The purpose of this is to inform relevant professionals involved in the care of children who meet assessment criterion for Endoscopic craniofacial surgery.
To provide families opportunity to make an informed choice for treatment options available for treatment of craniosynostosis
Ward Staff 3a including medical and nursing staff; Neurosurgical team; Hospital at Night; Paediatric Intensive Care; Anaesthetics
Endoscopic strip craniectomy (ESC) is a minimally invasive surgical procedure that can be used to treat
ESC may be offered as a treatment choice for children with the above conditions presenting to the craniofacial clinic <16 weeks of age.
Full informed consent around treatment options will be provided to empower parental choice.
Careful consideration of parental commitment to the post-operative orthotic course should be emphasised.
Parents should be apprised that this is a new procedure to Glasgow craniofacial service and long term outcomes are not available at present.
Patient selection should also be discussed with orthotics department for suitability of orthosis.
Minimally invasive technique. Incisions will be smallest size to safely perform osteotomies, an endoscope is used for appropriate visualisation.
Strip craniectomy to completely release the affected fused suture to allow for mobilisation of the skull to provide optimal post-operative outcomes following the period of helmet therapy.
The majority of patients undergoing endoscopic cranial surgery for craniosynostosis will be nursed in Ward 3A post-operatively. However, some high risk patients with pre-existing airway or respiratory compromise, or other significant co-morbidity, will still require critical care support post-operatively. This will be agreed by the Consultant Surgeon and Anaesthetist in advance of the procedure and a critical care bed booked appropriately.
Patients can be nursed in single room or four bed bay depending on clinical needs.
Recovery nurse will give a verbal handover to ward nurse with written instructions on the operation note.
Continuous Sp02 monitoring and a high level of observation for post-operative decline in Glasgow Coma Score or suggestion of intracranial bleeding.
Document HR, BP, Sp02, RR, Temp, CRT and GCS on PEWS chart
PEWS Policy for MEDICAL REVIEW should be activated at any time if indicated by PEWS score or concern about airway compromise.
Regular IV Paracetamol and Ibuprofen when tolerating milk/diet with PRN Oramorph will be prescribed according to the RHC Acute Pain Protocol. After the first 12-24hrs post op transition to oral paracetamol can be implemented.
A dose of antibiotics will be given at induction of anaesthesia. There is no routine requirement for post-operative antibiotics.
IV access must be maintained for at least 24 hrs
IV maintenance fluids (usually 70% maintenance plasmalyte in 5% dextrose) should be continued from theatre.
Encourage oral fluids and soft diet if weaned, and reduce IV fluids appropriately.
The HaN team do not possess airway skills. They will respond to routine tasks such as requests for re-siting of cannulae, and will of course attend in acute deterioration or emergency situation but they will not be the “decision makers” for the cases overnight.
Examples of who to contact in the following situations:
Patient will be reviewed by the craniofacial team. Child will be encouraged to eat and drink as able and nursed upright to assist with swelling. Continue with regular pain relief.
Dressings will be removed (if in-situ) to visualise wound, Steri-strips if utilised can remain in-situ for 5-7 days. Wound care advice will be provided by CNS.
Patients can be discharged following craniofacial/neurosurgical review.
Wound review will be completed at 2 weeks post-op by CNS
Initial follow up at craniofacial clinic will be 6 weeks post-op.
Prior to discharge family will be provided with appointment for orthotic department, Clinic 12 RCH.
Treatment will be provided by members of the orthotic department who have completed Orthomerica training and have working knowledge of moulding helmets.
Baseline non-invasive helmet scan pre surgery will be completed for comparison
Post-op helmet scan will be completed 2-4 days post-operatively where the first helmet will be manufactured by Orthomerica
On receipt of helmet in the orthotic department family will be appointed to attend for first helmet fitting. It is the clinical aim to commence orthosis 10-14days post operatively.
Each child will require 2-3 helmets that must be worn for 23hours/day for between 6-18months.
Frequent review and alterations will be provided by orthotic department (sometimes utilising telephone and virtual options):
Month 0-1 – Every 1-2 weeks
Month 1-3 – Every 2-3 weeks
Month 3-18 – Every 3-4 weeks
New Helmets may initially necessitate more frequent reviews at approx. 2-3 weeks.
Baseline anthropometric measurements will be obtained along with updated measurements for comparison at each review.
If suitable for the patient a scan and clinical photography will be taken at Pre-Op, every new helmet and finish of treatment and can be utilised for comparison.
More scans may be taken as required for orthotic needs and further assessment of progress.
Decision to stop helmet therapy will be jointly made between operating surgeon and lead orthotist.
Data collected will include;
Ongoing follow up as per usual course in craniofacial service will be provided to allow assessment of long term outcomes. This will be provided at 6 weeks, 6 months, 1 year post op, followed by age 3, age 5, age 10 and age 15.
Last reviewed: 10 January 2024
Next review: 31 July 2024
Author(s): Mr Sangra, Consultant (Neurosurgery); Mr Halsnad, Consultant (OMFS); Dr Young, Consultant (Anaesthetics); Dr Hivey (Anaesthetics); M Dixon (Orthotics); L Baillie, Craniofacial Clinical Nurse Specialist
Approved By: Craniofacial Surgery