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Table of Contents    
Year : 2011  |  Volume : 59  |  Issue : 6  |  Page : 823-828

Factors affecting the outcome of patients undergoing corrective surgery for craniosynostosis: A retrospective analysis of 95 cases

Department of Neuroanesthesiology, All India Institute of Medical Sciences, New Delhi, India

Date of Submission20-Jun-2011
Date of Decision31-Jul-2011
Date of Acceptance29-Oct-2011
Date of Web Publication2-Jan-2012

Correspondence Address:
Hemanshu Prabhakar
Department of Neuroanesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi-110029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.91358

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 » Abstract 

Background: Surgical procedures for correction of craniosynostosis are often performed in pediatric patients who have a small blood volume; it represents major surgery. Literature is scarce on factors affecting blood loss, intensive care unit (ICU) and hospital stay in these patients. Objectives: To identify the factors which directly affect the outcome of craniosynostosis surgery. Materials and Methods: A detailed review of records pertaining to preanesthetic evaluation, associated anomalies, intraoperative course, and postoperative follow-up was done for patients who underwent craniosynostosis surgery between June 2000 and June 2010. The correlation between different variables was evaluated using Spearman's rank correlation. Results: During the study period 95 patients (mean age 29 months, range: 3 months-13 years) underwent corrective surgery for craniosynostosis. Hospital stay was found to be significantly associated with type of surgery and postoperative complications (P<0.001) Factors such as number of associated medical conditions, number of postoperative complications, type of induction of anesthesia, duration of surgery, type of recovery affected the ICU stay in these patients (P = 0.01). Conclusion: The outcome of patients undergoing craniosynostosis in terms of ICU and hospital stay is affected by the number of medical and postoperative conditions, type of anesthesia induction, duration of surgery and type of recovery.

Keywords: Anesthesia, craniosynostosis, outcome, predictive factors

How to cite this article:
Goyal K, Chaturvedi A, Prabhakar H. Factors affecting the outcome of patients undergoing corrective surgery for craniosynostosis: A retrospective analysis of 95 cases. Neurol India 2011;59:823-8

How to cite this URL:
Goyal K, Chaturvedi A, Prabhakar H. Factors affecting the outcome of patients undergoing corrective surgery for craniosynostosis: A retrospective analysis of 95 cases. Neurol India [serial online] 2011 [cited 2018 Jan 18];59:823-8. Available from:

 » Introduction Top

Surgical procedures for correction of craniosynostosis are often performed in pediatric patients who have a small blood volume. It represents major surgery and results in unavoidable and extensive blood loss. The surgery involves extensive scalp dissection and calvarial and facial bone osteotomies. Major blood loss occurs during elevation of the vascular periosteum. Frontoorbital advancement is an extensive surgery and is associated with potential risks, the commonest being blood loss. Intraoperatively massive hemorrhage, particularly from the venous sinuses involves risk of air embolism or cerebral infarction. [1] Anesthetic management of craniosynostosis is challenging, not only during anesthesia but also during perioperative care because of age, associated congenital anomalies and systemic abnormalities. Literature is scarce on factors affecting hospital stay, intensive care unit (ICU) stay and blood loss in patients undergoing repair of craniosynostosis. The purpose of our retrospective study was to identify factors which independently affected the outcome of patients following craniosynostosis surgery.

 » Materials and Methods Top

With the approval from the local ethics committee, available medical records of all patients who underwent corrective surgery for craniosynostosis between June 2000 and June 2010 were collected. Data collected included: details of preanesthetic evaluation, preoperative clinical details, intraoperative course, and postoperative follow-up. Preoperative data included age, sex, weight, associated syndrome, number of sutures involved, type of surgery (such as frontoorbital advancement, strip craniectomy, etc.), associated congenital anomalies (such as delayed milestones, proptosis, hyperteleorism, syndactyly, etc.) and medical conditions (such as upper respiratory tract infection, raised intracranial pressure, anemia, neonatal asphyxia, etc.). Intraoperative data included type of anesthesia induction, fluids infused, blood loss, blood transfusion, intraoperative complications (such as Venous Air Embolism (VAE), brain bulge, hypothermia, dyselectrolytemia, etc.) and duration of surgery. Postoperative data included postoperative complications (such as fever, respiratory problems, cerebrospinal fluid leak, cardiac arrest, etc.), postoperative blood transfusion, duration of ICU and hospital stay, and condition at discharge. Postoperative recovery was assessed using Glasgow outcome score scale. [2]


Statistical analysis was done using software STATA 9.0 (College station, Texas, USA). The Spearman's rank correlation coefficient was used to assess the strength of association between continuous factors and hospital stay and ICU stay and categorical factors were tested with hospital stay/blood loss using Wilcoxon rank sum test/ Fischer's exact test. Univariate linear regression and logistic regression for hospital stay and blood loss (>30% of blood volume) were used. For both the outcomes, stepwise multivariate analysis with P=0.05 at entry and P0=0.10 at removal was carried out. The results were reported as β (95% confidence interval CI) and Odds Ratio (OR) (95% CI) for hospital stay and severe blood loss respectively. The P value < 0.05 was considered statistically significant.

