Long-term Outcomes of Craniofacial Reconstruction for Craniosynostosis: A 12-year Experience with 212 Patients
Mitchel Seruya, MD1, Robert F. Keating, MD2, Michael J. Boyajian, MD, FACS2, John S. Myseros, MD2, Amanda L. Yaun, MD2, Ali Al Attar, MD, PhD1, Jeffrey C. Posnick, DMD, MD, FRCS, FACS1.
1Georgetown University Hospital, Washington, DC, USA, 2Children's National Medical Center, Washington, DC, USA.
Purpose: Recently, there has been an increasing interest in minimally invasive approaches to the surgical management of craniosynostosis. Advocates of endoscopic sutural release cite its lower morbidity and mortality when compared to open approaches for cranial vault surgery. The purpose of this study was to critically assess the long-term clinical outcomes and associated factors for open craniofacial reconstruction performed over the past decade and offer a contemporary paradigm.
Methods: An IRB-approved, retrospective review was undertaken for successive craniosynostosis patients at Children’s National Medical Center and Georgetown University Hospital over 12 years ('97-'09). Outcomes were examined with respect to involved cranial suture(s), presence of associated syndrome, age at surgery, type of operation, intra-operative blood loss / transfusion requirements, hospital length of stay, postoperative complications, and incidence of reoperation with Whitaker classification being used for grading postoperative results.
Results: Over a 12.4 year study period, 212 patients (64%M/36%F) underwent primary open craniofacial repair. Mean follow-up was 36.3 months (1-138m). Indications included sagittal (N=96), metopic (N=40), unicoronal (N=33), bicoronal (N=24), multisuture (N=14), bilambdoid (N=3), unilambdoid (N=1), and pan (N=1) synostoses. 8.5% of patients were syndromic. Mean age at surgery was 11.3 months (0.2 - 117.8m) and the mean intraoperative blood loss was 26.5 cc/kg, with intraoperative transfusions of 26.6 cc/kg. The average hospital length of stay was 3.4 days. A 3.3% overall complication rate included brain contusion (0.9%), hematoma (0.9%), CSF leak (0.5%), infection (0.5%), and wound breakdown (0.5%) and a mortality rate of zero. The overall rate of re-operation was 10.8%, with individual rates of reoperation for type of synostosis reported in Table I. Patients were Whitaker classified as 78.3% category I, 10.9% category II, 0.9% category III, and 9.9% category IV.
Conclusions: In this large series of patients with craniosynostosis, treated by open cranial reconstruction over the past decade, long-term rates of morbidity, reoperation, and mortality continue to decline. Attention to hemodynamic control (systemic hypotension), perioperative steroids, utilization of absorbable rigid fixation, and shorter surgical times have all helped to lower overall morbidity and mortality while improving long-term outcomes. This represents a significant change from previous historical parameters and thus offers a more accurate metric of contemporary craniofacial surgery for eventual comparison to newer craniofacial techniques.
|TYPE OF SYNOSTOSIS AND RE-OPERATION RATE|
|No of patients||%|
|Bicoronal||9 / 24||37.5|
|Multiple||2 / 14||14.3|
|Metopic||5 / 40||12.5|
|Unicoronal||3 / 33||9.1|
|Sagittal||4 / 96||4.2|
|Unilambdoid||0 / 1||0.0|
|Bilambdoid||0 / 3||0.0|
|Pan||0 / 1||0.0|
|Syndromic||6 / 18||33.3|
|Non-syndromic||17 / 194||8.8|