Open Versus Endoscopic Surgery with Helmet Molding Therapy in Non-syndromic Patients with Craniosynostosis: An Updated Systematic Review and Meta-Analysis of Clinical Outcomes and Treatment-Related Costs

Open Versus Endoscopic Surgery with Helmet Molding Therapy in Non-syndromic Patients with Craniosynostosis: An Updated Systematic Review and Meta-Analysis of Clinical Outcomes and Treatment-Related Costs | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Open Versus Endoscopic Surgery with Helmet Molding Therapy in Non-syndromic Patients with Craniosynostosis: An Updated Systematic Review and Meta-Analysis of Clinical Outcomes and Treatment-Related Costs Omar R. Ortega-Ruiz, Mauricio Torres-Martínez, Mariana Villafranca-Cantú, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5404976/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Dec, 2024 Read the published version in Child's Nervous System → Version 1 posted 7 You are reading this latest preprint version Abstract Objective There is an ongoing debate regarding the optimal treatment for craniosynostosis as diverse factors influence the election between endoscopic and open surgery. Previous evidence favors endoscopic procedures; However, evidence remains unfulfilled by a limited number of patients and clustered in very few centers worldwide making it difficult to define it as a replicable technique in different populations. In recent years, evidence regarding endoscopic-assisted procedures has gone through a considerable spurt showing an increased interest among surgeons globally showing optimal outcomes in different populations and centers. In this systematic review and meta-analysis, we performed an updated analysis of previous reviews, including only non-syndromic patients. We also seek to provide a summary of the tendency of treatment observed in the literature. Similarly, this is the first study to include total costs within its analysis. Material and Methods Three previous meta-analyses published in 2018 yielded 11 eligible papers. We performed a systematic review and meta-analysis of the literature in MEDLINE and EMBASE databases through PubMed, Scopus, and Ovid to fill the gap of information between 2018 and 2024. 23 total articles were included in the final analysis. Results Variables analyzed were baseline characteristics, length of stay, blood loss, transfusion rates and volume, operative time, and costs. Analysis of data concluded a younger age at surgery in patients undergoing endoscopic surgery (p= <0.00001). Blood loss, transfusion rates, and volumes depicted favored outcomes for endoscopy with less blood loss during surgery (p = <0.00001), operative time (p=<0.00001), and transfusion rates (p=<0.00001) as well as lower transfused volumes (p = <0.00001). Conclusion Endoscopic surgery carries fewer complications than open surgery. Treatment-related costs are highly decreased in endoscopic procedures after including costs related to outpatient care. Open surgery can be considered in older children if no endoscope or experienced surgeons in endoscopic procedures are available. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Craniosynostosis is a congenital craniofacial disorder characterized by the premature fusion of one or more cranial sutures. It affects approximately 5.9 per 10,000 live births, thus rendering it the second most prevalent craniofacial disorder following orofacial clefts. [ 1 , 2 ] It may manifest either in isolation as a distinct condition (non-syndromic craniosynostosis) or in association with other congenital anomalies in a syndromic manner (Shruti and Gulati, 2022). [ 3 ] In both scenarios, craniosynostosis presents diverse morphological variations fundamentally attributed to the cranial suture(s) undergoing premature fusion. Sagittal craniosynostosis comprises approximately 50–58% of cases, whereas lambdoid craniosynostosis constitutes the least prevalent form, accounting for approximately 2–4% of cases. [ 4 ] If left untreated, this condition may prompt elevated intracranial pressure, neurocognitive impairments, and psychosocial challenges, while patients who undergo treatment typically course devoid of complications. [ 1 ] The treatment of craniosynostosis focuses on the surgical correction of the cranial defect while taking into consideration the need to expand or increase the intracranial volume, allowing for present and future decreases of intracranial pressure.[ 5 ] Surgical approaches are categorized into two primary groups: endoscopic and open procedures. Endoscopic procedures are typically followed by postoperative molding therapy with the aid of a helmet orthosis to enhance cranial remodeling. Endoscopic surgery was pioneered during the 1990s by Jimenez and Barone for early correction of craniosynostosis with continuous publications of diverse series of patients undergoing these procedures. [ 6 ] Even though surgical outcomes suggested reduced time of surgery, blood loss, lesser costs, and optimal remodeling results; the evidence was limited to a single center and a single surgical team, making it difficult to adopt endoscopic surgery as a worldwide valid technique. [ 7 ] Similarly, total costs of inpatient (surgery, hospitalization, transfusions, etc) and outpatient (consults, helmet orthosis) care can be discernible variables within procedure selection. Previous meta-analyses comparing endoscopic and open surgery groups revealed consistent perioperative outcomes with the series initially published by Jimenez and Barone [ 8 – 10 ]. Still, these previous meta-analyses presented syndromic patients within the pool of data analyzed due to the scarce literature comparing open versus endoscopic procedures present at that time. Pitfalls of including syndromic patients include increasing risk of bias among the results presented. In recent years, evidence regarding endoscopic-assisted procedures has been increasing, demonstrating acceptance of endoscopic surgery. In this systematic review and meta-analysis, we performed an updated analysis of previous reviews, including only non-syndromic patients. We also seek to provide a summary of the tendency of treatment observed in the literature. Similarly, this is the first study to include total costs within its analysis. Materials and methods Search Strategy and selection criteria The authors performed the elaboration of this systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) ( Fig. 1 ) . The protocol was not registered. We did a systematic search of the MEDLINE database via Scopus and PubMed and of the Embase database via OVID. Articles were eligible if they included cohorts comparing open procedures versus endoscopic surgery with a minimum number of 10 patients, non-syndromic patients, only pediatric patients and no adult subjects, diagnosed craniosynostosis of one or more sutures, age of patients from 1 month to 1 year of age. Some studies included syndromic patients in their cohorts; however, inclusion was possible as they presented separate data for them. Studies including syndromic patients with unavailability of separating data were excluded. Studies with no outcomes available were excluded. For patients who underwent endoscopic repair, inclusion was decided if posterior helmet molding therapy was described. Articles where helmet therapy was not mentioned or neglected were excluded. Surgical techniques were divided into open surgery and endoscopic procedures. For open surgery, techniques included were FOA, pi craniectomy, and CVR including possible modifications within the approaches. For endoscopic surgery, only strip craniectomy and suturectomy were included. Patients undergoing spring-assisted craniotomy were excluded from this study as its use usually requires a second intervention for spring removal. This statement could potentially bias results in the analysis. Three previous meta-analyses comparing endoscopic versus open approaches in craniosynostosis were published in 2018. The systematic search performed in this study was designed to search for literature to fill the gap of data between the years 2018 and 2024. All articles included in the previous meta-analysis were screened using the selection criteria previously established. Eleven articles met inclusion criteria whilst x articles were excluded as they failed to fulfill them ( Fig. 1 ). Study selection and data extraction Two authors (OROR & MTM) independently reviewed titles, abstracts, and citations using Rayyan Citation software. [ 11 ] After two rounds of screening for studies meeting inclusion criteria, both authors performed a full-text evaluation for final inclusion in this study. Any discrepancies in data extraction were resolved by consensus discussion with a senior author (J.C.H). Variables were extracted from the final included studies with a randomized evaluation by one author at the end of the extraction to corroborate data. Extracted variables were baseline characteristics (sex, age at surgery), number of cases, affected suture(s), blood loss volume, transfusion rates and volume, operative time, length of stay, and in-stay costs. Statistical analysis The variables were analyzed using Review Manager 5.3. Heterogeneity was assessed using Higgins I2. [ 12 ] Studies with heterogeneity over 40% I2 were considered heterogeneous and were analyzed using random effects models. Studies with less than 40% I2 were not regarded as heterogenous and were analyzed using a fixed effects model [ 13 ]. Continuous data was analyzed using the inverse-variance method with results expressed in mean difference and 95% confidence intervals (CI). Dichotomous data was analyzed using the Mantel-Haenszel method, and outcomes were reported with odds ratio (OR) and 95% CI. If not reported, mean and standard deviation were estimated from the sample size, median, range, and/or interquartile range. [ 14 ] Resulting values with associated p values < 0.05 were considered significant. The risk of bias in individual studies was assessed using the Cochrane Risk of Bias In Non-Randomized Studies of Interventions (ROBINS-I). [ 15 ] ( Fig. 2 ) The overall certainty of the study was graded according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group guidelines. [ 16 ] ( Fig. 3 ) Results 23 studies, reporting 2,018 patients, were included to review the current cumulative results [ 17 – 39 ]. The patient’s characteristics are shown in Table 1 . n Age (Months) Sex Affected Suture Open Endoscopic Open Endoscopic Open Endoscopic Open Endoscopic Abbott 2012 10 10 18.53(10.64) 3.08 (1.0) Male: 6 (60%) Female: 4 (40%) Male: 7 (70%) Female: 3 (30%) 10 sagittal 10 sagittal Arts 2018 62 116 10.53 (7.66) 3.86 (1.04) N/A N/A 30 sagittal 15 metopic 12 coronal unilateral 2 coronal bilateral 3 multi sutural 63 sagittal 35 metopic 14 coronal unilateral 1 coronal bilateral 3 multiple sutures Bonfield 2016 190 28 25.04 (25.24) 4.14 (0.89) N/A N/A 71 sagittal 32 unicoronal 14 bicoronal 42 metopic 31 multiple sutures 28 sagittal Braun 2018 9 8 13.73 (3.11) 2.35 (.36) Male: 9 (100%) Female: 0 (0%) Male: 7 (88%) Female: 1 (12.5%) 9 Single suture metopic 8 Single suture metopic Garber 2017 100 100 272.67 (66.99) 86.67 (23.32) Male: 74 (74%) Female 26 (26%) Male: 75 (75%) Female: 25 (25%) 1. 100 sagittal 2. 