underside of the bone. The surgeon en-larges the hole to approximately 1 cm with a Kerri-son rongeur under direct vision. Then, the surgeonremoves as much bone as possible with a Lexelrongeur in an area that is approximately 1 cm by 2to 3 cm. This is the time that a venous air embolismis most likely to occur, so team members monitorthe precordial Doppler closely. The scrub personsoaks a 3/4-inch by 3/4-inch piece of absorbablegelatin sponge soaked in thrombin and passes it tothe surgeon who places it over the incision to pro-vide hemostasis while making the second incision inthe same fashion (eg, making a burr hole and en-larging it with rongeurs).

Unlike some intracranial procedures andmost intra-abdominal procedures, this procedure

Figure 5. Minimally invasive incision sites markedbefore surgical prep.

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is not truly endoscopic; it is considered anendoscopically assisted procedure because thesurgeon can directly see portions of the surgicalarea. The endoscope allows the surgeon to seethe area between the dura and the fused sutureand to transilluminate tissue. After making twoincisions, the surgeon uses a 4-mm, 0-degreeendoscope to view the fused suture to look forattachments of dura and blood vessels and ob-serve for bleeding. Transillumination with theendoscope ensures that the entire segment isfree of underlying tissue before the bone is cut.Unlike a normal skull, the dura in infants withcraniosynostosis is not adhered to the bones atthe site of the fusion and is easily separated byusing a blunt dissector and suction while ob-serving with the endoscope.

The scrub person wipes blood from the endof the scope by using a clean, moistenedsponge to restore the visual field. The surgeonuses Tessier bone cutters to cut along each sideof the fused suture. Pieces of bone often comeout in small fragments with the bone cutter, but

occasionally a large segment of bone that repre-sents the entire suture will come out at once.The surgeon performs the entire procedurequickly to decrease anesthetic time and bloodloss but at the same time is vigilant not tocause any harm. When the surgeon has re-moved the suture, he or she places a 1-inch by3-inch strip of absorbable gelatin soaked inthrombin over the area for hemostasis. The sur-geon then irrigates the surgical site with antibi-otic irrigation, closes the galea (ie, the thickaponeurotic layer of the scalp) with 4-0 polyg-lactin suture, and closes the skin with 4-0 rap-idly absorbed polyglactin suture.

Throughout the procedure, the circulatingnurse communicates with the liaison nurse whoupdates the family on the patient’s status. Be-fore the end of the procedure, the circulatingnurse gives a report to the postanesthesia careunit (PACU) nurse who will be caring for thepatient. The circulating nurse communicatespertinent information regarding the surgery andthe patient’s postoperative status.

Figure 6. Required instruments and supplies on the Mayo stand.

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When the procedure is finished, a surgicalteam member places an impregnated nonadher-ent dressing and a nonadherent pad on the inci-sion sites and secures them with paper tape.Team members reposition the patient supine onthe bed, taking care to prevent the ET tube andIV lines from being dislodged. The surgeonfinishes bandaging the patient’s head by placingan abdominal pad over the top of the headalong the suture removal site and securing itwith stretchable netting over the infant’s head.The netting applies added pressure to the site todecrease postoperative venous bleeding (Figure8). This pressure dressing remains in place forapproximately eight hours. The nurse assessesthe patient’s skin for pressure points or skinbreakdown on the chest, forehead, chin, andknees where there was contact with the head-rest or the gel pads. The circulating nurse in-creases the temperature in the OR to help main-tain the patient’s body temperature. The nurseremains at the patient’s side until the patient isextubated by the anesthesia professional.

POSTOPERATIVE CAREWhen the patient is ready to go to the PACU, thecirculating nurse and the anesthesia professionalwrap the patient in a warm blanket and place himor her in the postoperative crib with the head ofthe bed elevated 30 to 45 degrees. The anesthesiaprofessional, surgical resident, and circulatingnurse transport the patient to the PACU. The

Figure 7. Extra instruments and supplies on the back table.

Figure 8. Netting is used to secure the dressing inplace and apply pressure to decrease bleeding.

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circulating nurse and PACU nurse confirm thepatient’s identity by using two patient identifiers.The anesthesia professional and circulating nurseeach provide a transfer of care report to thePACU nurse.

