Abstract: Posterior cervical decompression and fusion (PCF) is a common surgical technique used to treat various cervical spine pathologies. However, there are various complications associated with PCF that can negatively impact patient outcome. We performed a comprehensive literature review to identify the most common complications following PCF using PubMed, Cochrane Database of Systematic Reviews, and Google Scholar. The overall complication rates of PCF are estimated to range from about 15% to 25% in the current literature. The most common immediate complications include acute blood loss anemia, surgical site infection (SSI), C5 palsy, and incidental durotomy; the most common long-term complications include adjacent segment degeneration, junctional kyphosis, and pseudoarthrosis. Three principal mechanisms are thought to contribute to complications. First, higher number of fusion levels, obesity, and more complex pathologies can increase the invasiveness of the planned procedure, thus increase complications. Second, wound healing and arthrodesis may be impaired due to poor blood flow due to various patient factors such as smoking, diabetes, increased frailty, steroid use, and other medical comorbidities. Finally, increased biomechanical stress on the upper instrumented vertebra (UIV) and lowest instrumented vertebra (LIV) may predispose patient to chronic degeneration and result in adjacent level degeneration and/or junctional problems. Reducing the modifiable risk factors pre-operatively can decrease the overall complication rate. Neurologic deficits may be reduced with adequate intraoperative decompression of neural elements. SSI may be reduced with meticulous wound closure that minimizes dead space, drain placement, and the use of intra-wound antibiotics. Careful design of the fusion construct with consideration in spinal alignment and biomechanics can help to reduce the rate of junctional problems. Spine surgeons should be aware of these complications associated with PCF and the corresponding prevention strategies optimize patient outcomes.
PURPOSE: The gold-standard treatment for metopic craniosynostosis is open cranial vault reconstruction (OCVR) with fronto-orbital advancement. A recent alternative is minimally invasive strip craniectomy with orthotic helmet therapy (SCOT), which has perioperative outcomes superior to those of OCVR, though its long-term efficacy remains poorly defined.1 We sought to compare the long-term morphologic outcomes, patient satisfaction, and subjective appearance in patients with metopic synostosis who underwent OCVR versus SCOT. METHODS: Patients who underwent OCVR or SCOT between 2000 and 2017 for isolated metopic synostosis were identified at our institution. Inclusion criteria included (1) preoperative CT or laser scan imaging, (2) postoperative 3D photos, and (2) at least 3 years of follow-up. Interfrontal angle and interzygomaticofrontal distance measurements were taken from preoperative scans to assess baseline severity.2 Frontal width and intercanthal width, normalized by age and sex, and glabellar angle measurements were made on 3D photos at the latest follow up.2 Independent adolescents and craniofacial surgeons, blinded to the treatment of each patient, rated the appearance of postoperative photos. All patients' parents completed satisfaction surveys at the latest follow up. RESULTS: Thirty-five patients were included (15 SCOT and 20 OCVR). Mean follow-up time was similar for both groups (SCOT 7.9 ± 3.2 years versus OCVR 9.2 ± 4.1 years, P = 0.33). Baseline severity between groups was similar in both interfrontal angle (SCOT 116.6 degrees ± 8.8 degrees versus OCVR 110.5 degrees ± 10.1 degrees, P = 0.07) and interzygomaticofrontal distance (SCOT 67.5 ± 6.8 mm versus OCVR 66.5 ± 8.6 mm, P = 0.75). Postoperatively, the glabellar angle was equal between groups (SCOT 122.2 degrees ± 4.2 degrees versus OCVR 123.9 degrees ± 6.0 degrees, P = 0.16), as were age- and sex-adjusted frontal width (SCOT Z-score −0.8 ± 1.5 versus OCVR −1.7 ± 1.5, P = 0.09) and intercanthal width (SCOT Z-score 1.2 ± 1.2 versus OCVR 0.5 ± 1.1, P = 0.11). Independent laypersons rated the overall appearance of SCOT patients as equal to that of normal controls (P = 0.31) and better than that of OCVR patients (P = 0.04). Craniofacial surgeons assigned Whitaker class I to a greater proportion of SCOT patients (75.6% ± 6.4%) compared with OCVR patients (43.3% ± 9.5%, P = 0.02), particularly among patients with moderate-severe synostosis (SCOT 72.2% ± 5.6% versus OCVR 33.3% ± 9.2%, P = 0.02). Parents of patients who underwent SCOT and OCVR reported equivalent levels of satisfaction with the appearance of their child's forehead (93% versus 95%, P > 0.99) and with the overall results of the surgery (100% versus 95%, P > 0.99). Likewise, parents of children who underwent MISC were no more likely to report bullying (7% versus 15%, P = 0.82) or social exclusion (0% versus 15%, P = 0.34) due to their child's appearance. CONCLUSION: Minimally invasive strip craniectomy with orthotic helmet therapy was associated with equivalent long-term morphologic outcomes and patient satisfaction, and superior subjective appearance, compared with open cranial vault reconstruction among patients with metopic craniosynostosis. REFERENCES: 1. Yan H, Abel TJ, Alotaibi NM, et al. A systematic review of endoscopic versus open treatment of craniosynostosis. Part 2: the nonsagittal single sutures. J Neurosurg Pediatr. 2018;22(4):361–368. 2. Nguyen DC, Patel KB, Skolnick GB, et al. Are endoscopic and open treatments of metopic synostosis equivalent in treating trigonocephaly and hypotelorism? J Craniofac Surg. 2015;26(1):129–134.