100 sagittal 100 sagittal Guadix 2022 79 53 7.37 (3.32) 3.4 (1.14) Overall cohort proportions Males (70.5%) Females (29.5%) 64 sagittal (48.5%) 39 metopic (29.5%) 26 coronal (19.7%) 4 lambdoidal (3.0%) Ha 2020 16 15 10.4 (3.5) 3.3 (1.3) Male: 10 (63%) Female: 6 (37%) Male: 12 (80%) Female: 3 (20%) 16 metopic 15 metopic Han 2016 155 140 15.5 (16.5) 3.4 (1.2) N/A N/A 76 sagittal 31 metopic 28 coronal unilateral 7 lambdoid 1 coronal bilateral 12 multiple sutures (8 with 2 sutures, 3 with 3 sutures, 1 with 4 sutures) 94 sagittal 24 metopic 10 coronal unilateral 6 lambdoid 2 coronal bilateral 7 multiple sutures Isaac 2018 20 187 21 (10.71) 3.63 (1.01) Male: 10 (50%) Female: 10 (50%) Male: 137 (73%) Female: 50 (27%) 20 sagittal 187 sagittal Keshavarzi 2009 17 16 29.5 4.9 m Male: 11 (65%) Female: 6 (35%) Male: 14 (87%) Female: 2 (13%) 17 metopic 16 metopic Lepard 2021 31 19 8.93 (2.72) 2.63 (0.4) Male: 29 (93.5%). Female: 2 (6.5%) Male: 16 (84.2%) Female: 3 (15.8%) 31 sagittal 19 sagittal Liles 2019 17 16 5.69 (12.45) 2.96 (5) N/A N/A 17 sagittal 16 sagittal Magge 2019 21 30 5.06 (2.68) 3.11 (1.18) N/A N/A 21 sagittal 30 sagittal Melin 2020 51 33 19.93 (9.57) 3.83 (0.84) Male: 34 (66.7%) Female: 17 (33.3%) Male: 28 (84.8%) Female: 5 (15.2%) 22 Metopic (43.1%) 20 Sagittal (39.2%) 9 Unicoronal (17.6%) 13 Metopic (39.4%) 18 Sagittal (54.5%) 2 Unicoronal (6.1%) Mertens 2017 37 48 7.3 (2.2) 5.3 (1.5) 69 Male 16 Female 37 sagittal 48 sagittal Nguyen 2015 15 13 9.5 (6.97) 3.3 (1.44) Male: 11/15 (70%) Female: 4/15 (30%) Male: 11/15 (70%) Female: 4/15 (30%) 15 metopic 13 metopic Rattani 2020 6 13 11.68 (0.93) 3.88 (1.36) Male: 5 (83.3%) Female: 1 (16.7%) Male: 6 (46.15%) Female: 7 (53.85%) 3 Right lambdoid 3 Left lambdoid 5 Right lambdoid 8 Left lambdoid Schulz 2021 47 33 8.62 (3.21) 3.05 (0.59) Females 8 (17%) Males: 39 (83%) Females 10 (30%) Males 23 (70%) 29 Sagittal 18 Metopic 17 Sagittal 16 Metopic Shah 2011 42 47 6.8 (2.0) 3.6 (1.25) Male: 31 (74%) Female: 11 (26%) Male: 32 (68%) Female: 15 (32%) 42 sagittal 47 sagittal Van Nunen 2016 15 20 9.04 (5.46) 5.32 (.98) Male: 11 (73.3%) Female: 4 (26.7%) Male: 16 (80%) Female: 4 (20%) 15 sagittal 20 sagittal Vogel 2014 21 21 6.8 (1.83) 3.1(.91) Male: 16 (76%) Female: 5 (24%) Male: 12 (57%) Female: 9 (43%) 21 sagittal 21 sagittal Zubovic 2015 8 4 12.8 (7.6) 5.5 (.5) NA NA 8 lambdoid 4 lambdoid Zubovic 2020 41 38 8.7 (1.9) 3.5 (1.6) NA NA 20 Metopic 19 Unicoronal 2 Lambdoid 19 Metopic 12 Unicoronal 7 Lambdoid Mean (Standard Deviation) * Sex is presented as the number of patients (%). Table 1: Baseline characteristics of patients in endoscopic and open surgery groups. Time to start helmet therapy (Post Op. days) Hours per day Age at which helmet treatment ends (Months) Duration of treatment (Months) Number of helmets Individual helmet cost Total helmet costs Period of time between check-ups (weeks) Abbott 2012 - - - - - - $2,060.00 - Arts 2018 2 - - - - - - - Ha 2020 1-3 23 12 - 2-4 - - - Han 2016 7 - 12 - 3 8-16 Isaac 2018 1-7 - 12 8 - - - - Lepard 2021 1-7 23 12 - - - - - Liles 2019 - - - - 2 $1,650.00 $3,300.00 - Magge 2019 1 12 - - - - - Nguyen 2014 1-3 23 12 - 2-3 - - 2-4 Rattani 2020 - - 10.12 (1.78) 6.02 - - - - Schulz 2021 SCS* - - - 6.85 - - - - MCS** - - - 13.83 - - - - Shah 2011 - 23 12 8.7 2-3 - - 4-12 Vogel 2014 1-7 - 12 - 2 - $2,813.00 - Zubovic 2015 - - 12 - - - - - Zubovic 2020 1-3 23 12 - 3 - $10,072.00 2-3 weeks till 6 months old, then 4 weeks till 12 months old SCS: sagittal craniosynostosis* MCS: metopic craniosynostosis** Table 2: Characteristics of helmet molding therapy in patients undergoing endoscopic surgery. Abbott 2012 Liles 2019 Zubovic 2020 Garber 2017 Open Endoscopic Open Endoscopic Open Endoscopic Open Endoscopic CVR OSS In-Patient Costs $53,758.25 $15,149.25 $30,475.00 $13,746.00 $95,188.00 $38,868.00 - - - Procedure $40,947.00 $11,927.75 $18,647.00 $9,399.00 - - - - - ICU/Hospital costs $7,577.00 - $10,320.00 $3,846.00 - - - - - Other NON-ICU costs $5,501.00 $3,077.25 $1,508.00 $500.00 - - - - - Out-Patient Costs $7,327.50 $8,033.75 $2,107.00 $3,851.00 $400.00 $10,072.00 - - - Orthotic Services (total helmet services) - $2,060.00 $1,650.00 $3,300.00 $10,072.00 - - - Others $7,575.00 $6,286.00 $457.00 $551.00 $400.00 $800.00 - - - Overall cost $60,311.25 $23,157.00 $31,314.10 $18,081.47 $95,588.00 $50,840.00 $45,078.00 $20,535.00 $21,203.00 Table 3: Overall costs of procedures including in-patients and out-patients fees. Baseline Characteristics Age at Surgery A total of 22 studies described the age at surgery, with a total of 992 patients in the endoscopic group and 993 patients in the open group. A meta-analysis of these data revealed a mean difference of -7.19 [-8.32, -6.07], p = < 0.00001, concluding a younger age at surgery in the patients that underwent an endoscopic procedure. These findings are displayed in Fig. 4 . Surgical Outcomes Blood Loss A total of 14 studies described the blood loss, reported in mL, with a total of 774 patients in the Endoscopic group and 578 patients in the Open group. A meta-analysis of these data revealed a mean difference of -191.47 [-246.87, -136.08], p = < 0.00001, concluding a lower intraoperative blood loss in the endoscopic group. These findings are displayed in Fig. 5 . Transfusion Rates The transfusion rates were described in 19 studies, with a total of 875 patients in the endoscopic group and 868 patients in the open group. A meta-analysis of these data revealed a mean difference of 0.02 [0.01, 0.05], p = < 0.00001, concluding less transfusion rates in the endoscopic group. These findings are displayed in Fig. 5 . Transfusion Volume The transfusion volumes were described in 3 studies, with a total of 13 patients in the endoscopic group and 56 patients in the open group. A meta-analysis of these data revealed a mean difference of -258.25 [-307.20, -209.29], p = < 0.00001, concluding a lower transfusion volume in the endoscopic group. These findings are displayed in Fig. 5 . Operative Time The operative time was described in 15 studies, with a total of 664 patients in the endoscopic group and 517 patients in the open group. A meta-analysis of these data revealed a mean difference of -131.77 [-168.53, -95.02], p = < 0.00001, concluding a lower operative time in the endoscopic group. These findings are displayed in Fig. 5 . Post-Operative Outcomes Length of Stay The length of stay was described in 9 studies, with a total of 403 patients in the endoscopic group and 419 patients in the open group. A meta-analysis of these data revealed a mean difference of -2.18 [-2.73, -1.63], p = < 0.00001, concluding a shorter length of stay in the endoscopic group. These findings are displayed in Fig. 6 . In-Stay Costs A total of 4 studies described in-stay costs, with a total of 164 patients in the endoscopic group and 168 patients in the open group. A meta-analysis of these data revealed a mean difference of -19.44 [-21.15, -17.74], p = < 0.00001, concluding a lower in-stay costs in the endoscopic group. These findings are displayed in Fig. 6 . Discussion Minimally invasive suturectomy or endoscopic assisted suturectomy was a technique first described by Jimenez and Baron that addressed many of the disadvantages of open techniques such as prolonged operating time, extensive bleeding, the need for reoperations over time, and aesthetic outcomes. [ 6 ] Endoscopic strip craniectomy must be coupled with a remodeling device, that prevents the early fusion of the bone and allows more time for natural remodeling to take place. Sure devices are the postoperative helmet therapy or the springs. Spring-assisted remodeling could be employed if the family does not agree with helmet therapy or if the patient surpasses an optimal age for helmet use. Albeit there is evidence of optimal results in cranial shape growth in patients treated with springs, its use requires two separate procedures to remove the device. [ 40 ] Both can help redirect a balanced, tridimensional growth and individual adjustment as the patient’s head grows. This fact makes patient selection an important aspect of surgery since sagittal synostosis patients between the ages of 3–6 months benefit the most from the procedure allowing for earlier intervention but requiring prompt referral. [ 41 ] The endoscopic procedure’s success is heavily dependent on the rapid growth and development of the brain during the first 6 months of life, while the calvaria thickness is still quite modest allowing for rapid remodeling, hence the need for the orthotic remodeling device. Open surgery, on the other hand, can be done practically at any age, but preferably a bit later closer to 1 year of life when the blood volume is increased allowing for relatively safer operation. With the pooled number of patients, we found consistent outcomes in the perioperative performance of patients according to previous reviews. Operative time showed a mean difference of 131.77 min (p < 0.00001) favoring the endoscopic group. Similarly, blood loss and transfusion rates were significantly lower in patients undergoing endoscopic surgery compared to the control group with mean differences of 191.47 ml and an odds ratio of 0.002 respectively (p < 00001 and p < 00001). When transfusions were deemed necessary in the endoscopic groups, volumes were significantly lower with a mean difference of 258.25 ml (p < 00001) ( Fig. 5 ) . We found no differences between the rate of males and females undergoing surgical correction. Still, patients treated with endoscopic surgery were significantly younger when compared to patients treated with open surgery with a mean of 7.19 months younger (p < 0.00001) ( Fig. 4 ) . Endoscopic surgery has classically been accepted for patients before 6 months of age, and open procedures have been accepted for patients older than 6 months, as younger patients present with thin bones and a small-sized calvarium, allowing faster and easier procedures using endoscopic techniques. [ 42 ] Still, endoscopic procedures have been proven to properly aid in the correction of craniosynostosis in older patients. [ 43 ] Helmet molding therapy usually follows the endoscopic repair of craniosynostosis. According to most authors, helmet therapy usually starts on the first postoperative day and up to 7 days after surgery ( Table 2 ) [ 17 , 19 , 24 – 26 , 28 , 32 , 37 , 39 ] with a mean duration of 8.68 months using the orthosis around 23 hours a day. [ 24 , 26 , 28 , 32 – 35 , 39 ] Nevertheless, the duration of the helmet can differ between the suture(s) affected. Nguyen et al. (2024) showed a significantly increased duration of helmet therapy in patients with metopic craniosynostosis when compared to patients with sagittal defects. [ 44 ] Each patient requires around 2 or 3 helmets with some patients going up to 4 helmets. Each helmet bears an approximate cost of around US $ 1,650, but costs may differ between manufacturers. [ 24 , 25 , 29 , 32 , 35 , 37 , 39 ] Authors in previous works reported diminished costs even after treatment with helmet orthosis (Table 3) . Total costs are directly related to procedure charges, ICU or hospital costs, outpatient treatment (number of helmets and consults), and others. Nevertheless, patients in the endoscopic group have a lower total fee even after helmets and other charges for outpatient care. Table 2 Characteristics of helmet molding therapy in patients undergoing endoscopic surgery. Abbott 2012 Liles 2019 Zubovic 2020 Garber 2017 Open Endoscopic Open Endoscopic Open Endoscopic Open Endoscopic CVR OSS In-Patient Costs $53,758.25 $15,149.25 $30,475.00 $13,746.00 $95,188.00 $38,868.00 - - - Procedure $ 40,947.00 $ 11,927.75 $ 18,647.00 $ 9,399.00 - - - - - ICU/Hospital costs $ 7,577.00 - $ 10,320.00 $ 3,846.00 - - - - - Other NON-ICU costs $ 5,501.00 $ 3,077.25 $ 1,508.00 $ 500.00 - - - - - Out-Patient Costs $7,327.50 $8,033.75 $2,107.00 $3,851.00 $400.00 $10,072.00 - - - Orthotic Services (total helmet services) - $ 2,060.00 $ 1,650.00 $ 3,300.00 $ 10,072.00 - - - Others $ 7,575.00 $ 6,286.00 $ 457.00 $ 551.00 $ 400.00 $ 800.00 - - - Overall cost $60,311.25 $23,157.00 $31,314.10 $18,081.47 $95,588.00 $50,840.00 $45,078.00 $20,535.00 $21,203.00 Patients in the control group had a mean difference of 2.18 days more of hospital stay compared to the endoscopic group (p < 0.00001) which can have a direct rise in total costs for each patient ( Fig. 6 ) . In the present review, significantly reduced costs were observed for patients in the endoscopic group with a mean difference of $ 19,440 (p < 0.0001) ( Fig. 6 ) . Late correction of craniosynostosis can be related to a higher rate of complications, potential neurocognitive impairment, and a higher burden of costs for insurance, healthcare systems, and families. The surgical correction after 1 year of age has an estimation of an increased mean difference of $ 8400 (US dollars). [ 43 , 45 ] A recent retrospective 10-year series published in 2024 by Hevia-Rodriguez et al. points out optimal results in 71% of the assessed population that underwent endoscopic repair without the use of posterior orthotic therapy. [ 46 ] Aesthetic results were deemed optimal in most patients with reduced costs. Evidence comparing postoperative helmet molding therapy and deferred orthotic therapy remains unavailable. Literature comparing patients with orthotic therapy and patients without it could help determine if deferred orthotic therapy could be considered optimal in the case of low-income countries or families. Despite the aforementioned, the management of patients with craniosynostosis is highly heterogeneous. There is a substantial variation in the management of these patients with no standardized