To determine whether a blood transfusion isnecessary, the PACU nurse draws a blood samplefrom the patient’s IV and sends it to the labora-tory for a hematocrit level before transferring thepatient to the neurosurgical floor. The thresholdfor transfusion is a hematocrit level of 20% alongwith symptoms such as tachycardia or decreasedblood pressure. If the patient is stable, then thePACU nurse transfers the patient to the inpatientneurosurgical unit after approximately two hoursof monitoring in the PACU.

The patient receives IV antibiotics every eighthours for three doses—the first of three doses isadministered before surgery—and nurses adminis-ter rectal acetaminophen and IV morphine asneeded for pain. Signs and symptoms of pain ininfants include irritability, crying that is not con-soled by being held or fed, and increased heartand respiratory rate. Typically, the surgeon dis-charges the patient the day after surgery.

An orthotist fits the patient with a cranial remold-ing helmet between one and five days after dis-charge. The helmet is made of a hard plastic witha firm foam lining and weighs between 8 oz and16 oz (Figure 9). The patient wears the helmet untilhe or she is approximately nine to 10 months ofage; although some surgeons may require the infantto wear the helmet until one year of age. Althoughthe infant’s head shape is corrected in the first threeto four months, if helmet therapy is discontinued atthis time, regression of the skull shape can occur.The next two to three months of helmet use are re-quired to maintain the head shape. The patient nor-mally wears the helmet for 21 to 23 hours a day.The orthotist instructs family members regarding useof the helmet and outlines a schedule that includesan initial break-in period.13 The orthotist also pro-vides additional skin care tips and advice for clean-ing the helmet. Increased moisture can occur inside

the helmet as a result of sweating. Family membersmay apply corn starch or medicated baby powder tokeep the infant’s skin dry.13 The parents shouldcheck the infant’s skin for redness or irritation eachtime the helmet is removed. Heat rash can betreated with hydrocortisone cream. After the firstpostoperative week, the parents should shampoo theinfant’s head daily. The parents should wipe thehelmet with 70% alcohol, rinse it well, and com-pletely dry it before putting it back on the infant.13

Parents must return the infant to the orthotist ev-ery two to three weeks until the surgeon discontin-ues helmet therapy. The procedure is performedwhile the infant’s head is still growing rapidly;therefore, the helmet must be adjusted periodicallyto prevent excessive pressure on the sensitive skinof the infant’s head. Patients with sagittal synostosisusually require only one helmet. A modified helmet,known as the “Mohawk” helmet, is open on thesides, which allows for significant growth withoutthe sides becoming too tight.

The first postoperative visit with the surgeon oc-curs one month after surgery and then approxi-mately every two months until the patient is oneyear of age. When helmet treatment is discontinued,the surgeon performs a set of cranial measurements,and continues this annually until the child is six to

Figure 9. A baby wearing a specially designedcranial remolding helmet.

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Endoscopically Assisted Repair of Sagittal CraniosynostosisOverviewCraniosynostosis is premature closure of one or more of thecranial sutures of your baby’s skull. Sutures are bands ofconnective tissue between the skull bones that allow theskull to mold during birth and allow the brain to grow rap-idly in the first year of life. When a suture closes too soon,the skull may become misshapen.

What are the signs of craniosynostosis?A long, narrow head with frontal and occipital bossing (aridge or bulge along a suture line).

How is craniosynostosis diagnosed?Craniosynostosis is diagnosed by skull measurements,physical examination, and computerized tomography scanor x-rays to confirm the diagnosis.

What are the treatment options?Surgery is the only option. Endoscopic surgery is much lessinvasive than traditional surgical procedures and decreasesyour baby’s anesthesia time, hospital time, and need for bloodtransfusions. After surgery, your baby will wear a custom-made helmet to help the skull mold to the appropriate shape.

What will preoperative care include?

! Your baby should have an empty stomach before sur-gery. You may be instructed to feed your baby:! solid food 8 hours before surgery,! formula 6 hours before surgery or breast milk 4 hours

before surgery, and! clear liquids 2 hours before surgery.

! Before surgery, a nurse will measure your baby’s vitalsigns and ask about your baby’s allergies, previous sur-geries, current medications, and skin condition.

