Analysis of morbidity and mortality in surgical management of craniosynostosis.

Multidisciplinary care involving plastic surgery and neurosurgery is generally accepted as optimal to manage craniosynostosis to avoid complications and to identify patients at risk. We conducted a retrospective 30-year review of craniosynostosis surgery at a single major craniofacial institute to establish the rate and predictors of complications. Medical records of 796 consecutive patients who underwent primary surgery for craniosynostosis from 1981 to 2010 at our institute were analyzed for complications. Complications were defined as intraoperative and postoperative adverse events requiring changed management. Reoperation was defined as a repeat transcranial procedure. Multivariate logistic regression was used to identify predictors for complications or revision. Across the years, the procedures evolved from technically simple to complex, which increased complications but better outcomes. Complications occurred in 111 patients (14%), and 33 (5.4%) needed major revision. Multivariate analysis identified multisuture and syndromic craniosynostosis, more recent surgeries, younger age (<9 months), spring-assisted cranioplasty, longer surgery, and greater transfusion as predictors of complications. Patients with syndromic and multisutural craniosynostosis and those operated on younger than 9 months had increased risk of major revision surgery for regression to phenotype. Our experience over 30 years indicates that pediatric transcranial craniosynostosis surgery can be safely carried out in our tertiary referral center. There were no deaths from primary surgery, and complication and reoperation rates mirror those of other published studies. Syndromic and complex craniosynostosis predicted both complications and need for major revision. Spring cranioplasty was associated with higher complications. Overall results support a recommended age for craniosynostosis surgery between 9 and 12 months.

Changing epidemiology of nonsyndromic craniosynostosis and revisiting the risk factors.

Recent studies in Europe and the United States report increased incidence of metopic synostosis. Whether a similar trend had occurred in Australia remains unknown. This research aimed to determine changes in incidence and subtypes of craniosynostosis in Victoria and to identify perinatal risk factors. A retrospective audit of patients (n = 522) presenting to the Royal Children's Hospital in Melbourne with nonsyndromic craniosynostosis from 1982 to 2008 was undertaken. Perinatal data were sourced from the Victorian Perinatal Data Collection. The changes in incidence of craniosynostosis subtypes were calculated based on Poisson regression, and risk factors for craniosynostosis and subtypes were analyzed by univariate logistic regression analysis. The prevalence of nonsyndromic craniosynostosis was 3.1 in 10,000 live births in Victoria. On average, the incidence of nonsyndromic craniosynostosis increased by 2.5% per year among Victorian live births. Over 25 years, metopic synostosis incidence significantly increased by 7.1% per year in the population of Victoria, outpacing other subtypes. The risk factors for metopic synostosis include being male, multiple births (ie, twins), preterm gestation, low birth weight, high maternal age, and emergency cesarean birth. This study revealed a true increase in incidence of metopic synostosis in Victoria, which could be a result of increased frequency of multiple births, preterm gestation, low birth weight, and high maternal age in the Victorian population from 1982 to 2008. The incidence of other nonsyndromic craniosynostoses, which include sagittal, unicoronal, and multisutural craniosynostoses, however, has remained unchanged.

Avulsion transverse ligament injuries in children: successful treatment with nonoperative management. Report of three cases.

Neck injuries in children most commonly affect the upper cervical spine. Injuries of the transverse ligament and its attachments may result in C1-2 instability, but the optimum form of treatment is unknown. Three patients, who ranged in age from 5 to 11 years, sustained transverse atlantal ligament injuries with unilateral avulsion fracture of the osseous tubercle of C-1. One child was injured in a fall and two were involved in motor vehicle accidents. Although all patients presented with neck pain, none exhibited neurological deficits. Plain radiography demonstrated no evidence of osseous injury, but an increased predental interval was noted in each case. Computerized tomography (CT) scanning demonstrated the avulsion fractures, and magnetic resonance imaging revealed evidence of soft-tissue injuries in the occipital-C2 ligamentous complex. All children were managed with external immobilization (halo vest in two and a Sterno-Occipito-Mandibular Immobilizer brace in one), for 6 to 12 weeks. Follow-up CT scanning demonstrated reattachment of the avulsed osseous tubercle, and dynamic cervical spine radiographs revealed the absence of C1-2 instability. The results of these cases suggest a role for external immobilization in the treatment of osseous avulsion injuries of the transverse atlantal ligament in children.