protocols nor any systematic tools providing an evidence-based algorithm for the treatment of these patients. [ 47 ] Standardized clinical guidelines are still impeded due to scarce or nonexistent statistical evidence for many variables. Still, different recommendations can be made based on previous and present reviews among other literature available. Here, we present a graphic representation of the treatment algorithm for the management of patients with craniosynostosis based on the recommendations of experts and the tendencies observed in this review. (Fig. 7) . [ 48 ] This representation could provide easier analysis for younger physicians and aid them in analyzing previously published evidence. Limitations Limitations of this study include the lack of randomized controlled trials evaluating results between both groups. All studies included present a high degree of risk of bias mainly due to patient selection and confounding. The great majority of literature classifies surgery between open and endoscopic procedures therefore comparisons between techniques are potentially biased. Individual analysis comparing specific open surgery techniques versus endoscopic surgery could provide further insights into specific outcomes. Conclusions Perioperative outcomes obtained in this study are consistent with the previous series and meta-analysis after removing syndromic patients from the pool. Endoscopic procedures show lower rates of complications as well as lower costs for patients even after concluding helmet molding therapy. There is a concern about increased costs due to postoperative cranial orthosis; however, evidence shows total costs are lower in the endoscopic procedures even after including the helmets in the overall fee. This should be considered also in low-income countries as it could represent lower costs for healthcare systems and families with most centers having availability of endoscopes for other neurosurgical or surgical procedures. Different strategies should take place to promote early detection of patients with craniosynostosis among physicians in pediatric primary care looking to enhance efficient and early surgical consultation with a specialist. Early intervention with endoscopic surgery should be offered to all pediatric patients to seek a diminished rate of complications and diminished costs. Even though there are certain morphological tools to assess aesthetic postoperative outcomes such as cranial index (CI), CVA, and Whitaker classification, these instruments present a limited use for certain types of synostoses. This renders the need to seek developing alternatives to evaluate these outcomes. Declarations Author Contribution All authors contributed equally to the elaboration of this manuscript. Acknowledgement The authors want to acknowledge the illustration provided by Angela Isabella Arizpe Saldívar Data Availability All data is available in the manuscript. References Shlobin NA, Baticulon RE, Ortega CA, et al (2022) Global Epidemiology of Craniosynostosis: A Systematic Review and Meta-Analysis. World Neurosurg 164:413-423.e3. https://doi.org/10.1016/j.wneu.2022.05.093 Flaherty K, Singh N, Richtsmeier JT (2016) Understanding craniosynostosis as a growth disorder. 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BMJ 336:924–926. https://doi.org/10.1136/bmj.39489.470347.AD Magge SN, Bartolozzi AR, Almeida ND, et al (2019) A comparison of endoscopic strip craniectomy and pi craniectomy for treatment of sagittal craniosynostosis. J Neurosurg Pediatr 23:708–714. https://doi.org/10.3171/2019.1.PEDS18203 Abbott MM, Rogers GF, Proctor MR, et al (2012) Cost of Treating Sagittal Synostosis in the First Year of Life. J Craniofac Surg 23:88–93. https://doi.org/10.1097/SCS.0b013e318240f965 Arts S, Delye H, Van Lindert EJ (2018) Intraoperative and postoperative complications in the surgical treatment of craniosynostosis: minimally invasive versus open surgical procedures. J Neurosurg Pediatr 21:112–118. https://doi.org/10.3171/2017.7.PEDS17155 Bonfield CM, Sharma J, Cochrane DD, et al (2016) Minimizing blood transfusions in the surgical correction of craniosynostosis: a 10-year single-center experience. Childs Nerv Syst 32:143–151. https://doi.org/10.1007/s00381-015-2900-6 Braun TL, Eisemann BS, Olorunnipa O, et al (2018) Safety Outcomes in Endoscopic Versus Open Repair of Metopic Craniosynostosis. J Craniofac Surg 29:856–860. https://doi.org/10.1097/SCS.0000000000004299 Garber ST, Karsy M, Kestle JRW, et al (2017) Comparing Outcomes and Cost of 3 Surgical Treatments for Sagittal Synostosis: A Retrospective Study Including Procedure-Related Cost Analysis. Neurosurgery 81:680–687. https://doi.org/10.1093/neuros/nyx209 Guadix SW, Valenti A, Zappi KE, et al (2022) Examining the Role of Early Diagnostic Imaging for Craniosynostosis in the Era of Endoscopic Suturectomy: A Single Institution Experience. J Craniofac Surg 33:1363–1368. https://doi.org/10.1097/SCS.0000000000008534 Ha AY, Skolnick GB, Chi D, et al (2020) School-Aged Anthropometric Outcomes After Endoscopic or Open Repair of Metopic Synostosis. Pediatrics 146:e20200238. https://doi.org/10.1542/peds.2020-0238 Han RH, Nguyen DC, Bruck BS, et al (2016) Characterization of complications associated with open and endoscopic craniosynostosis surgery at a single institution. J Neurosurg Pediatr 17:361–370. https://doi.org/10.3171/2015.7.PEDS15187 Isaac KV, Meara JG, Proctor MR (2018) Analysis of clinical outcomes for treatment of sagittal craniosynostosis: a comparison of endoscopic suturectomy and cranial vault remodeling. J Neurosurg Pediatr 22:467–474. https://doi.org/10.3171/2018.5.PEDS1846 Keshavarzi S, Hayden MG, Ben-Haim S, et al (2009) Variations of Endoscopic and Open Repair of Metopic Craniosynostosis. J Craniofac Surg 20:1439–1444. https://doi.org/10.1097/SCS.0b013e3181af1555 Lepard J, Akbari SHA, Mooney J, et al (2021) Comparison of aesthetic outcomes between open and endoscopically treated sagittal craniosynostosis. J Neurosurg Pediatr 28:432–438. https://doi.org/10.3171/2021.3.PEDS20894 Liles C, Dallas J, Hale AT, et al (2019) The economic impact of open versus endoscope-assisted craniosynostosis surgery. J Neurosurg Pediatr 24:145–152. https://doi.org/10.3171/2019.4.PEDS18586 Melin AA, Moffitt J, Hopkins DC, et al (2020) Is Less Actually More? An Evaluation of Surgical Outcomes Between Endoscopic Suturectomy and Open Cranial Vault Remodeling for Craniosynostosis. J Craniofac Surg 31:924–926. https://doi.org/10.1097/SCS.0000000000006152 Mertens C, Wessel E, Berger M, et al (2017) The value of three-dimensional photogrammetry in isolated sagittal synostosis: Impact of age and surgical technique on intracranial volume and cephalic index─a retrospective cohort study. J Cranio-Maxillofac Surg 45:2010–2016. https://doi.org/10.1016/j.jcms.2017.09.019 Nguyen DC, Patel KB, Skolnick GB, et al (2015) Are Endoscopic and Open Treatments of Metopic Synostosis Equivalent in Treating Trigonocephaly and Hypotelorism? J Craniofac Surg 26:129–134. https://doi.org/10.1097/SCS.0000000000001321 Rattani A, Riordan CP, Meara JG, Proctor MR (2020) Comparative analysis of cranial vault remodeling versus endoscopic suturectomy in the treatment of unilateral lambdoid craniosynostosis. J Neurosurg Pediatr 26:105–112. https://doi.org/10.3171/2020.2.PEDS19522 Schulz M, Liebe-Püschel L, Seelbach K, et al (2021) Quantitative and qualitative comparison of morphometric outcomes after endoscopic and conventional correction of sagittal and metopic craniosynostosis versus control groups. Neurosurg Focus 50:E2. https://doi.org/10.3171/2021.1.FOCUS20988 Shah MN, Kane AA, Petersen JD, et al (2011) Endoscopically assisted versus open repair of sagittal craniosynostosis: the St. Louis Children’s Hospital experience: Clinical article. J Neurosurg Pediatr 8:165–170. https://doi.org/10.3171/2011.5.PEDS1128 Van Nunen DPF, Stubenitsky BM, Woerdeman PA, et al (2016) Minimally Invasive Strip Craniectomy Simplifies Anesthesia Practice in Patients With Isolated Sagittal Synostosis. J Craniofac Surg 27:1985–1990. https://doi.org/10.1097/SCS.0000000000003072 Vogel TW, Woo AS, Kane AA, et al (2014) A comparison of costs associated with endoscope-assisted craniectomy versus open cranial vault repair for infants with sagittal synostosis: Clinical article. J Neurosurg Pediatr 13:324–331. https://doi.org/10.3171/2013.12.PEDS13320 Zubovic E, Woo AS, Skolnick GB, et al (2015) Cranial Base and Posterior Cranial Vault Asymmetry After Open and Endoscopic Repair of Isolated Lambdoid Craniosynostosis. J Craniofac Surg 26:1568–1573. https://doi.org/10.1097/SCS.0000000000001891 Zubovic E, Lapidus JB, Skolnick GB, et al (2020) Cost comparison of surgical management of nonsagittal synostosis: traditional open versus endoscope-assisted techniques. J Neurosurg Pediatr 25:351–360. https://doi.org/10.3171/2019.11.PEDS19515 Di Rocco F, Proctor MR (2023) Technical evolution of pediatric neurosurgery: craniosynostosis from 1972 to 2023 and beyond. Childs Nerv Syst 39:2779–2787. https://doi.org/10.1007/s00381-023-06113-w Chong S, Wang K-C, Phi JH, et al (2016) Minimally Invasive Suturectomy and Postoperative Helmet Therapy : Advantages and Limitations. J Korean Neurosurg Soc 59:227–232. https://doi.org/10.3340/jkns.2016.59.3.227 Yousefi O, Taheri R, Sabahi M, et al (2023) Outcomes of the early endoscopic-assisted suturectomy for treatment of multisuture craniosynostosis. Neurosurg Rev 46:289. https://doi.org/10.1007/s10143-023-02191-1 Fotouhi AR, Patel KB, Skolnick GB, et al (2023) School-age anthropometric and patient-reported outcomes after open or endoscopic repair of sagittal craniosynostosis. J Neurosurg Pediatr 1–9. https://doi.org/10.3171/2023.5.PEDS2382 Nguyen HT, Washington GN, Cepeda A, et al (2024) Evaluation of Helmeting Therapy Duration After Endoscopic Strip Craniectomy for Metopic and Sagittal Craniosynostosis. J Craniofac Surg 35:415–418. https://doi.org/10.1097/SCS.0000000000009887 Habarth-Morales TE, Davis HD, Duca A, et al (2024) Factors associated with late surgical correction of craniosynostosis: A decade-long review of the United States nationwide readmission database. J Cranio-Maxillofac Surg S1010518224000635. https://doi.org/10.1016/j.jcms.2024.02.016 Hevia-Rodríguez P, Romero-López C, Martín-Fernández J, et al (2024) Endoscopy-Assisted Craniosynostosis Surgery without Postoperative Helmet Molding Therapy. World Neurosurg 183:79–85. https://doi.org/10.1016/j.wneu.2023.12.038 Kanack MD, Proctor MR, Meara JG, et al (2024) Hospital Variation and Resource Use for Infants with Craniosynostosis Undergoing Open, Endoscopic, and Distraction Osteogenesis Surgical Techniques. Cleft Palate Craniofacial J 10556656241227032. https://doi.org/10.1177/10556656241227032 Jimenez DF (2023) Endoscopic craniosynostosis surgery: an illustrated guide to endoscopic techniques, First edition. Elsevier, Philadelphia, PA Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 16 Dec, 2024 Read the published version in Child's Nervous System → Version 1 posted Editorial decision: Accepted 24 Nov, 2024 Reviews received at journal 24 Nov, 2024 Reviewers agreed at journal 24 Nov, 2024 Reviewers invited by journal 22 Nov, 2024 Editor assigned by journal 07 Nov, 2024 Submission checks completed at journal 07 Nov, 2024 First submitted to journal 06 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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2","display":"","copyAsset":false,"role":"figure","size":11323933,"visible":true,"origin":"","legend":"\u003cp\u003eROBINS-I tool for bias risk assessment in non-randomized control trials\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5404976/v1/fd5de21f6897346f78732437.png"},{"id":70927071,"identity":"d9b67c24-5540-470c-968d-470665e996dc","added_by":"auto","created_at":"2024-12-09 09:23:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1981298,"visible":true,"origin":"","legend":"\u003cp\u003eGRADE assessment for certainty\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5404976/v1/8caa94bd25dce7a6bdefaafb.png"},{"id":70924817,"identity":"fb848b07-9193-48f7-8000-d520dfa90667","added_by":"auto","created_at":"2024-12-09 09:07:06","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1259983,"visible":true,"origin":"","legend":"\u003cp\u003eForrest plot showing \u003cstrong\u003ea) \u003c/strong\u003edifferences in the age of patients undergoing surgery in both groups\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-5404976/v1/6bac2fbda7227a76a9b717eb.png"},{"id":70926684,"identity":"80005831-5c88-4461-a304-7184548dfc61","added_by":"auto","created_at":"2024-12-09 09:15:01","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1501261,"visible":true,"origin":"","legend":"\u003cp\u003eForrest plot for \u003cstrong\u003ea)\u003c/strong\u003e blood loss, \u003cstrong\u003eb)\u003c/strong\u003e transfusion rates, \u003cstrong\u003ec)\u003c/strong\u003etransfusion volumes, \u003cstrong\u003ed)\u003c/strong\u003e operative time\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-5404976/v1/11bd05b7915887c5a29870a5.png"},{"id":70926685,"identity":"f6b0ee78-bf86-4838-bc37-fbed595dd0f9","added_by":"auto","created_at":"2024-12-09 09:15:01","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":333563,"visible":true,"origin":"","legend":"\u003cp\u003eForrest plots for \u003cstrong\u003ea\u003c/strong\u003e) Length of stay, and \u003cstrong\u003eb) \u003c/strong\u003eIn-stay costs.