An Appraisal of the Cephalic Index in Sagittal Craniosynostosis, and the Unseen Third Dimension
Abstract
Background: The cephalic index is often used to evaluate sagittal craniosynostosis corrections; however, validation of this measure remains untested. Methods: A three-part study was designed to (1) determine the normal distribution of cephalic indices in untreated sagittal craniosynostosis; (2) examine index values in treated children, subsequently determined to require secondary surgery; and (3) explore the correlation between a photography-based assessment of scaphocephaly severity and the cephalic index. Results: Of 392 preoperatively measured patients (mean cephalic index, 70.7; 95 percent CI, 57.4 to 89.5), 343 (87.5 percent) had Z scores falling within 2 SD of the mean; only 49 (12.5 percent) fell more than 2 SD below the mean, whereas 13 percent exceeded the mean. For 10 patients requiring secondary surgery (mean cephalic index, 74.8; 95 percent CI, 68.1 to 83.4), the mean Z score was −0.5 (range, −2.5 to 1.6). The polled results of 10 observers revealed no significant correlation between subjectively ranked severity scores and cephalic indices. Conclusions: Although the average preoperative cephalic index in children with sagittal craniosynostosis was below normal, the majority of measurements fell within a statistically normal distribution. Furthermore, many children requiring secondary corrections were found to have relatively normal indices, suggesting that normal values are not necessarily predictive of satisfactory outcomes. We also found no correlation between this index and a subjective assessment of severity. These findings suggest that the cephalic index is not a reliable outcome measure, perhaps because of the inability for this ratio to capture the amount of correction of the reduced posterior skull height associated with sagittal craniosynostosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.
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Fearon et al. (2017) noted that the cephalic index cannot capture certain postoperative changes or accurately reflect the complexity of skull deformities.
“In addition, they note that the CI method cannot capture certain postoperative changes, such as changes in occipital skull height after sagittal suture synostosis surgery, or accurately reflect the complexity of skull deformities [7].”
From Developments in diagnostic and surgical techniques in children with sagittal suture craniosynostosis: a systematic review spanning the last 30 years (2025) · cites this paper as [7]
Fearon et al. (2017) found no significant correlation between cephalic index and subjectively assessed severity in 392 craniosynostosis patients.
“They found no significant correlation between the measured CI and the subjectively assessed severity.”
From Developments in diagnostic and surgical techniques in children with sagittal suture craniosynostosis: a systematic review spanning the last 30 years (2025) · cites this paper as [7]
Diagnosis of craniosynostosis is typically based on clinical examination focused on skull shape, with additional methods such as head circumference, cranial ultrasound, and 3D stereophotography, and CT or MRI reserved for complex cases.
“The diagnosis of craniosynostosis is typically based on a clinical examination focused on skull shape. Additional methods, such as head circumference measurement, cranial ultrasound (CUS), and 3D stereophotography, may be used, with computed tomography (CT) or magnet resonance imaging (MRI) reserved for complex cases [2, 7, 8].”
From Developments in diagnostic and surgical techniques in children with sagittal suture craniosynostosis: a systematic review spanning the last 30 years (2025) · cites this paper as [7]
Fearon et al. found that the CI does not always represent the severity of craniosynostosis.
“Fearon et al validated the CI, as part of a clinical examination, and found that it does not always represent the severity of craniosynostosis, as it now categorises a three-dimensional malformation using a two-dimensional indication or measure [7].”
From Developments in diagnostic and surgical techniques in children with sagittal suture craniosynostosis: a systematic review spanning the last 30 years (2025) · cites this paper as [7]
Today the most common approach for evaluating suspected craniosynostosis is a detailed clinical examination by skilled professionals, where characteristic skull morphology serves as the primary indicator for provisional diagnosis.
“Today the most common approach for evaluating suspected craniosynostosis is a detailed clinical examination by skilled professionals, where characteristic skull morphology serves as the primary indicator for provisional diagnosis.”
From Developments in diagnostic and surgical techniques in children with sagittal suture craniosynostosis: a systematic review spanning the last 30 years (2025) · cites this paper as [7]
In more challenging or atypical cases, additional imaging techniques like CT and MRI may be employed.
“In more challenging or atypical cases, additional imaging techniques like CT and MRI may be employed [2, 7, 8, 37].”
From Developments in diagnostic and surgical techniques in children with sagittal suture craniosynostosis: a systematic review spanning the last 30 years (2025) · cites this paper as [7]
Diagnostic confirmation typically involves measurement of head circumference, ultrasonography and, if required and technically possible, three-dimensional stereophotography.
“Diagnostic confirmation typically involves the use of methods such as measurement of the head circumference, ultrasonography and if required and technically possible three-dimensional stereophotography.”
From Developments in diagnostic and surgical techniques in children with sagittal suture craniosynostosis: a systematic review spanning the last 30 years (2025) · cites this paper as [7]
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- Authors
- Fearon, J. A., Ditthakasem, K., Herbert, M., & Kolar, J.
- Affiliations
- Medical City Dallas Hospital (US)
- ORCID
- Fearon, Jeffrey A.
- Venue
- Plastic & Reconstructive Surgery
- Published
- 2017-07
- Volume
- 140
- Issue
- 1
- Pages
- 138-145
- ISSN
- 0032-1052 (ISSN-L)
- OpenAlex
- W2729984968
- Cited by
- 83
- References
- 21
- Citations by year
- 2026: 5 · 2025: 10 · 2024: 11 · 2023: 18 · 2022: 7 · 2021: 10 · 2020: 6 · 2019: 7 · 2018: 7 · 2017: 2
- FWCI
- 3.98
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Plastic & Reconstructive Surgery (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Craniofacial Disorders and Treatments
- Health Sciences › Medicine › Surgery › Pectus Deformity Diagnosis and Treatment
- Health Sciences › Dentistry › Orthodontics › Orthodontics and Dentofacial Orthopedics
- Keywords
- cephalic index, sagittal craniosynostosis, scaphocephaly, outcome measures
- MeSH terms
- Cephalometry, Child, Child, Preschool, Craniosynostoses, Female, Humans, Male, Retrospective Studies, Severity of Illness Index
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