Craniofacial surgery: complications and their prevention

Pediatric Cranial Defects: What Size Warrants Repair?

PURPOSE

Identifying which cranial defects among children warrant surgical repair is integral to providing adequate protection of the skull whereas minimizing exposure to surgical complications. This review examines the available evidence regarding the role of defect size in determining the appropriateness of nonsurgical versus surgical management.

METHODS

An electronic literature review was performed using PubMed and Google Scholar to identify publications that provided rationales for nonsurgical management of cranial defects in the pediatric population based on size. Titles and abstracts were reviewed by the authors to determine eligibility for full-text analysis. Ineligible studies were categorized and relevant data from fully analyzed texts were recorded.

RESULTS

Of the 523 articles that were reviewed, 500 were ineligible for full-text analysis due to the following most common reasons: no cranial defect described (227, 45%), did not discuss management of cranial defects (68, 14%), or surgery was performed on all defects in evaluation of a technique or protocol (86, 17%). Ten publications provided relevant data. The suggested size below which surgery was not recommended varied widely between articles. Beyond the age of 1 to 2 years, no general agreement on recommended management in children was found. Craniofacial surgeons had divergent views on the minimum diameter for a "critical" defect and the size for which surgical repair is necessary.

CONCLUSIONS

Little guidance or consensus exists regarding the indications for surgical correction of cranial defects based on the size of the defect. Objective data is needed to classify "clinically critical defects" in the pediatric population.

Ventricular shunt complications in patients undergoing posterior vault distraction osteogenesis

PURPOSE

The primary objective of this study is to investigate post-operative morbidity and shunt revision rates of patients with shunt-dependent hydrocephalus (SDH) undergoing posterior vault distraction osteogenesis (PVDO) compared to patients undergoing conventional posterior vault reconstruction (PVR).

METHODS

A retrospective case-controlled cohort analysis of all patients with SDH undergoing PVDO and PVR for syndromic or complex craniosynostosis was performed. Demographic information, perioperative variables, distraction protocols, and shunt-related complications-infection, surgical revision of shunt, increased length of stay (LOS), and readmission within 90 days of surgery-were compared using the appropriate statistical tests.

RESULTS

Fourteen patients with ventricular shunts who underwent PVDO and eight patients with shunts who underwent PVR were identified. Shunt-related complication rates were significantly higher with PVDO (n = 5) compared to PVR (n = 0), p = 0.0093. Among the five patients who suffered complications, the most common were shunt infection (n = 4), shunt malfunction (n = 4), and wound infections (n = 3). All patients with complications required additional operations for shunt revision and/or replacement; four patients required multiple takebacks for such procedures, with an average of three additional procedures per patient.

CONCLUSIONS

In complex or syndromic craniosynostosis patients who have previously undergone ventricular shunting, PVDO is associated with higher shunt-related complications and need for additional procedures when compared to traditional PVR. While the benefits of PVDO in the treatment of syndromic craniosynostosis are well documented, the risks of PVDO in the face of a VP shunt must be considered. Further investigation into patient-specific risk factors and risk reduction strategies is warranted.

Posterior Vault Distraction Osteogenesis in Nonsyndromic Patients: An Evaluation of Indications and Safety

PURPOSE

The purpose of this study was to evaluate the indications, safety, and short-term outcomes of posterior vault distraction osteogenesis (PVDO) in patients with no identified acrocephalosyndactyly syndrome (study) and to compare those to a syndromic cohort (controls).

METHODS

Demographic and perioperative data were recorded and compared across the study and control groups for those who underwent PVDO between January 2009 and December 2016. Univariate analysis was conducted using χ and Fisher exact tests for categorical variables, and Mann-Whitney U test for continuous variables.