\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-5404976/v1/f8443158efefac85488937e3.png"},{"id":70924806,"identity":"8df71f15-106b-48db-9ef0-c9f21e359ce3","added_by":"auto","created_at":"2024-12-09 09:07:01","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":1182383,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 6.\u003c/strong\u003e Diagnosis, treatment, and follow-up algorithm for patients with craniosynostosis.\u003c/p\u003e","description":"","filename":"Figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-5404976/v1/197894eaca893869dea30e30.png"},{"id":72201952,"identity":"4e21d761-264a-4557-8c63-917bf2706c66","added_by":"auto","created_at":"2024-12-23 16:12:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":25122708,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5404976/v1/efab4a96-c7b6-4126-a811-cf175ac97161.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Open Versus Endoscopic Surgery with Helmet Molding Therapy in Non-syndromic Patients with Craniosynostosis: An Updated Systematic Review and Meta-Analysis of Clinical Outcomes and Treatment-Related Costs","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCraniosynostosis is a congenital craniofacial disorder characterized by the premature fusion of one or more cranial sutures. It affects approximately 5.9 per 10,000 live births, thus rendering it the second most prevalent craniofacial disorder following orofacial clefts. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] It may manifest either in isolation as a distinct condition (non-syndromic craniosynostosis) or in association with other congenital anomalies in a syndromic manner (Shruti and Gulati, 2022). [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] In both scenarios, craniosynostosis presents diverse morphological variations fundamentally attributed to the cranial suture(s) undergoing premature fusion.\u003c/p\u003e \u003cp\u003eSagittal craniosynostosis comprises approximately 50\u0026ndash;58% of cases, whereas lambdoid craniosynostosis constitutes the least prevalent form, accounting for approximately 2\u0026ndash;4% of cases. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] If left untreated, this condition may prompt elevated intracranial pressure, neurocognitive impairments, and psychosocial challenges, while patients who undergo treatment typically course devoid of complications. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe treatment of craniosynostosis focuses on the surgical correction of the cranial defect while taking into consideration the need to expand or increase the intracranial volume, allowing for present and future decreases of intracranial pressure.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Surgical approaches are categorized into two primary groups: endoscopic and open procedures. Endoscopic procedures are typically followed by postoperative molding therapy with the aid of a helmet orthosis to enhance cranial remodeling.\u003c/p\u003e \u003cp\u003eEndoscopic surgery was pioneered during the 1990s by Jimenez and Barone for early correction of craniosynostosis with continuous publications of diverse series of patients undergoing these procedures. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Even though surgical outcomes suggested reduced time of surgery, blood loss, lesser costs, and optimal remodeling results; the evidence was limited to a single center and a single surgical team, making it difficult to adopt endoscopic surgery as a worldwide valid technique. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Similarly, total costs of inpatient (surgery, hospitalization, transfusions, etc) and outpatient (consults, helmet orthosis) care can be discernible variables within procedure selection. Previous meta-analyses comparing endoscopic and open surgery groups revealed consistent perioperative outcomes with the series initially published by Jimenez and Barone [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Still, these previous meta-analyses presented syndromic patients within the pool of data analyzed due to the scarce literature comparing open versus endoscopic procedures present at that time. Pitfalls of including syndromic patients include increasing risk of bias among the results presented. In recent years, evidence regarding endoscopic-assisted procedures has been increasing, demonstrating acceptance of endoscopic surgery.\u003c/p\u003e \u003cp\u003e In this systematic review and meta-analysis, we performed an updated analysis of previous reviews, including only non-syndromic patients. We also seek to provide a summary of the tendency of treatment observed in the literature. Similarly, this is the first study to include total costs within its analysis.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearch Strategy and selection criteria\u003c/h2\u003e \u003cp\u003eThe authors performed the elaboration of this systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. The protocol was not registered. We did a systematic search of the MEDLINE database via Scopus and PubMed and of the Embase database via OVID. Articles were eligible if they included cohorts comparing open procedures versus endoscopic surgery with a minimum number of 10 patients, non-syndromic patients, only pediatric patients and no adult subjects, diagnosed craniosynostosis of one or more sutures, age of patients from 1 month to 1 year of age. Some studies included syndromic patients in their cohorts; however, inclusion was possible as they presented separate data for them. Studies including syndromic patients with unavailability of separating data were excluded. Studies with no outcomes available were excluded. For patients who underwent endoscopic repair, inclusion was decided if posterior helmet molding therapy was described. Articles where helmet therapy was not mentioned or neglected were excluded. Surgical techniques were divided into open surgery and endoscopic procedures. For open surgery, techniques included were FOA, pi craniectomy, and CVR including possible modifications within the approaches. For endoscopic surgery, only strip craniectomy and suturectomy were included. Patients undergoing spring-assisted craniotomy were excluded from this study as its use usually requires a second intervention for spring removal. This statement could potentially bias results in the analysis.\u003c/p\u003e \u003cp\u003eThree previous meta-analyses comparing endoscopic versus open approaches in craniosynostosis were published in 2018. The systematic search performed in this study was designed to search for literature to fill the gap of data between the years 2018 and 2024. All articles included in the previous meta-analysis were screened using the selection criteria previously established. Eleven articles met inclusion criteria whilst x articles were excluded as they failed to fulfill them \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy selection and data extraction\u003c/h3\u003e\n\u003cp\u003eTwo authors (OROR \u0026amp; MTM) independently reviewed titles, abstracts, and citations using Rayyan Citation software. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] After two rounds of screening for studies meeting inclusion criteria, both authors performed a full-text evaluation for final inclusion in this study. Any discrepancies in data extraction were resolved by consensus discussion with a senior author (J.C.H). Variables were extracted from the final included studies with a randomized evaluation by one author at the end of the extraction to corroborate data. Extracted variables were baseline characteristics (sex, age at surgery), number of cases, affected suture(s), blood loss volume, transfusion rates and volume, operative time, length of stay, and in-stay costs.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe variables were analyzed using Review Manager 5.3. Heterogeneity was assessed using Higgins I2. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Studies with heterogeneity over 40% I2 were considered heterogeneous and were analyzed using random effects models. Studies with less than 40% I2 were not regarded as heterogenous and were analyzed using a fixed effects model [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Continuous data was analyzed using the inverse-variance method with results expressed in mean difference and 95% confidence intervals (CI). Dichotomous data was analyzed using the Mantel-Haenszel method, and outcomes were reported with odds ratio (OR) and 95% CI. If not reported, mean and standard deviation were estimated from the sample size, median, range, and/or interquartile range. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Resulting values with associated p values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered significant.\u003c/p\u003e \u003cp\u003eThe risk of bias in individual studies was assessed using the Cochrane Risk of Bias In Non-Randomized Studies of Interventions (ROBINS-I). [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e The overall certainty of the study was graded according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group guidelines. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e23 studies, reporting 2,018 patients, were included to review the current cumulative results [\u003cspan\u003e17\u003c/span\u003e\u0026ndash;\u003cspan\u003e39\u003c/span\u003e]. The patient\u0026rsquo;s characteristics are shown in Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"767\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eAge (Months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eSex\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eAffected Suture\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eEndoscopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eEndoscopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eEndoscopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eEndoscopic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAbbott 2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.53(10.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.08 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 6 (60%)\u003c/p\u003e\n \u003cp\u003eFemale: 4 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 7 (70%)\u003c/p\u003e\n \u003cp\u003eFemale: 3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eArts 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.53 (7.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.86 (1.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 sagittal\u003c/p\u003e\n \u003cp\u003e15 metopic\u003c/p\u003e\n \u003cp\u003e12 coronal unilateral\u003c/p\u003e\n \u003cp\u003e2 coronal bilateral\u003c/p\u003e\n \u003cp\u003e3 multi sutural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63 sagittal\u003c/p\u003e\n \u003cp\u003e35 metopic\u003c/p\u003e\n \u003cp\u003e14 coronal unilateral\u003c/p\u003e\n \u003cp\u003e1 coronal bilateral\u003c/p\u003e\n \u003cp\u003e3 multiple sutures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBonfield 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.04 (25.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.14 (0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71 sagittal\u003c/p\u003e\n \u003cp\u003e32 unicoronal\u003c/p\u003e\n \u003cp\u003e14 bicoronal\u003c/p\u003e\n \u003cp\u003e42 metopic\u003c/p\u003e\n \u003cp\u003e31 multiple sutures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBraun 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.73 (3.