Facial feminization surgery is an increasingly performed component of gender affirmation surgery for transgender women. Preoperative facial CT is performed to plan the adjustment of the patient's masculine characteristics to feminine and to plan operative navigation around specific readily identifiable anatomic structures. In the upper face, surgery is performed to reduce the prominence of the brow and increase the nasofrontal angle; the radiology report should indicate the frontal sinus and supraorbital foramen anatomy. In the midface, rhinoplasty is performed to increase the nasofrontal and nasolabial angles; the radiology report should indicate the presence of a dorsal hump and septal deviation or spurring. In the lower face, the prominence of the chin and squareness of the jaw are adjusted via genioplasty and mandible contouring, respectively; the radiology report should describe the location and potential anatomic variations of the inferior alveolar nerve and mental foramina as well as the presence of dental abnormalities that directly inform the surgical approach. CT may also be performed if there is clinical suspicion for postoperative complications such as hardware fracture or osteotomy through the supraorbital or mental foramen. Familiarity with these findings will facilitate improved communication between radiologists and surgeons, thereby contributing to the care of transgender women.
Strip craniectomy with orthotic helmet therapy (SCOT) is an increasingly supported treatment for metopic craniosynostosis, although the long-term efficacy of deformity correction remains poorly defined. We compared the longterm outcomes of SCOT versus open cranial vault reconstruction (OCVR).Patients who underwent OCVR or SCOT for isolated metopic synostosis with at least 3 years of follow-up were identified at our institution. Anthropometric measurements were used to assess baseline severity and postoperative skull morphology. Independent laypersons and craniofacial surgeons rated the appearance of each patient's 3D photographs, compared to normal controls.Thirty-five patients were included (15 SCOT and 20 OCVR), with similar follow-up between groups (SCOT 7.9 ± 3.2 years, OCVR 9.2 ± 4.1 years). Baseline severity and postoperative anthropometric measurements were equivalent. Independent adolescent raters reported that the forehead, eye, and overall appearance of SCOT patients was better than OCVR patients (P < 0.05, all comparisons). Craniofacial surgeons assigned Whitaker class I to a greater proportion of SCOT patients with moderate-to-severe synostosis (72.2 ± 5.6%) compared with OCVR patients with the same severity (33.3 ± 9.2%, P = 0.02). Parents of children who underwent SCOT reported equivalent satisfaction with the results of surgery (100% versus 95%, P > 0.99), and were no more likely to report bullying (7% versus 15%, P = 0.82).SCOT was associated with superior long-term appearance and perioperative outcomes compared with OCVR. These findings suggest that SCOT should be the treatment of choice for patients with a timely diagnosis of metopic craniosynostosis.
