Complications and Avoidance

Introduction

Review of complications associated with the surgical treatment of craniosynostosis varies widely due to reports that extend over many years and epochs, as well as there being a large number of different procedures being reported during these periods. A 2015 publication in the Journal of Neurosurgery by Lin Y, et al., analyzed and compared the complication rates of patients under 12 months of age undergoing treatment for nonsyndromic craniosynostosis by two groups as well as a review of the current literature. The groups analyzed included a large administrative claims database (KID: Kid’s Inpatient database) and a clinical registry of the American College of Surgeons (Peds NSQIP: Pediatric National Surgical Quality Improvement Program). Also included was a review of the literature current up to that time. The complications identified were grouped into seven major categories: infection, wound disruption, seizures, cardiac events, strokes and/or intracranial hemorrhage, blood transfusions, and sepsis. Results are presented in Table 16.1 . This chapter also presents the complications associated with the cohort of nonsyndromic craniosynostosis treated by our team during the past 25 years using endoscopic techniques. Our results are summarized in Table 16.2 . We do not consider a blood transfusion to be a complication but report it for comparison purposes. Asides from presenting our complication rate, we also present our perspective on causes as well management principles.

Dural Tears

The most common unexpected complication is our series was a dural tear with an overall rate of 0.9%. This problem occurred in 9 patients. Four sagittal, three coronal, one bicoronal, and one metopic patient were affected. Three of the dural tears were due to the cranial perforator being advanced passed the skull’s inner table and cutting the underlying dura matter. In every case, the dura was successfully repaired ( Fig. 16.1 ). In the sagittal group, a large dural cut occurred in one 4-month-old male when the left paramedian osteotomy was being made with the Mayo scissors. It led to a 4-cm dural cut with breach of the cerebral cortex, whose bleeding was easily managed with bipolar coagulation and Surgiflo. In order to fully repair the tear, more cranium was removed laterally so as to increase dural exposure. The repair was done with 4-0 Neurolon and under direct endoscopic illumination and visualization. Subsequent sequela included a cerebrospinal fluid (CSF) leak, pseudomeningocele, and, later, a secondary repair. The last dural tear was a small dural cut (≈1 cm) that occurred while doing a wedge osteotomy which was placed too close to the right coronal suture. This tear was similarly repaired with no lasting consequences. In the coronal cohort, there were three tears when the osteotomies were made very near the open end of the coronal suture in close proximity to the pterion and behind the greater wing of the sphenoid wing. A similar situation occurred in one bicoronal patient that required a second procedure to repair the tear and stop the CSF leak and pseudomeningocele progression. A very small tear of the dura lateral to the anterior sagittal sinus occurred in a single metopic patient, which was repaired with two single Neurolon sutures. No further complications were associated with this small tear. No dural lacerations occurred in the lambdoid suture releases. None of the dural tears in our series resulted in neurologic problems or complications. None of the dural tear repairs required extending the surgery to an open procedure in order to repair the tear.

Infections

As a complication following surgery, our infections can be divided into two primary categories: (1) superficial suture abscess with or without erythema and (2) deep subgaleal infections. There have been six of these in the former group with two in the sagittal, two in the metopic, and two in the coronal groups. The typical clinical presentation is that of a whitish pustule present somewhere along the incision ( Fig. 16.2 ). It may or not be associated with surrounding erythema. At the clinic, the area can be cleaned and drained. If a visible suture is seen, it may be easily removed. The patient is placed on a 7-day regimen of oral prophylactic antibiotic such as Keflex. In all cases, the suture abscess quickly resolves and no further treatment was found to be necessary.

Fortunately, more complex infections consisting of tissue/scalp induration, swelling, erythema, and tenderness (with/without fever) have only presented in six cases (0.75%). In the majority of the cases the infection becomes apparent within 4 weeks of surgery. There was one case in each of the sagittal, coronal, and lambdoid group, and three in the metopic cohort. In one of the metopic cases, the patient had developed contract dermatitis to the helmet’s padding and an incision and deep tissue infection ensued ( Fig. 16.3 ). In all of these infections, the patients had to undergo a secondary procedure for treatment of the infection ( Fig. 16.4 ). Following secondary surgery, the patients were treated with a 14- to 20-day course of antibiotics via PICC (peripherally inserted central catheter) line. In all cases the infection was adequately treated and controlled. No patient had to undergo a third surgery.