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.35 (.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 9 (100%)\u003c/p\u003e\n \u003cp\u003eFemale: 0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 7 (88%)\u003c/p\u003e\n \u003cp\u003eFemale: 1 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 Single suture metopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 Single suture metopic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGarber 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e272.67 (66.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e86.67 (23.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 74 (74%) Female 26 (26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 75 (75%)\u003c/p\u003e\n \u003cp\u003eFemale: 25 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1. 100 sagittal\u003c/p\u003e\n \u003cp\u003e2. 100 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGuadix 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.37 (3.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.4 (1.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eOverall cohort proportions\u003c/p\u003e\n \u003cp\u003eMales (70.5%)\u003c/p\u003e\n \u003cp\u003eFemales (29.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e64 sagittal (48.5%)\u003c/p\u003e\n \u003cp\u003e39 metopic (29.5%)\u003c/p\u003e\n \u003cp\u003e26 coronal (19.7%)\u003c/p\u003e\n \u003cp\u003e4 lambdoidal (3.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHa 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.4 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.3 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 10 (63%)\u003c/p\u003e\n \u003cp\u003eFemale: 6 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 12 (80%)\u003c/p\u003e\n \u003cp\u003eFemale: 3 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 metopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 metopic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHan 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15.5 (16.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.4 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e76 sagittal\u003c/p\u003e\n \u003cp\u003e31 metopic\u003c/p\u003e\n \u003cp\u003e28 coronal unilateral\u003c/p\u003e\n \u003cp\u003e7 lambdoid\u003c/p\u003e\n \u003cp\u003e1 coronal bilateral\u003c/p\u003e\n \u003cp\u003e12 multiple sutures (8 with 2 sutures, 3 with 3 sutures, 1 with 4 sutures)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e94 sagittal\u003c/p\u003e\n \u003cp\u003e24 metopic\u003c/p\u003e\n \u003cp\u003e10 coronal unilateral\u003c/p\u003e\n \u003cp\u003e6 lambdoid\u003c/p\u003e\n \u003cp\u003e2 coronal bilateral\u003c/p\u003e\n \u003cp\u003e7 multiple sutures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIsaac 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (10.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.63 (1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 10 (50%)\u003c/p\u003e\n \u003cp\u003eFemale: 10 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 137 (73%)\u003c/p\u003e\n \u003cp\u003eFemale: 50 (27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e187 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eKeshavarzi 2009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.9 m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 11 (65%)\u003c/p\u003e\n \u003cp\u003eFemale: 6 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 14 (87%)\u003c/p\u003e\n \u003cp\u003eFemale: 2 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 metopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 metopic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLepard 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.93 (2.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.63 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 29 (93.5%). Female: 2 (6.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 16 (84.2%)\u003c/p\u003e\n \u003cp\u003eFemale: 3 (15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLiles 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.69 (12.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.96 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMagge 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.06 (2.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.11 (1.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMelin 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19.93 (9.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.83 (0.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 34 (66.7%)\u003c/p\u003e\n \u003cp\u003eFemale: 17 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 28 (84.8%)\u003c/p\u003e\n \u003cp\u003eFemale: 5 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22 Metopic (43.1%)\u003c/p\u003e\n \u003cp\u003e20 Sagittal (39.2%)\u003c/p\u003e\n \u003cp\u003e9 Unicoronal (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 Metopic (39.4%)\u003c/p\u003e\n \u003cp\u003e18 Sagittal (54.5%)\u003c/p\u003e\n \u003cp\u003e2 Unicoronal (6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMertens 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.3 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.3 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e69 Male\u003c/p\u003e\n \u003cp\u003e16 Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNguyen 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.5 (6.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.3 (1.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 11/15 (70%)\u003c/p\u003e\n \u003cp\u003eFemale: 4/15 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 11/15 (70%)\u003c/p\u003e\n \u003cp\u003eFemale: 4/15 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 metopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 metopic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRattani 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.68 (0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.88 (1.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 5 (83.3%)\u003c/p\u003e\n \u003cp\u003eFemale: 1 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 6 (46.15%)\u003c/p\u003e\n \u003cp\u003eFemale: 7 (53.85%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 Right lambdoid\u003c/p\u003e\n \u003cp\u003e3 Left lambdoid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 Right lambdoid\u003c/p\u003e\n \u003cp\u003e8 Left lambdoid\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSchulz 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.62 (3.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.05 (0.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemales 8 (17%) Males: 39 (83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemales 10 (30%) Males 23 (70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29 Sagittal\u003c/p\u003e\n \u003cp\u003e18 Metopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 Sagittal\u003c/p\u003e\n \u003cp\u003e16 Metopic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eShah 2011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.8 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.6 (1.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 31 (74%)\u003c/p\u003e\n \u003cp\u003eFemale: 11 (26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 32 (68%)\u003c/p\u003e\n \u003cp\u003eFemale: 15 (32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVan Nunen 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.04 (5.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.32 (.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 11 (73.3%)\u003c/p\u003e\n \u003cp\u003eFemale: 4 (26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 16 (80%)\u003c/p\u003e\n \u003cp\u003eFemale: 4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVogel 2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.8 (1.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.1(.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 16 (76%)\u003c/p\u003e\n \u003cp\u003eFemale: 5 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale: 12 (57%)\u003c/p\u003e\n \u003cp\u003eFemale: 9 (43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eZubovic 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.8 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.5 (.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 lambdoid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 lambdoid\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eZubovic 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.7 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.5 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 Metopic\u003c/p\u003e\n \u003cp\u003e19 Unicoronal\u003c/p\u003e\n \u003cp\u003e2 Lambdoid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 Metopic\u003c/p\u003e\n \u003cp\u003e12 Unicoronal\u003c/p\u003e\n \u003cp\u003e7 Lambdoid\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eMean (Standard Deviation)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003eSex is presented as the number of patients (%).\u0026nbsp;\u003c/p\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eBaseline characteristics of patients in endoscopic and open surgery groups.\u0026nbsp;\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"774\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTime to start helmet therapy (Post Op. days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHours per day\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAge at which helmet treatment ends (Months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of treatment (Months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of helmets\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIndividual helmet cost\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTotal helmet costs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod of time between check-ups (weeks)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eAbbott 2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e$2,060.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eArts 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eHa 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eHan 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8-16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eIsaac 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eLepard 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eLiles 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e$1,650.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e$3,300.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eMagge 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eNguyen 2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2-4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eRattani 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.12 (1.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eSchulz 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSCS*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMCS**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eShah 2011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4-12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eVogel 2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e$2,813.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eZubovic 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eZubovic 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e$10,072.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2-3 weeks till 6 months old, then 4 weeks till 12 months old\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eSCS: sagittal craniosynostosis*\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMCS: metopic craniosynostosis**\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2:\u0026nbsp;\u003c/strong\u003eCharacteristics of helmet molding therapy in patients undergoing endoscopic surgery.