RESULTS

Sixty-three subjects were included: 19 in the nonsyndromic cohort, 44 in the syndromic cohort. The cohorts had similar proportion of subjects exhibiting pansynostosis (42.1% of nonsyndromic versus 36.4% of syndromic, P = 0.667). The nonsyndromic cohort was significantly older (4.04 ± 3.66 years versus 2.55 ± 3.34 years, P = 0.046) and had higher rate of signs of raised intracranial pressure (68.4% versus 25.0%, P = 0.001) than the syndromic cohort. There was no significant difference in perioperative variables or rate of complications (P > 0.05). The mean total advancement distance achieved was similar, 27 ± 6 mm in the nonsyndromic versus 28 ± 8 mm in the syndromic cohort (P = 0.964). All nonsyndromic subjects with signs of raised intracranial pressure demonstrated improvement at an average follow-up of 22 months.

CONCLUSION

As in the syndromic patient, PVDO is a safe and, in the short-term, effective modality for cranial vault expansion in the nonsyndromic patient. The benefits and favorable perioperative profile of PVDO may therefore be extended to patient populations other than those with syndromic craniosynostosis.

Clinical Significance of Venous Anomalies in Syndromic Craniosynostosis

Background

The pattern of cranial venous drainage in syndromic craniosynostosis is unpredictable and not adequately understood. Collateral channels substitute for stenotic venous sinuses and pose potential risk for surgical intervention. The purpose of this study was to analyze the patterns of venous drainage in patients with syndromic craniosynostosis and their influence on operative planning and morbidity.

Methods

A retrospective study of patients with syndromic craniosynostosis from 2000 to 2013 was performed. Demographic data were collected including phenotype and associated pathologies. Pre- and/or postoperative venous imaging was reviewed for venous sinus stenosis, collateral emissaries, and persistent fetal sinuses. Categorization of anomalous venous drainage was performed, and the relationship with surgical morbidity was assessed.

Results

Forty-one patients were identified. Anomalies were present in 31 patients (76%) consisting of dural sinus stenosis in 28 (68%), dilated emissaries in 26 (63%), and fetal sinuses in 7 (17%). Pfeiffer syndrome was most commonly associated with anomalous drainage (100%). Venous anomalies were associated with elevated intracranial pressure (ICP), shunted hydrocephalus, Chiari malformations, and sleep apnea. In 5 cases, the surgical plan was adjusted based on anomalous anatomy. No mortalities occurred. Intraoperative complication rate was 7.3%, all with anomalous drainage. Median estimated blood loss was 1,100 cc for patients with anomalies versus 400 cc without anomalies (P = 0.181).

Conclusion

Cranial venous anomalies are commonly detected in patients with syndromic craniosynostosis and may affect surgical morbidity and outcome with a higher estimated blood loss, alteration of procedure, and postoperative morbidity. Detailed preoperative imaging of the venous drainage is therefore recommended in cases of syndromic synostosis.

Use of computer-assisted design and manufacturing to localize dural venous sinuses during reconstructive surgery for craniosynostosis

OBJECTIVE

Cranial vault remodeling surgery for craniosynostosis carries the potential risk of dural venous sinus injury given the extensive bony exposure. Identification of the dural venous sinuses can be challenging in patients with craniosynostosis given the lack of accurate surface-localizing landmarks. Computer-aided design and manufacturing (CAD/CAM) has allowed surgeons to pre-operatively plan these complex procedures in an effort to increase reconstructive efficiency. An added benefit of this technology is the ability to intraoperatively map the dural venous sinuses based on pre-operative imaging. We utilized CAD/CAM technology to intraoperatively map the dural venous sinuses for patients undergoing reconstructive surgery for craniosynostosis in an effort to prevent sinus injury, increase operative efficiency, and enhance patient safety. Here, we describe our experience utilizing this intraoperative technology in pediatric patients with craniosynostosis.

METHODS

We retrospectively reviewed the charts of children undergoing reconstructive surgery for craniosynostosis using CAD/CAM surgical planning guides at our institution between 2012 and 2016. Data collected included the following: age, gender, type of craniosynostosis, estimated blood loss, sagittal sinus deviation from the sagittal suture, peri-operative outcomes, and hospital length of stay.

