30. Durotomies in Cranial Vault Remodeling for Craniosynostosis: An Analysis of Outcomes

PURPOSE: While previous investigations into complications of cranial vault remodeling have commented on the incidence of durotomies, there is little information detailing the risk factors or sequelae associated with them. Durotomies are thought to result in an increased risk of complications ranging from small subclinical CSF leakage, pseudomeningocele, herniation of the underlying brain parenchyma or infection. This study aims to evaluate the outcomes of patients who sustain durotomies during cranial vault remodeling for craniosynostosis. METHODS: A retrospective chart review was performed at a tertiary pediatric craniofacial center between 2013 and 2021 to evaluate the outcomes of patients undergoing fronto-orbital advancement (FOA). Patients who sustained dural disruptions were identified and separated into two cohorts, those who had unintentional durotomies and those with unintentional durotomies for ICP measurement. All patients with durotomies underwent immediate repair with a 4-0 Nurolon suture and/or collagen based dural grafts at the discretion of the neurosurgeon. Statistical analyses of the entire cohort using simple and logistic regression as well as between the two durotomy cohorts with independent samples t-tests and chi-squared tests were performed. Coarsened exact matching was used to create two matched groups based on sex, race, age, affected suture(s), syndromic status, prior craniofacial surgery, and post-operative antibiotics for further analysis with Exact McNemar tests. RESULTS: A total of 310 patients who underwent FOA between 2013 to 2021 met inclusion criteria for this study. 136 patients had documented dural disruption with 83 unintentional durotomies and 62 intentional durotomies for direct intracranial pressure measurements. Most patients were male (66.2%), age 0-12 months (38.7%), and non-syndromic (82.3%). Patients in the durotomy group were significantly older (24.3% vs. 10.3% ≥ 5 years old, p <.001) with a higher ASA class (4.3 vs. 2.4, p <.001) and more likely to have a syndromic diagnosis (29.0% vs. 15.0%, p =.015). A history of a prior intracranial operation, excluding FOA, was associated with an increased risk of dural disruption (40.3% vs. 24.8%, p =.018). There were no significant differences in the odds of pre-operative or post-operative complications based on the presence of any durotomy in the whole cohort and CEM analyses. Intentional durotomy was a protective factor against peri-operative complications in adjusted multiple logistic regression (OR 0.18; 95% CI 0.03-0.70, p=0.32) and CEM (8 [10.8%] vs 1 [1.35%], p=0.039. CONCLUSION: This single institution, retrospective analysis demonstrates that durotomy, whether intentional or unintentional, does not confer an increased risk of infection, perioperative, or postoperative complications when properly managed intraoperatively via immediate repair. Further studies are warranted to ensure the reproducibility of these outcomes in lower volume craniofacial centers and those with different perioperative management approaches.