\u0026nbsp;\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"802\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eAbbott 2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eLiles 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eZubovic 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003eGarber 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eEndoscopic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eEndoscopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eEndoscopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eEndoscopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCVR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOSS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eIn-Patient Costs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$53,758.25\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$15,149.25\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$30,475.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$13,746.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$95,188.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$38,868.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eProcedure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$40,947.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$11,927.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$18,647.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$9,399.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eICU/Hospital costs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$7,577.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$10,320.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$3,846.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eOther NON-ICU costs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$5,501.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$3,077.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$1,508.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$500.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eOut-Patient Costs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$7,327.50\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$8,033.75\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$2,107.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$3,851.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$400.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$10,072.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eOrthotic Services (total helmet services)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$2,060.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$1,650.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$3,300.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$10,072.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$7,575.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$6,286.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$457.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$551.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$400.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e$800.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eOverall cost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$60,311.25\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$23,157.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$31,314.10\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$18,081.47\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$95,588.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$50,840.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$45,078.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$20,535.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e$21,203.00\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\u003cstrong\u003eTable 3:\u0026nbsp;\u003c/strong\u003eOverall costs of procedures including in-patients and out-patients fees.\u0026nbsp;\n\u003c/div\u003e\n\u003ch3\u003eBaseline Characteristics\u003c/h3\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eAge at Surgery\u003c/h2\u003e\n \u003cp\u003eA total of 22 studies described the age at surgery, with a total of 992 patients in the endoscopic group and 993 patients in the open group. A meta-analysis of these data revealed a mean difference of -7.19 [-8.32, -6.07], p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.00001, concluding a younger age at surgery in the patients that underwent an endoscopic procedure. These findings are displayed in Fig.\u0026nbsp;\u003cspan\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eSurgical Outcomes\u003c/h3\u003e\n\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003eBlood Loss\u003c/h2\u003e\n \u003cp\u003eA total of 14 studies described the blood loss, reported in mL, with a total of 774 patients in the Endoscopic group and 578 patients in the Open group. A meta-analysis of these data revealed a mean difference of -191.47 [-246.87, -136.08], p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.00001, concluding a lower intraoperative blood loss in the endoscopic group. These findings are displayed in Fig.\u0026nbsp;\u003cspan\u003e5\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003eTransfusion Rates\u003c/h2\u003e\n \u003cp\u003eThe transfusion rates were described in 19 studies, with a total of 875 patients in the endoscopic group and 868 patients in the open group. A meta-analysis of these data revealed a mean difference of 0.02 [0.01, 0.05], p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.00001, concluding less transfusion rates in the endoscopic group. These findings are displayed in Fig.\u0026nbsp;\u003cspan\u003e5\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eTransfusion Volume\u003c/h2\u003e\n \u003cp\u003eThe transfusion volumes were described in 3 studies, with a total of 13 patients in the endoscopic group and 56 patients in the open group. A meta-analysis of these data revealed a mean difference of -258.25 [-307.20, -209.29], p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.00001, concluding a lower transfusion volume in the endoscopic group. These findings are displayed in Fig.\u0026nbsp;\u003cspan\u003e5\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003eOperative Time\u003c/h2\u003e\n \u003cp\u003eThe operative time was described in 15 studies, with a total of 664 patients in the endoscopic group and 517 patients in the open group. A meta-analysis of these data revealed a mean difference of -131.77 [-168.53, -95.02], p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.00001, concluding a lower operative time in the endoscopic group. These findings are displayed in Fig.\u0026nbsp;\u003cspan\u003e5\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003ePost-Operative Outcomes\u003c/h2\u003e\n \u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003eLength of Stay\u003c/h2\u003e\n \u003cp\u003eThe length of stay was described in 9 studies, with a total of 403 patients in the endoscopic group and 419 patients in the open group. A meta-analysis of these data revealed a mean difference of -2.18 [-2.73, -1.63], p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.00001, concluding a shorter length of stay in the endoscopic group. These findings are displayed in Fig.\u0026nbsp;\u003cspan\u003e6\u003c/span\u003e.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003eIn-Stay Costs\u003c/h2\u003e\n \u003cp\u003eA total of 4 studies described in-stay costs, with a total of 164 patients in the endoscopic group and 168 patients in the open group. A meta-analysis of these data revealed a mean difference of -19.44 [-21.15, -17.74], p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.00001, concluding a lower in-stay costs in the endoscopic group. These findings are displayed in Fig.\u0026nbsp;\u003cspan\u003e6\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eMinimally invasive suturectomy or endoscopic assisted suturectomy was a technique first described by Jimenez and Baron that addressed many of the disadvantages of open techniques such as prolonged operating time, extensive bleeding, the need for reoperations over time, and aesthetic outcomes. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Endoscopic strip craniectomy must be coupled with a remodeling device, that prevents the early fusion of the bone and allows more time for natural remodeling to take place. Sure devices are the postoperative helmet therapy or the springs. Spring-assisted remodeling could be employed if the family does not agree with helmet therapy or if the patient surpasses an optimal age for helmet use. Albeit there is evidence of optimal results in cranial shape growth in patients treated with springs, its use requires two separate procedures to remove the device. [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eBoth can help redirect a balanced, tridimensional growth and individual adjustment as the patient\u0026rsquo;s head grows. This fact makes patient selection an important aspect of surgery since sagittal synostosis patients between the ages of 3\u0026ndash;6 months benefit the most from the procedure allowing for earlier intervention but requiring prompt referral. [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] The endoscopic procedure\u0026rsquo;s success is heavily dependent on the rapid growth and development of the brain during the first 6 months of life, while the calvaria thickness is still quite modest allowing for rapid remodeling, hence the need for the orthotic remodeling device. Open surgery, on the other hand, can be done practically at any age, but preferably a bit later closer to 1 year of life when the blood volume is increased allowing for relatively safer operation.\u003c/p\u003e \u003cp\u003e With the pooled number of patients, we found consistent outcomes in the perioperative performance of patients according to previous reviews. Operative time showed a mean difference of 131.77 min (p\u0026thinsp;\u0026lt;\u0026thinsp;0.00001) favoring the endoscopic group. Similarly, blood loss and transfusion rates were significantly lower in patients undergoing endoscopic surgery compared to the control group with mean differences of 191.47 ml and an odds ratio of 0.002 respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;00001 and p\u0026thinsp;\u0026lt;\u0026thinsp;00001). When transfusions were deemed necessary in the endoscopic groups, volumes were significantly lower with a mean difference of 258.25 ml (p\u0026thinsp;\u0026lt;\u0026thinsp;00001) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eWe found no differences between the rate of males and females undergoing surgical correction. Still, patients treated with endoscopic surgery were significantly younger when compared to patients treated with open surgery with a mean of 7.19 months younger (p\u0026thinsp;\u0026lt;\u0026thinsp;0.00001) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Endoscopic surgery has classically been accepted for patients before 6 months of age, and open procedures have been accepted for patients older than 6 months, as younger patients present with thin bones and a small-sized calvarium, allowing faster and easier procedures using endoscopic techniques. [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] Still, endoscopic procedures have been proven to properly aid in the correction of craniosynostosis in older patients. [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHelmet molding therapy usually follows the endoscopic repair of craniosynostosis. According to most authors, helmet therapy usually starts on the first postoperative day and up to 7 days after surgery \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003e)\u003c/b\u003e [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] with a mean duration of 8.68 months using the orthosis around 23 hours a day. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33 CR34\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] Nevertheless, the duration of the helmet can differ between the suture(s) affected. Nguyen et al. (2024) showed a significantly increased duration of helmet therapy in patients with metopic craniosynostosis when compared to patients with sagittal defects. [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] Each patient requires around 2 or 3 helmets with some patients going up to 4 helmets. Each helmet bears an approximate cost of around US \u003cspan\u003e$\u003c/span\u003e1,650, but costs may differ between manufacturers. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] Authors in previous works reported diminished costs even after treatment with helmet orthosis \u003cb\u003e(Table\u0026nbsp;3)\u003c/b\u003e. Total costs are directly related to procedure charges, ICU or hospital costs, outpatient treatment (number of helmets and consults), and others. Nevertheless, patients in the endoscopic group have a lower total fee even after helmets and other charges for outpatient care.