Endoscopic strip craniectomy with helmet therapy for craniosynostosis: a retrospective review of the Sydney experience

Introduction: Endoscopic strip craniectomy (ESC) followed by helmet therapy is a minimally invasive technique that has emerged as an alternative to open cranial vault procedures to manage young infants with craniosynostosis. In 2022, the Sydney Children’s Hospitals Network adopted ESC as part of a revised, age-sensitive management algorithm for craniosynostosis. This study is a retrospective chart review of patients with craniosynostosis treated with ESC and postoperative helmet therapy at the Sydney Children’s Hospitals Network. Methods: Patients with craniosynostosis seen at the Sydney Children’s Hospitals Network between November 2022 and January 2025 were included in the study. Patient demographics, operative and helmet details, outcomes and complications were collected. Results: A total of 82 patients (25 female; 57 male; mean age 3.4 months) underwent ESC during the study period to treat sagittal (39), metopic (29), unicoronal (11), multi-suture (2) and lambdoid (1) craniosynostosis in a combined approach with plastic surgery and neurosurgery. Intraoperative (6%) and postoperative (14.6%) complications did not result in any long-term consequences. The transfusion rate was 48.7 per cent. The duration of helmet therapy was six to eight months, with an average of 10 fitting appointments. Five (6.1%) patients had late surgery (one due to unsatisfactory aesthetic correction, four related to elevated intracranial pressure). Conclusion: Endoscopic strip craniectomy with helmet therapy is a safe and effective treatment for infants under four months of age with craniosynostosis and should be available for patients. However, the need for frequent helmet adjustments poses a burden on families, which must be considered in preoperative planning and counselling. Longer follow-up and quantitative morphometric comparison with established techniques (eg, spring cranioplasty, fronto-orbital advancement and remodelling) is needed.