|2009 Annual Meeting Abstracts
Traumatic Brain Injury as a Result of Cranial Bone Defects Following Fronto-Orbital Advancement
Shareef Jandali, MD1, Mirko S. Gilardino, MD, MSc, FRCSC2, Scott P. Bartlett, MD2, Linton A. Whitaker, MD2.
1University of Pennsylvania Health System, Philadelphia, PA, USA, 2Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Fronto-orbital advancement (FOA) is a surgical technique used in the repair of craniosynostosis which involves wide exposure of the skull, craniotomy and repositioning of the supraorbital ridge and frontal bone. This procedure often results in a cranial defect posterior to the advanced skull segments. In spite of its frequent use, no data exists regarding the risk of traumatic brain injury secondary to the bony defect prior to its re-ossification, a process that can take up to 12 months. In addition, an average of 20% of these patients fail to completely re-ossify these defects, necessitating a cranioplasty for closure. The risk of brain injury through such defects is an important question often asked by the family when discussing possible risks of cranial remodeling. It is our impression that despite the presence of post-operative bony cranial defects, the actual rate of traumatic brain injury is extremely low. The purpose of this study was to investigate the incidence of post-operative traumatic brain injury in a large population of pediatric patients undergoing FOA.
A retrospective analysis of the 416 patients who underwent FOA for craniosynostosis at the Children’s Hospital of Philadelphia between 1997 and 2007 was performed. Patients with less than two years of follow-up were excluded, yielding a total of 396 patients. Traumatic brain injury (TBI) was defined as damage to brain tissue caused by external mechanical force as evidenced by either a witnessed loss of consciousness or a CT-documented contusion or intracranial hemorrhage. The incidence of TBI was determined by reviewing office charts, ER records, and neurosurgical consultations.
There was a total of 317 ER visits for the 396 patients who met the inclusion criteria. The number of documented cases of head trauma (any sharp or blunt injuries to the face, scalp, or neck) was 35 and CT scans of the head were obtained in 16 patients. All head CT scans were negative except one, which showed a subgaleal hematoma and did not meet the criteria for a TBI. There were no other documented episodes of head trauma or loss of consciousness in any of the patient charts. Thus, there were no traumatic brain injuries in any of the patients in the study group. The 95% CI for this zero numerator gives an incidence range of 0-760 per 100,000 children.
Despite the production of significant skull defects following FOA, the risk of traumatic brain injury prior to re-ossification, or after failed complete re-ossification, is exceptionally low. This is clinically relevant when considering whether to perform a cranioplasty in a young patient for closure of bony defects in order to protect the underlying brain. This study shows that it is safe to leave bony defects open until a definitive cranioplasty can be performed at an older age.