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What to do with an incidental finding of a fused sagittal suture: a modified Delphi study
Sarah N Chiang1,2, Jocelyn Reckford1, Allyson L Alexander3
11Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri.
Insights
Premature fusion of the sagittal suture in children requires careful management. Surgery is generally not recommended for those over 18 months without symptoms, but shared decision-making is advised for younger children.
Area of Science:
- Pediatric Neurosurgery
- Craniofacial Surgery
- Developmental Pediatrics
Background:
- Premature fusion of the sagittal suture occurs in up to 5% of normocephalic children.
- The clinical significance and optimal management of this finding are not well-established.
- A multicenter consensus is needed to guide treatment and monitoring.
Purpose of the Study:
- To establish a multicenter consensus on the management of incidentally discovered premature fusion of the sagittal suture.
- To develop an optimal treatment and monitoring algorithm for this condition.
- To survey expert opinions from neurosurgeons and plastic surgeons specializing in craniosynostosis.
Main Methods:
- A modified Delphi method involving four rounds of anonymous surveys and open discussions.
- Expert panelists included 10 neurosurgeons and 9 plastic surgeons from 9 institutions.
- Case studies of patients with incidentally fused sagittal sutures were presented to gauge management preferences.
Main Results:
- The term "premature fusion of the sagittal suture" was preferred by 93% of surgeons.
- Consensus was reached: no surgery for patients over 18 months without signs of increased intracranial pressure (ICP).
- For infants under 18 months, shared decision-making with caregivers regarding potential surgery is recommended.
Conclusions:
- A consensus was achieved on managing premature fusion of the sagittal suture using the Delphi method.
- Surgical intervention is not advised for asymptomatic patients over 18 months of age.
- Shared decision-making is crucial for children under 18 months, considering head shape and neurodevelopmental concerns.
Objective:
As many as 5% of normocephalic children may have a prematurely fused sagittal suture, yet the clinical significance and best course of management of this finding remain unclear. Providers in the Synostosis Research Group were surveyed to create a multicenter consensus on an optimal treatment and monitoring algorithm for this condition.
Methods:
A four-round modified Delphi method was utilized. The first two rounds consisted of anonymous surveys distributed to 10 neurosurgeons and 9 plastic surgeons with expertise in craniosynostosis across 9 institutions, and presented 3 patients (aged 3 years, 2 years, and 2 months) with incidentally discovered fused sagittal sutures, normal cephalic indices, and no parietal dysmorphology. Surgeons were queried about their preferred term for this entity and how best to manage these patients. Results were synthesized to create a treatment algorithm. The third and fourth feedback rounds consisted of open discussion of the algorithm until no further concerns arose.
Results:
Most surgeons preferred the term "premature fusion of the sagittal suture" (93%). At the conclusion of the final round, all surgeons agreed to not operate on the 3- and 2-year-old patients unless symptoms of intracranial hypertension or papilledema were present. In contrast, 50% preferred to operate on the 2-month-old. However, all agreed to utilize shared decision-making, taking into account any concerns about future head shape and neurodevelopment. Panelists agreed that patients over 18 months of age without signs or symptoms suggesting elevated intracranial pressure (ICP) should not undergo surgical treatment.
Conclusions:
Through the Delphi method, a consensus regarding management of premature fusion of the sagittal suture was obtained from a panel of North American craniofacial surgeons. Without signs or symptoms of ICP elevation, surgery is not recommended in patients over 18 months of age. However, for children younger than 18 months, surgery should be discussed with caregivers using a shared decision-making process.