! The OR nurse, anesthesia professional, and your surgeonwill talk with you in the preoperative area where you canask questions.

What happens during surgery?We position your baby on his or her stomach with his orher head on a special headrest that allows the surgeon towork. The surgeon makes 2 small incisions on your baby’shead and uses an endoscope to see the fused suture. Thesurgeon uses special scissors to cut and remove the fusedbone. Your baby will be in the OR for about 2 hours be-fore he or she is taken to the recovery area.

What are possible complications of surgery?

! Your baby could get an infection, pneumonia, or bleedtoo much.

! Your baby might require a blood transfusion or further surgery.

What will postoperative care include?After surgery,

! your baby is admitted to the recovery area and monitoredclosely.

! you may hold your baby and feed him or her fluids.! your nurse will provide pain medicine for your baby as

needed.! patients are typically discharged the day after surgery.

What happens after discharge?! Keep your baby’s incisions dry for the first 7 to 10 days.

Then wash your baby’s incisions daily with mild,perfume-free soap and gently pat dry. Do not use lotionor powder on the incisions until they are completelyhealed. You may then use medicated baby powder tokeep your baby’s skin dry under the helmet.

! 1 to 5 days after discharge, an orthotist will fit your babyfor a cranial remolding helmet. This is worn 21 to 23 hoursa day for 3 to 9 months. Take your baby to the orthotistevery 2 to 3 weeks until the surgeon discontinues treatment.

! See the surgeon 1 month after surgery and then every 2months until your baby is 1 year old.

! Follow helmet instructions. Failure to do so may result inthe skull returning to its previous shape.

Call your doctor immediately if your babyexperiences:! nausea or vomiting not relieved with nausea medication;! increased fussiness or crying not relieved with pain

medication;! increased sleepiness or decreased alertness;! increased redness, swelling, or drainage at the incisions site; or! fever greater than 101° F (38.3° C) or chills.

ResourceWhat is craniosynostosis. Johns Hopkins Medicine Neurologyand Neurosurgery. http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/pediatric_neurosurgery/conditions/craniosynostosis/. Accessed December6, 2010.

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seven years of age. Imaging is not routinely per-formed. The orthotist generally obtains serial three-dimensional laser scans during the helmeting pro-cess, which is part of the helmet manufacturing andmaintenance, but the scans are not used for analysisof results.

SUMMARYEndoscopic correction along with postoperativeorthosis has proven to be a safe and effectivemethod to treat sagittal synostosis and have a pos-itive effect on head growth and cranial morphol-ogy. From 2004 to 2008, 52 patients with isolatedsagittal synostosis were treated by endoscopicallyassisted correction of sagittal craniosynostosis atCHB with excellent cosmetic and functional out-comes. Furthermore, as surgical teams gained ex-perience with the procedure, length of hospitalstay, surgical time, and blood loss decreased(Table 2).10 Specific issues, such as positioning,hypothermia, and blood loss, must be addressedin the care of such young children undergoingsurgery. Diligent preparation by all perioperativeteam members ensures the best outcome for theseyoung patients.

References1. Suture. In: Stedman’s Medical Dictionary. New York,

NY: Houghton Mifflin Co; 1995:193.2. Cartwright CC. Assessing asymmetrical infant head

shapes. Nurse Pract. 2002;27(8):33-39.

3. Jane JA Jr, Lin KY, Jane JA Sr. Sagittal synostosis.Neurosurg Focus. 2000;9(3):e3.

4. Koh JL, Gries H. Perioperative management of pediat-ric patients with craniosynostosis. Anesthesiol Clin.2007;25(3):465-481.

5. Komotar RJ, Zacharia BE, Ellis JA, Feldstein NA,Anderson RC. Pitfalls for the pediatrician: positionalmolding or craniosynostosis? Pediatr Ann. 2006;35(5):365-375.

6. Scaphocephaly. Skull Base Institute. http://www.skullbaseinstitute.com/craniosynostosis-craniofacial/craniosynostosis-scaphocephaly.html. Accessed Decem-ber 6, 2010.