 » Results Top

During the ten years' study period 95 patients underwent corrective surgery for craniosynostosis. The mean age was 29 months, with youngest child was three months of age and the oldest 13 years. The mean weight was 10.43 kg (range 4-37 kg).There was a male preponderance (1.77: 1). The demographic and perioperative data are given in [Table 1]. The various associated congenital anomalies and coexisting diseases are tabulated in [Table 2] and [Table 3]. Several intraoperative and postoperative complications were also noted in these patients [Table 4] and [Table 5]. Children undergoing frontoorbital advancement and remodeling had a longer hospital stay as compared to those undergoing strip craniectomy and other procedures [(β(95% CI)1.37 (0.45, 2.30;P <0.001)] [Table 6]. The association between the number of postoperative complications and ICU stay was found to be significant [β(95% CI)0.90 (0.50, 1.30; <0.001)] [Table 7]. Type of surgery was found to be associated with significant blood loss [β(95% CI)5.23 (1.11, 24.58;P =0.04)] [Table 8].
Table 1: Demographic and perioperative data (n=95)

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Table 2: Coexisting congenital anomalies in patients with craniosynostosis (n=95)

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Table 3: Associated medical conditions in patients with craniosynostosis (n=95)

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Table 4: Intraoperative complications in craniosynostosis patients undergoing corrective surgery (n=95)

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Table 5: Postoperative complications in craniosynostosis patients undergoing corrective surgery (n=95)

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Table 6: Factors affecting hospital stay

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Table 7: Correlation with syndromic craniosynostosis, type of surgery, type of anesthesia induction and blood loss, blood transfusion, ICU stay, and hospital stay

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Table 8: Factors affecting Blood loss

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 » Discussion Top

The median hospital stay for our patients was five days and was significantly associated with the type of surgery, number of postoperative complications, and ICU stay. In a study by Hasan et al.,[3] in patients undergoing craniofacial reconstruction, a positive correlation was observed between the duration of tracheal intubation and mechanical ventilation and the perioperative factors including anesthesia time, surgical time, volume of crystalloids, and the volume of packed red blood cells infused during surgery. In our series, children undergoing frontoorbital advancement and remodeling stayed longer in hospital as compared to those undergoing strip craniectomy and other procedures. Frontoorbital advancement is an extensive surgery, associated with more blood loss and therefore more complications, thus longer hospital stay could be expected. Numbers of postoperative complications are expected to prolong their hospital stay. Patients with more ICU stay have proportionately more hospital stay. In our study type of surgery and ICU stay were independent risk factors for hospital stay.

The median ICU stay in our study was two days. An association was observed between ICU stay and factors such as number of medical conditions, number of postoperative complications, and type of anesthesia induction. Number of postoperative complications was found to be an independent factor with significant association with ICU stay. In our series, inhalational induction of anesthesia prolonged the ICU stay when compared with intravenous induction of anesthesia. Safe use of remifentanil during repair of craniosynostosis has been reported. [4] Others who have compared the use of sevoflurane/remifentanil to isoflurane/remifentanil, have found comparable outcomes. [5] In our study type of recovery was found to be a significant determinant of ICU stay.

The reported blood loss during craniosynostosis ranged from 15-91% of estimated blood volume EBV. [6],[7],[8] In our study, the mean intraoperative blood loss was 18.6% of EBV. We have categorized blood loss into two: mild to moderate blood loss (≤ 30% of EBV) and severe blood loss (>30% EBV). In our study, we found significant blood loss with type of surgery. An earlier study has shown greater blood loss in patients with recognized craniofacial syndromes, pansynostosis, and operating time longer than 5 h and age of 18 months or younger, similar to the findings in our study. [9] Frontoorbital advancement has to be done as early as possible to increase the intracranial volume thus allowing brain growth and halting mental retardation. [10] In general, techniques associated with more bony dissection (more blood loss) are associated with better cosmetic outcome. [11] Several investigators have found that spring-mediated cranioplasty required less blood products' replacement than cranial vault remodeling and might provide the same cosmetic outcome as cranial vault remodeling. [12],[13],[14] Complex calvarial vault remodeling promotes better outcome in comparison to less invasive procedures like strip craniectomy. [11],[15] Within the range of pediatric transcranial procedures performed, the potential for complications is greater for complex osteotomies in syndromic conditions than for single sutural synostosis correction. In our study, syndromic craniosynostosis as compared to non-syndromic patients was not found to be significantly associated with severe blood loss. The reported proportion of patients receiving blood transfusion during craniosynostosis surgery has been 36-144% of EBV. [1],[6],[7],[8],[10],[16],[17] In our study, the mean intraoperative blood transfusion was 15% of EBV and postoperative blood transfusion was 30.2 % of EBV, total perioperative blood transfusion was 45.2% of EBV. Uppington et al., [10] reported the factors associated with transfusion rates; types of suture repair, operating neurosurgeon and anesthesiologists caring for the patient. We suggest that during craniosynostosis surgery it is prudent to replace blood loss with packed red blood cells if necessary and to use crystalloids for other fluid requirements. Rapid blood transfusion in an infant can result in hyperkalemia and cardiac arrest, primarily because of high concentration of potassium in stored blood. [18] Furthermore, coagulopathy is associated with blood loss 1.5 times of EBV. [19] In our series, two patients (2.1%) developed hyperkalemia as a result of massive blood transfusion. These patients had massive blood loss and ultimately suffered cardiac arrest as the bleeding could not be controlled.