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of helmet molding therapy in patients undergoing endoscopic surgery.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c4\" namest=\"c3\" rowspan=\"2\"\u003e \u003cp\u003eAbbott 2012\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003eLiles 2019\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c8\" namest=\"c7\" rowspan=\"2\"\u003e \u003cp\u003eZubovic 2020\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eGarber 2017\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEndoscopic\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEndoscopic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEndoscopic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEndoscopic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCVR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOSS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e In-Patient Costs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e$53,758.25\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e$15,149.25\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e$30,475.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e$13,746.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e$95,188.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e$38,868.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eProcedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e40,947.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e11,927.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e18,647.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e9,399.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eICU/Hospital costs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e7,577.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e10,320.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e3,846.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOther NON-ICU costs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e5,501.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e3,077.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1,508.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e500.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOut-Patient Costs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e$7,327.50\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e$8,033.75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e$2,107.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e$3,851.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e$400.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e$10,072.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOrthotic Services (total helmet services)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2,060.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1,650.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e3,300.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e10,072.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e7,575.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e6,286.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e457.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e551.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e400.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e800.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOverall cost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e$60,311.25\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e$23,157.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e$31,314.10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e$18,081.47\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e$95,588.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e$50,840.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e$45,078.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e$20,535.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e$21,203.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePatients in the control group had a mean difference of 2.18 days more of hospital stay compared to the endoscopic group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.00001) which can have a direct rise in total costs for each patient \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e6\u003c/span\u003e \u003cb\u003e)\u003c/b\u003e. In the present review, significantly reduced costs were observed for patients in the endoscopic group with a mean difference of \u003cspan\u003e$\u003c/span\u003e19,440 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e6\u003c/span\u003e \u003cb\u003e)\u003c/b\u003e. Late correction of craniosynostosis can be related to a higher rate of complications, potential neurocognitive impairment, and a higher burden of costs for insurance, healthcare systems, and families. The surgical correction after 1 year of age has an estimation of an increased mean difference of \u003cspan\u003e$\u003c/span\u003e8400 (US dollars). [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] A recent retrospective 10-year series published in 2024 by Hevia-Rodriguez et al. points out optimal results in 71% of the assessed population that underwent endoscopic repair without the use of posterior orthotic therapy. [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] Aesthetic results were deemed optimal in most patients with reduced costs. Evidence comparing postoperative helmet molding therapy and deferred orthotic therapy remains unavailable. Literature comparing patients with orthotic therapy and patients without it could help determine if deferred orthotic therapy could be considered optimal in the case of low-income countries or families.\u003c/p\u003e \u003cp\u003eDespite the aforementioned, the management of patients with craniosynostosis is highly heterogeneous. There is a substantial variation in the management of these patients with no standardized protocols nor any systematic tools providing an evidence-based algorithm for the treatment of these patients. [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] Standardized clinical guidelines are still impeded due to scarce or nonexistent statistical evidence for many variables. Still, different recommendations can be made based on previous and present reviews among other literature available. Here, we present a graphic representation of the treatment algorithm for the management of patients with craniosynostosis based on the recommendations of experts and the tendencies observed in this review. \u003cb\u003e(Fig.\u0026nbsp;7)\u003c/b\u003e. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] This representation could provide easier analysis for younger physicians and aid them in analyzing previously published evidence.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eLimitations of this study include the lack of randomized controlled trials evaluating results between both groups. All studies included present a high degree of risk of bias mainly due to patient selection and confounding.\u003c/p\u003e \u003cp\u003eThe great majority of literature classifies surgery between open and endoscopic procedures therefore comparisons between techniques are potentially biased. Individual analysis comparing specific open surgery techniques versus endoscopic surgery could provide further insights into specific outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePerioperative outcomes obtained in this study are consistent with the previous series and meta-analysis after removing syndromic patients from the pool. Endoscopic procedures show lower rates of complications as well as lower costs for patients even after concluding helmet molding therapy. There is a concern about increased costs due to postoperative cranial orthosis; however, evidence shows total costs are lower in the endoscopic procedures even after including the helmets in the overall fee. This should be considered also in low-income countries as it could represent lower costs for healthcare systems and families with most centers having availability of endoscopes for other neurosurgical or surgical procedures.\u003c/p\u003e \u003cp\u003eDifferent strategies should take place to promote early detection of patients with craniosynostosis among physicians in pediatric primary care looking to enhance efficient and early surgical consultation with a specialist. Early intervention with endoscopic surgery should be offered to all pediatric patients to seek a diminished rate of complications and diminished costs. Even though there are certain morphological tools to assess aesthetic postoperative outcomes such as cranial index (CI), CVA, and Whitaker classification, these instruments present a limited use for certain types of synostoses. This renders the need to seek developing alternatives to evaluate these outcomes.\u003c/p\u003e"},{"header":"Declarations","content":" \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed equally to the elaboration of this manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors want to acknowledge the illustration provided by Angela Isabella Arizpe Sald\u0026iacute;var\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data is available in the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eShlobin NA, Baticulon RE, Ortega CA, et al (2022) Global Epidemiology of Craniosynostosis: A Systematic Review and Meta-Analysis. World Neurosurg 164:413-423.e3. https://doi.org/10.1016/j.wneu.2022.05.093\u003c/li\u003e\n\u003cli\u003eFlaherty K, Singh N, Richtsmeier JT (2016) Understanding craniosynostosis as a growth disorder. WIREs Dev Biol 5:429\u0026ndash;459. https://doi.org/10.1002/wdev.227\u003c/li\u003e\n\u003cli\u003eN M S, Gulati S (2022) Craniosynostosis: A pediatric neurologist\u0026rsquo;s perspective. J Pediatr Neurosci 17:54. https://doi.org/10.4103/jpn.JPN_25_22\u003c/li\u003e\n\u003cli\u003eKimonis V, Gold J-A, Hoffman TL, et al (2007) Genetics of Craniosynostosis. Semin Pediatr Neurol 14:150\u0026ndash;161. https://doi.org/10.1016/j.spen.2007.08.008\u003c/li\u003e\n\u003cli\u003eWolfswinkel EM, Sanchez‐Lara PA, Jacob L, Urata MM (2021) Postoperative helmet therapy following fronto‐orbital advancement and cranial vault remodeling in patients with unilateral coronal synostosis. Am J Med Genet A 185:2670\u0026ndash;2675. https://doi.org/10.1002/ajmg.a.62256\u003c/li\u003e\n\u003cli\u003eJimenez DF, Barone CM (1998) Endoscopic craniectomy for early surgical correction of sagittal craniosynostosis. J Neurosurg 88:77\u0026ndash;81. https://doi.org/10.3171/jns.1998.88.1.0077\u003c/li\u003e\n\u003cli\u003eJimenez DF, McGinity MJ, Barone CM (2019) Endoscopy-assisted early correction of single-suture metopic craniosynostosis: a 19-year experience. J Neurosurg Pediatr 23:61\u0026ndash;74. https://doi.org/10.3171/2018.6.PEDS1749\u003c/li\u003e\n\u003cli\u003eGoyal A, Lu VM, Yolcu YU, et al (2018) Endoscopic versus open approach in craniosynostosis repair: a systematic review and meta-analysis of perioperative outcomes. Childs Nerv Syst ChNS Off J Int Soc Pediatr Neurosurg 34:1627\u0026ndash;1637. https://doi.org/10.1007/s00381-018-3852-4\u003c/li\u003e\n\u003cli\u003eYan H, Abel TJ, Alotaibi NM, et al (2018) A systematic review and meta-analysis of endoscopic versus open treatment of craniosynostosis. Part 1: the sagittal suture. 