RESULTS

Thirty-two patients underwent reconstructive cranial surgery for craniosynostosis, with a median age of 11 months (range, 7-160). Types of synostosis included metopic (6), unicoronal (6), sagittal (15), lambdoid (1), and multiple suture (4). Sagittal sinus deviation from the sagittal suture was maximal in unicoronal synostosis patients (10.2 ± 0.9 mm). All patients tolerated surgery well, and there were no occurrences of sagittal sinus, transverse sinus, or torcular injury.

CONCLUSIONS

The use of CAD/CAM technology allows for accurate intraoperative dural venous sinus localization during reconstructive surgery for craniosynostosis and enhances operative efficiency and surgeon confidence while minimizing the risk of patient morbidity.

Perioperative complications associated with intracranial procedures in patients with nonsyndromic single-suture craniosynostosis

Within the diagnosis "craniosynostosis," there is a subset of patients who present with isolated, nonsyndromic, single-suture involvement. This study evaluates perioperative complications in this specific subset of patients over 4 decades at a single institution. To do so, we performed a retrospective review on consecutive patients undergoing correction of single-suture synostosis from May 1977 to January 2013 at a tertiary pediatric craniofacial center. Demographic information, operative details, and perioperative course were collected. Complications were categorized as either major or minor. A χ(2) test and Fisher exact test were used to compare all categorical variables. Continuous variables were analyzed using Wilcoxon rank-sum and Kruskal-Wallis tests.Seven hundred forty-six patients underwent surgical correction of nonsyndromic craniosynostosis. Of these, there were 307 (41.2%) sagittal, 201 (26.9%) metopic, and 238 (31.9%) unicoronal. Thirty-four patients had complications (4.6%). Eight were considered major (1.1%), including one postoperative mortality in a patient with hypoplastic left-sided heart syndrome. Minor complications occurred in 26 patients (3.5%) and included subgaleal hematoma (n = 3), seroma (n = 4), and superficial wound infection (n = 5). Metopic and sagittal suture involvement was significantly associated with a higher complication rate (P = 0.04). A child with isolated single suture synostosis and any comorbidity had a significantly greater risk of any complication (P < 0.001; odds ratio, 3.8) and specifically an increased risk of major complication (P = 0.031; odds ratio, 6.0). Subclassification of patients by time period yielded no statistically significant changes in perioperative morbidity. To conclude, these data allow us to counsel families more accurately with regard to morbidity and mortality and may potentially serve as a benchmark for future quality improvement work.

Craniosynostosis: imaging review and primer on computed tomography

Craniosynostosis is encountered in the pediatric population in isolated or syndromic forms. The resulting deformity depends on the number and type of sutures involved and, in multi-sutural synostosis, the order of suture fusion. Primary craniosynostosis needs to be differentiated from the secondary variety and positional or deformational mimics. Syndromic craniosynostoses are associated with other craniofacial deformities. Evaluation with 3-D CT plays an important role in accurate diagnosis and management; however, implementation of appropriate CT techniques is essential to limit the radiation burden in these children. In this article, the authors briefly review the classification, embryopathogenesis and epidemiology and describe in detail the radiologic appearance and differential diagnoses of craniosynostosis.

Posterior cranial vault expansion using distraction osteogenesis

PURPOSE

Posterior vault expansion using distraction osteogenesis has become a vital instrument in our institution, particularly as a first-line treatment in syndromic craniosynostosis. In this review, we highlight the several advantages, diverse utility, and technicalities of the operative procedure.

METHODS

A review of the literature and explanation of the technical details of the procedures were described in this manuscript.

RESULTS/CONCLUSION

Posterior cranial vault distraction offers several benefits over traditional expansion procedures.

