Craniosynostosis surgery practice patterns in the United States: what are we doing and how are we doing it?

OBJECTIVE The surgical management of craniosynostosis varies without consensus on technique or standard outcomes reporting. The authors of this study aimed to investigate current surgical management of craniosynostosis in the United States. METHODS Two hundred seventy-five surgeons actively treating craniosynostosis in the United States were surveyed. The results from a 28-item instrument were analyzed according to surgeon specialty, surgeon tenure, and geographic location of practice. RESULTS The overall response rate was 47.6% (131/275), and final analyses included 58 plastic and reconstructive surgeons and 69 neurosurgeons from 79 different institutions. The majority of surgeons used internal data registries (65.4%); however, only 17.4% of neurosurgeons and 34.5% of plastic surgeons (p = 0.04) contributed to national or international registries. Neurosurgeons were more likely to offer endoscopic strip craniectomy for unicoronal craniosynostosis (75.4% vs 50.0%, p = 0.05) and unilateral lambdoid craniosynostosis (69.6% vs 48.3%, p = 0.018). Plastic surgeons were more likely to offer spring-assisted cranioplasty for bilambdoid synostosis (20.7% vs 7.2%, p = 0.036) and most other sutures. For all sutures, open cranial vault remodeling remains the most frequently offered technique. Plastic surgeons more often selected the surgical technique based on physical examination (86.2% vs 68.1%, p = 0.02) and recognized a "gold-standard" treatment (51.7% vs 17.4%, p < 0.001). Region did not significantly impact the techniques offered. Compared to surgeons with fewer years of experience, those with 6 or more years of experience were less likely to offer cranial vault remodeling for unilateral lambdoid craniosynostosis (p = 0.002) and those with more than 10 years of experience were less likely to offer cranial vault remodeling for bilateral lambdoid craniosynostosis (p = 0.011). CONCLUSIONS The authors present the largest description of current craniosynostosis practices in the United States. Reported surgical offerings were overall similar across specialties, regions, and years of surgeon experience. Nearly all surveyed surgeons continue to offer open cranial vault remodeling as an option for all included craniosynostosis variations. Endoscopic strip craniectomy is the second most proposed technique for most sutures, but distraction methods are similarly or more frequently offered in cases of bilateral and multisuture synostoses. Plastic surgeons also report greater spring-assisted repair offers than neurosurgeons, whereas the longest practicing surgeons are less likely to offer open repair in lambdoid cases. Encouraging further contributions to national databases, such as that of the Synostosis Research Group, may provide robust outcome data that can help to identify best practices for managing this complicated pathology.