Facial feminization surgery (FFS) is an increasingly performed component of gender affirmation surgery for transgender women. Preoperative facial CT is performed to plan the adjustment of the patient's masculine characteristics to feminine, and to plan operative navigation around specific readily identifiable anatomic structures. In the upper face, surgery is performed to reduce the prominence of the brow and increase the nasofrontal angle; the radiology report should indicate the frontal sinus and supraorbital foramen anatomy. In the midface, rhinoplasty is performed to increase the nasofrontal and nasolabial angles; the radiology report should indicate presence of a dorsal hump and septal deviation or spurring. In the lower face, prominence of the chin and squareness of the jaw are adjusted via genioplasty and mandible contouring, respectively; the radiology report should describe the location and potential anatomic variations of the inferior alveolar nerve and mental foramina, as well as presence of dental abnormalities that directly inform the surgical approach. CT may also be performed if there is clinical suspicion for postoperative complications such as hardware fraction or osteotomy through the supraorbital or mental foramen. Familiarity with these findings will facilitate improved communication between radiologists and surgeons, thereby contributing to the care of transgender women.
This retrospective cohort study seeks to identify risk factors associated with complications following posterior cervical laminectomy and fusion (PCLF) surgery.Adults undergoing PCLF from 2012 through 2018 at a single center were identified. Demographic and radiographic data, surgical characteristics, and complication rates were compared. Multivariate logistic regression models identified independent predictors of complications following surgery.A total of 196 patients met the inclusion criteria and were included in the study. The medical, surgical, and overall complication rates were 10.2%, 23.0%, and 29.1% respectively. Risk factors associated with medical complications in multivariate analysis included impaired ambulation status (odds ratio [OR], 2.27; p=0.02) and estimated blood loss over 500 mL (OR, 3.67; p=0.02). Multivariate analysis revealed preoperative narcotic use (OR, 2.43; p=0.02) and operative time (OR, 1.005; p=0.03) as risk factors for surgical complication, whereas antidepressant use was a protective factor (OR, 0.21; p=0.01). Overall complication was associated with preoperative narcotic use (OR, 1.97; p=0.04) and higher intraoperative blood loss (OR, 1.0007; p=0.03).Preoperative narcotic use and estimated blood loss predicted the incidence of complications following PCLF for CSM. Ambulation status was a significant predictor of the development of a medical complication specifically. These results may help surgeons in counseling patients who may be at increased risk of complication following surgery.
Background/Purpose: The physical effects of clefting can obscure the psychosocial aspects of the disease. With this in mind, the idea for a unique mental health booklet arose. 9 Reasons to Smile: Family Fun Activity Booklet was developed when Smile Train international programs suspended all cleft treatment for patients at the height of the COVID-19 pandemic. Patients could not receive cleft surgery and other nonsurgical treatments, such as nutritional support, orthodontic care, dental care, psychosocial care, and speech therapy, to ensure long-term, successful rehabilitation. Suspension of cleft treatment poses significant challenges for children and families. Recognizing these challenges, Smile Train developed this booklet to raise awareness for psychosocial health as it is not readily accessible or prioritized around the world. The booklet includes art projects on self-love, engaging games to help children explore their emotions, their relationships, and their self-confidence. Methods/Description: The booklet was developed with support from Fundaci'on Cl'inica Noel, a Smile Train Partner in Colombia. It was first launched in English, French, and Spanish during the World Health Organization Walk the Talk Virtual Event on May 17, 2020. A global launch for the booklet in 10 languages took place on June 17, 2020. To further increase awareness for psychosocial health, Smile Train hosted a live, virtual celebration of 9 Reasons to Smile on July 21st and Smile Train Brazil and Mexico participated in their own local celebrations. The event convened representatives from the global health and global cleft communities to discuss art, health, clefts, and the importance of maintaining self-esteem and positivity through adversity. Results: The booklet is now available in 15+ languages and is shared through WhatsApp messaging platforms worldwide. The global virtual celebration had over 4000 views on Facebook and YouTube, and its reach continues to grow. Smile Train has received thousands of photos and stories from families and partners sharing their experiences using the booklet and its tremendous impact on their lives. The overwhelming response confirms the demand for programs and resources that focus on cleft patients and their psychosocial health needs. Conclusions: There is a need for supporting psychosocial services in global cleft care which is particularly evident during the COVID-19 pandemic. Access to these services is not always prioritized in many countries around the world and the enthusiasm for the 9 Reasons to Smile booklet indicates the positive impact such resources have on mental health. Smile Train is committed to raising awareness on the importance of psychosocial health in global cleft care and will continue to support and scale initiatives for cleft patients and their families around the globe.