7. American Academy of Pediatrics Task Force on InfantPositioning and SIDS. Positioning and SIDS. Pediat-rics. 1992;89(6 Pt1):1120-1126.

8. Robinson S, Proctor M. Diagnosis and management ofdeformational plagiocephaly. J Neurosurgical Pediatr.2009;3(4):284-295.

9. Biggs W. The “epidemic” of deformational plagioceph-aly and the American Academy of Pediatrics’ response.J Prosthet Orthot. 2004;16(4S):5-8.

10. Meier PM, Goobie SM, DiNardo JA, Proctor MR,Zurakowski D, Soriano SG. Endoscopic strip craniec-tomy in early infancy: the initial five years of anesthe-sia experience. Anesth Analg. 2011;112(2):407-414.

11. Johnson JO, Jimenez DF, Tobias JD. Anaesthetic careduring minimally invasive neurosurgical procedures ininfants and children. Paediatr Anaesth. 2002;12(6):478-488.

12. DORO® Headrest System. Pro Med Instruments, Inc.http://www.headrest.de/contentcenter/daten/files/Cranial_E.pdf. Accessed December 6, 2010.

13. Boston Band for plagiocephaly cranial remodeling or-thosis. National Orthotics and Prosthetics Company.http://www.bostonbrace.com/Content/Boston_Band_for_Plagiocephaly.asp. Accessed December 6, 2009.

Lesley Brown, RN, is a staff nurse in the mainOR and specializes in neurosurgery nursing atthe Children’s Hospital Boston/Harvard Medi-cal School, Boston, MA. Ms Brown has nodeclared affiliation that could be perceived asposing a potential conflict of interest in thepublication of this article.

Mark R. Proctor, MD, is a neurosurgeon inthe Department of Neurosurgery at the Chil-dren’s Hospital Boston/Harvard MedicalSchool, Boston, MA. Dr Proctor has no de-clared affiliation that could be perceived asposing a potential conflict of interest in thepublication of this article.

TABLE 2. Data for Infants Who UnderwentEndoscopically Assisted Strip Craniectomy atChildren’s Hospital Boston Between 2004 and2008 (N ! 52)1

Mean age at surgery 3.08 monthsMean surgical time 44.7 minutesMean length of hospital stay 1.17 daysNeed for transfusion 4 patientsAverage length of helmet therapy use 7.14 monthsMean time of follow-up 1.92 years

1. Meier PM, Goobie SM, DiNardo JA, Proctor MR, Zurakowski D, SorianoSG. Endoscopic strip craniectomy in early infancy: the initial five years ofanesthesia experience. Anesth Analg. 2011;112(2):407-414.

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CONTINUING EDUCATION PROGRAM

3.4www.aorn.org/CEEndoscopically Assisted Correction

of Sagittal Craniosynostosis

PURPOSE/GOAL

To educate perioperative nurses about endoscopically assisted correction of sagittalcraniosynostosis.

OBJECTIVES

1. Describe craniosynostosis.2. Explain how craniosynostosis is diagnosed.3. Discuss treatment of craniosynostosis.4. Identify problems that may occur if craniosynostosis is not treated.5. Describe perioperative care of an infant undergoing endoscopically assisted cor-

rection of sagittal craniosynostosis.

The Examination and Learner Evaluation are printed here for your conven-ience. To receive continuing education credit, you must complete the Exami-nation and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS1. Premature fusion of a suture results in arrest of

growth that normally occursa. parallel to the suture.b. perpendicular to the suture.

2. Scaphocephaly is characterized bya. a short, wide skull with occipital bossing and a

palpable ridge along the sagittal suture.b. a long, narrow-shaped skull with frontal and

occipital bossing and a palpable ridge alongthe sagittal suture.

c. a short, wide skull with parietal and coronalbossing and a palpable ridge along the coronalsuture.

d. a long, narrow skull with parietal bossingand a palpable ridge along the lambdoidsuture.