This study was a retrospective study, which has some inherent deficiencies. Even then this analysis provided good information for neurosurgeons and anesthesiologists involved in the care of children with craniosynostosis. A prospective study may be required to find various risk factors associated with morbidity and mortality in children with craniosynostosis undergoing surgical corrections.

 » References Top

1.Phillips RL, Mulliken JB. Venous air embolism during a craniofacial procedure. Plast Reconstr Surg 1988;82:155-9.   Back to cited text no. 1
2.Jennett B, Bond MR. Assessment of outcome after severe brain damage. Lancet 1975;1:480-4.  Back to cited text no. 2
3.Hasan RA, Nikolis A, Dutta S, Jackson IT. Clinical outcome of perioperative airway and ventilatory management in children undergoing craniofacial surgery. J Craniofac Surg 2004;15: 655-61.  Back to cited text no. 3
4.Chiaretti A, Pietrini D, Piastra M, Polidori G, Savioli A, Velardi F, et al. Safety and efficacy of remifentanil in craniosynostosis repair in children less than 1 year old. Pediatr Neurosurg 2000;33:83-8.  Back to cited text no. 4
5.Pietrini D, Ciano F, Forte E, Tosi F, Zanghi F, Velardi F, et al. Sevoflurane- remifentanil vs. Isoflurane -remifentanil for the surgical correction of craniosynostosis in infants. Pediatr Anaesth 2005;15:653-62.  Back to cited text no. 5
6.Harrop CW, Avery BS, Marks SM, Putnam GD. Craniosynostosis in babies: Complications and management of 40 cases. Br J Oral Maxillofac Surg 1996;34:158-61.  Back to cited text no. 6
7.Kearney RA, Rosales IK, Howes WJ. Craniosynostosis: An assessment of blood loss and transfusion practices. Can J Anaesth 1989;36:473-7.  Back to cited text no. 7
8.Tuncbilek G, Vargel I, Erdem A, Mavli ME, Benli K, Erk Y. Blood loss and transfusion rates during repair of craniofacial deformities. J Craniofac Surg 2005;16:59-62.  Back to cited text no. 8
9.White N, Marcus R, Dover S, Solanki G, Nishikawa H, Millar C, et al. Predictors of blood loss in fronto- orbital advancement and remodeling. J Craniofac Surg 2009;20:378-81.  Back to cited text no. 9
10.Uppington J, Goat VA. Anaesthesia for major craniofacial surgery: A report of 23 cases in children under four years of age. Ann R Coll Surg Engl 1987;69:175-8.   Back to cited text no. 10
11.Boop FA, Shewmake K, Chadduck WM. Synostectomy versus complex cranioplasty for the treatment of sagittal synostosis. Child's Nerv Syst 1996;12:371-5.  Back to cited text no. 11
12.Ririe DG, David LR, Glazier SS, Smith TE, Argenta LC. Surgical advancement influences perioperative care: A comparison of two surgical techniques for sagittal craniosynostosis repair. Anesth Analg 2003;97:699-703.   Back to cited text no. 12
13.Guimaraes -Ferreira J, Gewalli F, David L, Olsson R, Friede H, Lauritzen CG. Spring - mediated cranioplasty compared with the modified pi-plasty for sagittal synostosis. Scand J Plast Reconstr Surg Hand Surg 2003;37:208-15.  Back to cited text no. 13
14.David LR, Proffer P, Hurst WJ, Glazier S, Argenta LC. Spring - mediated cranial reshaping for craniosynostosis. J Craniofac Surg 2004;15:810-6.   Back to cited text no. 14
15.Maugans TA, Mccomb JG, Levy ML. Surgical management of sagittal synostosis; a comparative analysis of strip craniectomy and calvarial vault remodeling. Pediatr Neurosurg 1997;27:137-48.  Back to cited text no. 15
16.Faberowski LW, Black S, Mickle JP. Blood loss and transfusion practice in the perioperative management of craniosynostosis repair. J Neurosurg Anesthesiol 1999;11:167-72.  Back to cited text no. 16
17.Meyer P, Renier D, Arnaud E. Blood loss during repair of craniosynostosis. Br J Anaesth 1993;71:854-7.  Back to cited text no. 17
18.Bithal P, Jayalaxmi TS, Dash HH, Batra RK, Arora MK. Anaesthetic management for surgical correction of craniosynostosis. J Aanaesthesiol Clin Pharmacol 1988;4:105-9.  Back to cited text no. 18
19.Williams GD, Ellengbogen RG, Gruss JS. Abnormal coagulation during pediatric craniofacial surgery. Pediatr Neurosurg 2001;35:5-12.  Back to cited text no. 19


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]

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