Maternal reports of satisfaction with care and outcomes for children with craniosynostosis

Craniosynostosis is a congenital deformity caused by premature fusion of cranial suture(s). Surgical outcomes of craniosynostosis have been well documented; however, limited published data are available regarding access to care and social and psychological health outcomes for children with craniosynostosis. The authors conducted a population-based, multistate study of maternal perceptions of care and outcomes for children with craniosynostosis born from January 1998 through December 2003. Mothers of 147 children were contacted and asked to complete a structured telephone interview; 82 mothers (55.8%) participated. Overall, the mean ages of children and their mothers at the time of interview were 4.4 and 34.8 years, respectively. Mothers interviewed tended to be white and, at a minimum, high school graduates. Most mothers reported being satisfied with the craniosynostosis-related information and support provided by medical care providers, and access to primary and specialty care was most often rated as satisfactory. Mothers tended to report the physical health of their child to be good; however, delays in cognitive and emotional development, hearing loss, and speech problems were identified. In addition, statistically significant differences among mothers in each state were noted for reports of the quality of team care, primary care, learning interventions, and perceived need for additional surgeries. These results suggest some limitations in craniosynostosis-related care and provide guidance to medical and surgical care providers in making need-based improvements in craniosynostosis surgery and care. Future studies are recommended to replicate this evaluation in additional populations.

Posterior calvarial vault expansion using distraction osteogenesis

OBJECTIVES

Management of raised intracranial pressure in syndromic multi-suture craniosynostosis by cranial vault expansion can be achieved by a number of techniques. We present our initial experience in treating this group of patients with posterior calvarial distraction.

MATERIALS AND METHODS

Six patients underwent distraction osteogenesis of their posterior calvarial vault.

RESULTS

The mean period of distraction was 28 days. The mean consolidation period was 49 days. The mean distance of advancement was 24 mm. Five out of six patients completed their period of distraction and three of these cases also completed their period of consolidation. Significant calvarial expansion and improvement of head shape was achieved in all cases.

CONCLUSIONS

Posterior calvarial distraction is a safe and more efficient method of calvarial expansion than conventional techniques. These are early promising results, and future modification of the distraction devices will be needed if the effective consolidation time is to be increased.

Management of facial asymmetry

Asymmetries of the craniofacial region encompass a multitude of diverse and potentially complex abnormalities that may be the result of numerous causes. The expression and degree of asymmetry for a given condition, although a highly variable process, is the ultimate determinant of the nature of its treatment. This article highlights some of the key features and treatment strategies for various common facial asymmetries.

Evaluation of the necessity of postoperative imaging after craniosynostosis surgery

OBJECT

Childhood radiation exposure increases the lifetime risk of cancer from an estimated 0.07 to 0.35%. Neurological evaluation of patients after cranial vault reconstruction for synostosis repair is often complicated by pain medication, sedation, intubation, swelling, and dressings; therefore computed tomography (CT) scans are routinely ordered by some surgeons on the 1st postoperative day. The object of this study was to evaluate the utility of these scans.

METHODS

Medical records and CT scans were reviewed for patients at the authors' institution who underwent cranial vault reconstruction to repair synostosis between January 1, 2003, and July 31, 2005.

RESULTS

Of the 111 patients identified in the review, 84 had a CT scan on postoperative Day 1, and seven of these patients underwent shunt insertion for treatment of hydrocephalus. Thirty-three patients underwent bifrontal craniotomies, whereas 51 underwent total vault reconstruction (TVR). Postoperative CT scans revealed minor contusions in three (9%) of 33 patients in the bifrontal craniotomy group and in seven (14%) of 51 patients in the TVR group. No significant subdural or epidural hematomas were observed. In the seven patients who required shunt placement, two (29%) had CT evidence of shunt malfunction, leading to shunt revision.

CONCLUSIONS

None of the CT findings analyzed in this series was associated with clinical events such as seizures, prolonged intensive care unit stay, or reoperation in patients without shunt placement after cranial reconstructive procedures, although a relatively high incidence of CT evidence of shunt malfunction was found in patients with shunts. These data do not support the routine use of CT scanning after cranial reconstructive procedures unless the patient has received a shunt for hydrocephalus. Patients who experience unexpected intraoperative or postoperative events should be examined using CT.