A Head of the Curve: Investigating Helmet Therapy Compliance in Patients With Craniosynostosis

BACKGROUND: Adherence to helmet therapy is critical for achieving optimal cranial molding following endoscopic strip craniectomy (ESC). Limited data exist on factors influencing compliance, which may inform surgical planning and family counseling. This study evaluated clinical and sociodemographic factors associated with helmet therapy compliance in infants with sagittal craniosynostosis. METHODS: A retrospective review was performed of patients with nonsyndromic sagittal craniosynostosis who underwent ESC with postoperative helmet therapy between 2015 and 2024. Patients with open cranial vault reconstruction or other craniosynostosis types were excluded. Demographic, socioeconomic, morphometric, and helmet therapy variables were collected. Compliance was defined as completing therapy and attending >90% of follow-up visits. Patients were classified as compliant (CP) or noncompliant (NC). Statistical analysis was performed in R with significance set at P<0.05. RESULTS: Of 48 patients, 40 (83.3%) were CP and 8 (16.7%) NC. Median age at surgery was 3 months; 77.1% were male, and 62.5% had private insurance. CP patients underwent surgery at a younger age (3.0 versus 4.0 mo, P=0.038) and had fewer days between helmet visits (7.6 versus 9.5, P=0.004). No differences were observed in insurance, race, distance, or therapy duration. Morphometric outcomes were similar between groups. NC patients were more likely to require secondary surgery (25% versus 0%, P=0.012). CONCLUSION: Additional preoperative counseling that addresses potential adherence barriers may help guide surgical planning and improve outcomes for helmet therapy compliance. Families facing greater logistical and socioeconomic challenges may benefit from alternative surgical options.