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Wiley-Blackwell, Chichester, England ; Hoboken, NJ\u003c/li\u003e\n\u003cli\u003eWan X, Wang W, Liu J, Tong T (2014) Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 14:135. https://doi.org/10.1186/1471-2288-14-135\u003c/li\u003e\n\u003cli\u003eSterne JA, Hern\u0026aacute;n MA, Reeves BC, et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919. https://doi.org/10.1136/bmj.i4919\u003c/li\u003e\n\u003cli\u003eGuyatt GH, Oxman AD, Vist GE, et al (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 336:924\u0026ndash;926. https://doi.org/10.1136/bmj.39489.470347.AD\u003c/li\u003e\n\u003cli\u003eMagge SN, Bartolozzi AR, Almeida ND, et al (2019) A comparison of endoscopic strip craniectomy and pi craniectomy for treatment of sagittal craniosynostosis. J Neurosurg Pediatr 23:708\u0026ndash;714. https://doi.org/10.3171/2019.1.PEDS18203\u003c/li\u003e\n\u003cli\u003eAbbott MM, Rogers GF, Proctor MR, et al (2012) Cost of Treating Sagittal Synostosis in the First Year of Life. J Craniofac Surg 23:88\u0026ndash;93. https://doi.org/10.1097/SCS.0b013e318240f965\u003c/li\u003e\n\u003cli\u003eArts S, Delye H, Van Lindert EJ (2018) Intraoperative and postoperative complications in the surgical treatment of craniosynostosis: minimally invasive versus open surgical procedures. J Neurosurg Pediatr 21:112\u0026ndash;118. https://doi.org/10.3171/2017.7.PEDS17155\u003c/li\u003e\n\u003cli\u003eBonfield CM, Sharma J, Cochrane DD, et al (2016) Minimizing blood transfusions in the surgical correction of craniosynostosis: a 10-year single-center experience. Childs Nerv Syst 32:143\u0026ndash;151. https://doi.org/10.1007/s00381-015-2900-6\u003c/li\u003e\n\u003cli\u003eBraun TL, Eisemann BS, Olorunnipa O, et al (2018) Safety Outcomes in Endoscopic Versus Open Repair of Metopic Craniosynostosis. J Craniofac Surg 29:856\u0026ndash;860. https://doi.org/10.1097/SCS.0000000000004299\u003c/li\u003e\n\u003cli\u003eGarber ST, Karsy M, Kestle JRW, et al (2017) Comparing Outcomes and Cost of 3 Surgical Treatments for Sagittal Synostosis: A Retrospective Study Including Procedure-Related Cost Analysis. Neurosurgery 81:680\u0026ndash;687. https://doi.org/10.1093/neuros/nyx209\u003c/li\u003e\n\u003cli\u003eGuadix SW, Valenti A, Zappi KE, et al (2022) Examining the Role of Early Diagnostic Imaging for Craniosynostosis in the Era of Endoscopic Suturectomy: A Single Institution Experience. J Craniofac Surg 33:1363\u0026ndash;1368. https://doi.org/10.1097/SCS.0000000000008534\u003c/li\u003e\n\u003cli\u003eHa AY, Skolnick GB, Chi D, et al (2020) School-Aged Anthropometric Outcomes After Endoscopic or Open Repair of Metopic Synostosis. Pediatrics 146:e20200238. https://doi.org/10.1542/peds.2020-0238\u003c/li\u003e\n\u003cli\u003eHan RH, Nguyen DC, Bruck BS, et al (2016) Characterization of complications associated with open and endoscopic craniosynostosis surgery at a single institution. J Neurosurg Pediatr 17:361\u0026ndash;370. https://doi.org/10.3171/2015.7.PEDS15187\u003c/li\u003e\n\u003cli\u003eIsaac KV, Meara JG, Proctor MR (2018) Analysis of clinical outcomes for treatment of sagittal craniosynostosis: a comparison of endoscopic suturectomy and cranial vault remodeling. J Neurosurg Pediatr 22:467\u0026ndash;474. https://doi.org/10.3171/2018.5.PEDS1846\u003c/li\u003e\n\u003cli\u003eKeshavarzi S, Hayden MG, Ben-Haim S, et al (2009) Variations of Endoscopic and Open Repair of Metopic Craniosynostosis. J Craniofac Surg 20:1439\u0026ndash;1444. https://doi.org/10.1097/SCS.0b013e3181af1555\u003c/li\u003e\n\u003cli\u003eLepard J, Akbari SHA, Mooney J, et al (2021) Comparison of aesthetic outcomes between open and endoscopically treated sagittal craniosynostosis. J Neurosurg Pediatr 28:432\u0026ndash;438. https://doi.org/10.3171/2021.3.PEDS20894\u003c/li\u003e\n\u003cli\u003eLiles C, Dallas J, Hale AT, et al (2019) The economic impact of open versus endoscope-assisted craniosynostosis surgery. J Neurosurg Pediatr 24:145\u0026ndash;152. https://doi.org/10.3171/2019.4.PEDS18586\u003c/li\u003e\n\u003cli\u003eMelin AA, Moffitt J, Hopkins DC, et al (2020) Is Less Actually More? An Evaluation of Surgical Outcomes Between Endoscopic Suturectomy and Open Cranial Vault Remodeling for Craniosynostosis. J Craniofac Surg 31:924\u0026ndash;926. https://doi.org/10.1097/SCS.0000000000006152\u003c/li\u003e\n\u003cli\u003eMertens C, Wessel E, Berger M, et al (2017) The value of three-dimensional photogrammetry in isolated sagittal synostosis: Impact of age and surgical technique on intracranial volume and cephalic index─a retrospective cohort study. J Cranio-Maxillofac Surg 45:2010\u0026ndash;2016. https://doi.org/10.1016/j.jcms.2017.09.019\u003c/li\u003e\n\u003cli\u003eNguyen DC, Patel KB, Skolnick GB, et al (2015) Are Endoscopic and Open Treatments of Metopic Synostosis Equivalent in Treating Trigonocephaly and Hypotelorism? J Craniofac Surg 26:129\u0026ndash;134. https://doi.org/10.1097/SCS.0000000000001321\u003c/li\u003e\n\u003cli\u003eRattani A, Riordan CP, Meara JG, Proctor MR (2020) Comparative analysis of cranial vault remodeling versus endoscopic suturectomy in the treatment of unilateral lambdoid craniosynostosis. J Neurosurg Pediatr 26:105\u0026ndash;112. https://doi.org/10.3171/2020.2.PEDS19522\u003c/li\u003e\n\u003cli\u003eSchulz M, Liebe-P\u0026uuml;schel L, Seelbach K, et al (2021) Quantitative and qualitative comparison of morphometric outcomes after endoscopic and conventional correction of sagittal and metopic craniosynostosis versus control groups. Neurosurg Focus 50:E2. https://doi.org/10.3171/2021.1.FOCUS20988\u003c/li\u003e\n\u003cli\u003eShah MN, Kane AA, Petersen JD, et al (2011) Endoscopically assisted versus open repair of sagittal craniosynostosis: the St. Louis Children\u0026rsquo;s Hospital experience: Clinical article. J Neurosurg Pediatr 8:165\u0026ndash;170. https://doi.org/10.3171/2011.5.PEDS1128\u003c/li\u003e\n\u003cli\u003eVan Nunen DPF, Stubenitsky BM, Woerdeman PA, et al (2016) Minimally Invasive Strip Craniectomy Simplifies Anesthesia Practice in Patients With Isolated Sagittal Synostosis. J Craniofac Surg 27:1985\u0026ndash;1990. https://doi.org/10.1097/SCS.0000000000003072\u003c/li\u003e\n\u003cli\u003eVogel TW, Woo AS, Kane AA, et al (2014) A comparison of costs associated with endoscope-assisted craniectomy versus open cranial vault repair for infants with sagittal synostosis: Clinical article. J Neurosurg Pediatr 13:324\u0026ndash;331. https://doi.org/10.3171/2013.12.PEDS13320\u003c/li\u003e\n\u003cli\u003eZubovic E, Woo AS, Skolnick GB, et al (2015) Cranial Base and Posterior Cranial Vault Asymmetry After Open and Endoscopic Repair of Isolated Lambdoid Craniosynostosis. J Craniofac Surg 26:1568\u0026ndash;1573. https://doi.org/10.1097/SCS.0000000000001891\u003c/li\u003e\n\u003cli\u003eZubovic E, Lapidus JB, Skolnick GB, et al (2020) Cost comparison of surgical management of nonsagittal synostosis: traditional open versus endoscope-assisted techniques. J Neurosurg Pediatr 25:351\u0026ndash;360. https://doi.org/10.3171/2019.11.PEDS19515\u003c/li\u003e\n\u003cli\u003eDi Rocco F, Proctor MR (2023) Technical evolution of pediatric neurosurgery: craniosynostosis from 1972 to 2023 and beyond. Childs Nerv Syst 39:2779\u0026ndash;2787. https://doi.org/10.1007/s00381-023-06113-w\u003c/li\u003e\n\u003cli\u003eChong S, Wang K-C, Phi JH, et al (2016) Minimally Invasive Suturectomy and Postoperative Helmet Therapy : Advantages and Limitations. J Korean Neurosurg Soc 59:227\u0026ndash;232. https://doi.org/10.3340/jkns.2016.59.3.227\u003c/li\u003e\n\u003cli\u003eYousefi O, Taheri R, Sabahi M, et al (2023) Outcomes of the early endoscopic-assisted suturectomy for treatment of multisuture craniosynostosis. Neurosurg Rev 46:289. https://doi.org/10.1007/s10143-023-02191-1\u003c/li\u003e\n\u003cli\u003eFotouhi AR, Patel KB, Skolnick GB, et al (2023) School-age anthropometric and patient-reported outcomes after open or endoscopic repair of sagittal craniosynostosis. J Neurosurg Pediatr 1\u0026ndash;9. https://doi.org/10.3171/2023.5.PEDS2382\u003c/li\u003e\n\u003cli\u003eNguyen HT, Washington GN, Cepeda A, et al (2024) Evaluation of Helmeting Therapy Duration After Endoscopic Strip Craniectomy for Metopic and Sagittal Craniosynostosis. J Craniofac Surg 35:415\u0026ndash;418. https://doi.org/10.1097/SCS.0000000000009887\u003c/li\u003e\n\u003cli\u003eHabarth-Morales TE, Davis HD, Duca A, et al (2024) Factors associated with late surgical correction of craniosynostosis: A decade-long review of the United States nationwide readmission database. J Cranio-Maxillofac Surg S1010518224000635. https://doi.org/10.1016/j.jcms.2024.02.016\u003c/li\u003e\n\u003cli\u003eHevia-Rodr\u0026iacute;guez P, Romero-L\u0026oacute;pez C, Mart\u0026iacute;n-Fern\u0026aacute;ndez J, et al (2024) Endoscopy-Assisted Craniosynostosis Surgery without Postoperative Helmet Molding Therapy. World Neurosurg 183:79\u0026ndash;85. https://doi.org/10.1016/j.wneu.2023.12.038\u003c/li\u003e\n\u003cli\u003eKanack MD, Proctor MR, Meara JG, et al (2024) Hospital Variation and Resource Use for Infants with Craniosynostosis Undergoing Open, Endoscopic, and Distraction Osteogenesis Surgical Techniques. Cleft Palate Craniofacial J 10556656241227032. https://doi.org/10.1177/10556656241227032\u003c/li\u003e\n\u003cli\u003eJimenez DF (2023) Endoscopic craniosynostosis surgery: an illustrated guide to endoscopic techniques, First edition. Elsevier, Philadelphia, PA\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5404976/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5404976/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective There is an ongoing debate regarding the optimal treatment for craniosynostosis as diverse factors influence the election between endoscopic and open surgery. Previous evidence favors endoscopic procedures; However, evidence remains unfulfilled by a limited number of patients and clustered in very few centers worldwide making it difficult to define it as a replicable technique in different populations. In recent years, evidence regarding endoscopic-assisted procedures has gone through a considerable spurt showing an increased interest among surgeons globally showing optimal outcomes in different populations and centers. In this systematic review and meta-analysis, we performed an updated analysis of previous reviews, including only non-syndromic patients. We also seek to provide a summary of the tendency of treatment observed in the literature. Similarly, this is the first study to include total costs within its analysis.\u003c/p\u003e\n\u003cp\u003eMaterial and Methods Three previous meta-analyses published in 2018 yielded 11 eligible papers. We performed a systematic review and meta-analysis of the literature in MEDLINE and EMBASE databases through PubMed, Scopus, and Ovid to fill the gap of information between 2018 and 2024. 23 total articles were included in the final analysis.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults Variables analyzed were baseline characteristics, length of stay, blood loss, transfusion rates and volume, operative time, and costs. Analysis of data concluded a younger age at surgery in patients undergoing endoscopic surgery (p= \u0026lt;0.00001). Blood loss, transfusion rates, and volumes depicted favored outcomes for endoscopy with less blood loss during surgery (p = \u0026lt;0.00001), operative time (p=\u0026lt;0.00001), and transfusion rates (p=\u0026lt;0.00001) as well as lower transfused volumes (p = \u0026lt;0.00001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusion Endoscopic surgery carries fewer complications than open surgery. Treatment-related costs are highly decreased in endoscopic procedures after including costs related to outpatient care. Open surgery can be considered in older children if no endoscope or experienced surgeons in endoscopic procedures are available.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Open Versus Endoscopic Surgery with Helmet Molding Therapy in Non-syndromic Patients with Craniosynostosis: An Updated Systematic Review and Meta-Analysis of Clinical Outcomes and Treatment-Related Costs","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-09 09:06:56","doi":"10.21203/rs.3.rs-5404976/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2024-11-24T20:08:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-24T16:39:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"148719324205104187001494226575191497469","date":"2024-11-24T16:23:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-22T17:48:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-07T13:02:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-07T13:01:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child's Nervous System","date":"2024-11-06T18:31:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0ba5a1d8-9497-4a8c-97e0-540777386c12","owner":[],"postedDate":"December 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:04:41+00:00","versionOfRecord":{"articleIdentity":"rs-5404976","link":"https://doi.org/10.1007/s00381-024-06692-2","journal":{"identity":"childs-nervous-system","isVorOnly":false,"title":"Child's Nervous System"},"publishedOn":"2024-12-16 15:58:16","publishedOnDateReadable":"December 16th, 2024"},"versionCreatedAt":"2024-12-09 09:06:56","video":"","vorDoi":"10.1007/s00381-024-06692-2","vorDoiUrl":"https://doi.org/10.1007/s00381-024-06692-2","workflowStages":[]},"version":"v1","identity":"rs-5404976","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5404976","identity":"rs-5404976","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}