The Risk of Growing Skull Fractures in Craniofacial Patients

Abstract

Background/Aims: Growing skull fractures (GSFs) are unusual sequelae of head injury in young children which have also been reported to occur after craniofacial procedures complicated by inadvertent durotomy. We reviewed the craniofacial experience in a single institution, detailing 180 cases of craniofacial surgery and suspected dural tears and their relationship to the subsequent development of GSFs. This experience was then compared to that of the pertinent published literature. Methods: A retrospective review of the senior authors’ craniofacial surgical experience from 2000 to 2007 was performed. This was compared to an English-language literature review of GSFs after craniofacial surgery. Results: In our institution, 180 cases of craniofacial surgery (83 open, 97 endoscopic) were performed, with an average follow-up of 23.5 months. Twenty-five patients (15 open, 10 endoscopic surgeries) had operative dural compromise. One of these patients developed a persistent pseudomeningocele requiring reoperation. Twelve cases of GSF after craniofacial surgery were identified in a review of the English-language literature, of which 7 (58%) had coronal suture fusion. Conclusions: While durotomy may occur during craniofacial surgery, the subsequent development of a GSF appears to be an unlikely event with an aggressive intraoperative approach of identification and repair. Coronal craniosynostosis may confer an increased risk for this complication.

Incomplete Reossification After Craniosynostosis Surgery

“…Also, the presence of a defect of the dura is described as a cause for incomplete reossification. 3,19,29,30,[37][38][39][40] …”

“…Also, GSF after surgery, 3,38,43,19 encephalocele, 28 pseudomeningocele, 22,44 and leptomeningeal cyst, 40 ''atrogenic intradiploic meningoencephalocele after craniosynostosis surgery'' 45 are different names to describe the closely resembling situation of incomplete reossification resulting from a dura defect. Variable terminology makes it difficult to easily acquire and compare literature.…”

“…[13][14][15][16] Integrity of the dura is obligatory: the situation of a dura defect after craniosynostosis surgery may cause a GSF as after trauma. 3,19,30,[37][38][39][40] Fourteen of these patients were presented by Zemann. 19 Risk factors for a dura tear include: the dura in infants is tightly adherent to the under surface of bone at the suture lines, 37,39 reoperation, because of adhesions formed after initial surgery, 5,19 and raised intracranial pressure.…”

“…19 Some authors warn for the potential of missing a dura defect because of its limited exposure, for the most probable site of injury of the dura exactly underlies the bone edge. 37 Given the potential of a bony defect to occur after primary closure of a dura defect even with well-placed sutures, 3 we recommend proper documentation of every dura laceration during surgery and specific attention during follow-up.…”

“…1- 3 Multiple techniques have been described and practiced for the correction of craniosynostosis, depending on the suture(s) affected and age of presentation. [3][4][5][6][7][8][9][10][11][12] In many techniques, the skull is left not completely covered with bone, for the patient will grow new bone in these gaps. Studies have shown the dura to be the main source of new bone in this reossification process.…”