Cost Benefits of Endoscope-assisted Surgery for Craniosynostosis

Comprehensive assessment puts costs well below open surgery.

Researchers at Monroe Carell Jr. Children’s Hospital at Vanderbilt are closing a gap in the research on surgical options for single sagittal craniosynostosis. Chevis Shannon, Dr.P.H., research professor and director of the Surgical Outcomes Center for Kids, and Christopher Bonfield, M.D., pediatric neurosurgeon, were principal investigators on a study comparing the broad-scale costs of the two most common repair methods.

In results published in the Journal of Neurosurgery Pediatrics, the team found that, overall, open surgery was 73 percent more expensive than endoscope-assisted minimally-invasive repair for single sagittal craniosynostosis, with equivalent one-year clinical outcomes.

“We wanted to know not only the actual procedure and hospitalization cost, but the cost of helmet therapy, outpatient management, complications, emergency room visits, second surgeries, and other expenses,” Shannon said. “This had not been well-studied.”

“We wanted to know not only the actual procedure and hospitalization cost, but the cost of helmet therapy, outpatient management, complications, emergency room visits, second surgeries, and other expenses.”

Clear Cost Savings

Shannon and Bonfield led a team in analyzing 17 open and 16 endoscope-assisted cases. The mean age for the open cohort was 5.69 months (consistent with the necessity of open surgery in older infants) and 2.96 months for endoscope-assisted cases.

Open repair required more OR time (203 vs. 145 minutes), more ICU days (three vs. one day), longer hospital stays (four vs. one day), more transfusions (88 vs. 6 percent), and more ED visits (three vs. one). Counterbalancing these costs were helmets, which were required for all of the endoscope-assisted infants, but only six percent in the open repair group.

Total costs were $31,314 for open and $18,081 for endoscope-assisted surgeries. Outcomes were positive for both cohorts, with neither experiencing major surgical complications or surgical revisions. “Our study suggests that endoscopic-assisted repair is more cost-effective than open repair for treatment of sagittal synostosis,” Bonfield said. “However, each case is evaluated and discussed individually. Factors such as patient age and distance the family lives from the orthotist/helmet clinic also need to be considered in the treatment of the patient.”

An Under-recognized Condition

Craniosynostosis affects about one in 2,100 to 2,500 live births, and the sagittal form represents 40 to 58 percent of these cases. It may be autosomal dominant or recessive, or caused by nonheritable mutations. The vast majority of cases are idiopathic.

Initial diagnosis is made by combining head measurements with palpation and visual assessment of head shape. Skull X-rays or low-radiation dose CT scans are often used to confirm the diagnosis. Absent a red flag from family history, and sometimes masked by natural distortions in infants’ head shapes, the condition can go unrecognized over the initial months of life.

“The window of opportunity for endoscope-assisted repair is from one to four months,” Shannon said. “Yet often we are not seeing these babies until after that window is closed. We are hopeful that our findings, if replicated in an independent multi-center study, will support the need for earlier recognition so that consideration can be given to this cost-saving procedure.”

“The window of opportunity for endoscope-assisted repair is from one to four months.”

Bringing True Costs to Light

Shannon plans to follow the current cohort up to five years to examine any complications that began after the one-year study period. She is also working to further probe the true costs of these procedures, including parents’ time off from work, cost of sibling care, and transportation.

Her team is also investigating long-term outcomes of patients with single sagittal craniosynostosis. There are no clear data regarding the optimal timing of surgical repair, advanced radiologic modalities, or neurodevelopmental evaluations for these patients before or after surgery, Shannon explained. It’s not clear what the impact of the surgery is on long-term neurodevelopmental outcomes.

“Yet often we are not seeing these babies until after that window is closed.”

“We don’t have good data about what this impact is,” Shannon said. “We’re writing a multi-institutional grant right now to look at that from both radiographic and neurodevelopmental perspectives. This has been evaluated from a suture standpoint and from a complications standpoint, but not really from a long-term perspective.”