Surgery for isolated sagittal synostosis: a neuro-developmental necessity or an isolated cosmetic challenge? Mini-survey and literature review.

INTRODUCTION

While surgery of single-suture sagittal craniosynostosis (SS) is effective for cranial shape correction, its role in preventing neurocognitive impairment or intracranial pressure (ICP)-related sequelae is uncertain. We conducted a mini-survey of experts and a narrative literature review to evaluate current perspectives and evidence guiding treatment indications for SS.

METHODS

A mini-survey was distributed to 25 pediatric neurosurgery experts following a debate at the 2025 Varna meeting. Respondents were presented with clinical scenarios of infants with moderate or severe SS and queried regarding counseling on non-cosmetic consequences of nonoperative management. In parallel, a narrative PubMed literature review (December 2025) examined neurocognitive outcomes, ICP prevalence, treatment timing, surgical technique, and methods of ICP assessment in SS.

RESULTS

Survey responses demonstrated marked heterogeneity in expert opinion. While many surgeons viewed cosmetic correction as the primary indication for surgery, others recommended intervention to mitigate uncertain risks of neurodevelopmental delay or elevated ICP. The literature consistently shows that most children with SS achieve normal-range intellectual functioning and attend regular schools, though mild and heterogeneous vulnerabilities in language, attention, motor skills, and learning are described compared to the normal population. These differences are also detectable in infancy, suggesting a prenatal contribution to altered brain development, that may persist despite surgery. Evidence linking surgery, age at intervention, or surgical technique to improved long-term neurocognitive outcomes is inconsistent. Untreated SS carries a variable risk of elevated ICP, which is imperfectly detected by non-invasive surrogates; postoperative ICP elevation occurs in a minority of cases.

CONCLUSION

SS is generally associated with favorable neurocognitive and developmental outcomes, though mild neurodevelopmental differences and ICP-related risks warrant careful long-term surveillance. Given limited and heterogeneous evidence, individualized counseling and shared decision-making remain essential.