Caleigh S Roach, Belen Wertheimer, Khushi H Shah, Victor M Lu
Pediatric craniosynostosis care is multidisciplinary, with Plastics and Neurosurgery sharing operative responsibility, and the contemporary specialty distribution, trends in surgical approach, and effect of primary specialty on 30-day outcomes remain uncharacterized at the population level. In a retrospective cohort of 14,612 craniosynostosis cases from the NSQIP Pediatric database (2016-2024), comprising 8448 Neurosurgery and 6164 Plastics cases, Cochran-Armitage tests assessed temporal trends, and inverse probability of treatment weighting was applied across 37 covariates, with specialty-by-approach interaction testing, false discovery rate (FDR) correction, and prespecified nonsyndromic, infant-only, and procedural-mix sensitivity analyses. Strip craniectomy rose from 17.0% to 35.8% (+2.34%/yr, P<0.001) at parallel within-specialty rates. Neurosurgery was associated with lower transfusion (adjusted OR 0.71, 95% CI 0.66-0.76, FDR P<0.001), lower prolonged length of stay (OR 0.87, FDR P=0.020), and shorter operative time (-7.2 min, FDR P=0.002), without differences in other safety endpoints. Approach effects were larger: strip craniectomy reduced transfusion (OR 0.46, 0.43-0.50), prolonged length of stay (OR 0.68), and operative time (-46.1 min). The specialty-by-approach interaction for transfusion (OR 0.76, P=0.001) was stronger within strip craniectomy (OR 0.66) than open vault remodeling (OR 0.82), and accounting for procedural mix abolished the operative-time and length-of-stay differences while a smaller transfusion association persisted. Neurosurgery and Plastics were the surgeons of record in a 60:40 distribution with parallel strip craniectomy adoption; the modest Neurosurgery advantages were confined to process measures, attenuated after accounting for procedural mix, and showed no differences in major safety endpoints, indicating that approach and procedural mix, not specialty, determine 30-day outcomes.