3. The clinician makes a diagnosis of sagittal cra-niosynostosis based primarily on1. a family history.2. color Doppler ultrasound.3. physical examination.4. skull measurements.

a. 1 and 3 b. 2 and 4c. 1, 3, and 4 d. 1, 2, 3, and 4

4. Untreated craniosynostosis may cause1. blunted cognitive development.2. delayed psychomotor development.3. increased intracranial pressure.4. problems with psychosocial development.

a. 1 and 3 b. 2 and 4c. 1, 2, and 4 d. 1, 2, 3, and 4

5. Treatment options for repair of craniosynostosisinclude

EXAMINATION

580 AORN Journal ! May 2011 Vol 93 No 5 © AORN, Inc, 2011

1. cranial vault remodeling for older children.2. endoscopically assisted correction of

craniosynostosis.3. open-strip craniectomy.4. the Pi procedure.

a. 1 and 3 b. 2 and 4c. 1, 2, and 4 d. 1, 2, 3, and 4

6. The optimal age for an infant to undergo endo-scopically assisted correction of sagittal cranio-synostosis isa. younger than three months of age.b. three to six months of age.c. six to nine months of age.d. older than nine months of age.

7. If a change in the sound of the Doppler indicatesit detects air in the bloodstream, then the surgeonfloods the surgical field with normal saline solu-tion to reduce bone, sinus, and dural exposure toair.a. true b. false

8. Using an endoscope to perform this procedureallows the surgeon to1. decrease bone bleeding.2. prevent venous air embolus.3. see the area between the dura and the fused

suture.4. transilluminate tissue to ensure that the entire

segment is free of underlying tissue before thebone is cut.a. 1 and 2 b. 3 and 4c. 1, 2, and 3 d. 1, 2, 3, and 4

9. The threshold for transfusion is a hematocrit levelof _____, along with symptoms such as tachycar-dia or decreased blood pressure.a. 20% b. 25%c. 30% d. 35%

10. After surgery, the infant wears a cranial remold-ing helmet for 21 to 23 hours a day until he orshe is approximately nine to 10 months of age.a. true b. false

The behavioral objectives and examination for this program were prepared by Rebecca Holm, MSN, RN, CNOR, clinical editor,with consultation from Susan Bakewell, MS, RN-BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewellhave no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.

CE EXAMINATION www.aornjournal.org

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of Sagittal Craniosynostosis

This evaluation is used to determine the extent towhich this continuing education program metyour learning needs. Rate the items as described

below.

OBJECTIVESTo what extent were the following objectives of thiscontinuing education program achieved?

1. Describe craniosynostosis.Low 1. 2. 3. 4. 5. High

2. Explain how craniosynostosis is diagnosed.Low 1. 2. 3. 4. 5. High

3. Discuss treatment of craniosynostosis.Low 1. 2. 3. 4. 5. High

4. Identify problems that may occur if craniosynos-tosis is not treated.Low 1. 2. 3. 4. 5. High

5. Describe perioperative care of an infant undergo-ing endoscopically assisted correction of sagittalcraniosynostosis.Low 1. 2. 3. 4. 5. High

CONTENT6. To what extent did this article increase your

knowledge of the subject matter?Low 1. 2. 3. 4. 5. High

7. To what extent were your individual objectivesmet? Low 1. 2. 3. 4. 5. High

8. Will you be able to use the information fromthis article in your work setting?1. Yes 2. No

9. Will you change your practice as a result ofreading this article? (If yes, answer question#9A. If no, answer question #9B.)

9A. How will you change your practice? (Select allthat apply)1. I will provide education to my team regard-

ing why change is needed.2. I will work with management to change/

implement a policy and procedure.3. I will plan an informational meeting with

physicians to seek their input and acceptanceof the need for change.

4. I will implement change and evaluate theeffect of the change at regular intervals untilthe change is incorporated as best practice.

5. Other:

9B. If you will not change your practice as a resultof reading this article, why? (Select all thatapply)1. The content of the article is not relevant to

my practice.2. I do not have enough time to teach others

about the purpose of the needed change.3. I do not have management support to make a

change.4. Other:

10. Our accrediting body requires that we verify thetime you needed to complete the 3.4 continuingeducation contact hour (204-minute) program:

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Centerapproves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of thisactivity for relicensure.

Event: #11013; Session: #4066 Fee: Members $17, Nonmembers $34

The deadline for this program is May 31, 2014.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Eachapplicant who successfully completes this program can immediately print a certificate of completion.

LEARNER EVALUATION

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