Craniofacial Trauma: An Assessment of Risk Related to Timing of Surgery C. Derdyn, M.D., J. A. Persing, M.D., W. C. Broadus, M.D., Ph.D., |. B, Delashaw, M.D., J. Jane, M.D., Ph.D., P. A. Levine, M.D., and J. Torner, Ph.D. Charloweseilte, Va Following the retrospective analysis of approximately 4000 head-injury patients, 49 were identified with a combination of displaced facial fractures and significant cerebral trauma. ‘The purpose ofthis study was to define clinical and radiographic features in these patients that te asvocited witha poor progmosis, which in tum might influence the timing of facial fracture repair. The pres- ence of an upper-level facial fracture, low Glasgow coma Score, intracranial hemorrhage, displacement of nor- mally midline cerebral structures, and. multisystem trauma was associated with a. statistically significant poorer prognosis. Additionally, in demographically sim ilar groups of patients (age, sex, concomitant injury) preselected for intracranial pressures of less than 15 InmtTg at the time of surgery, no significant difference in survival was appreciated in patients who underwent early (0 to 8 days), middle (4 10 7 days), or late (>7 days) surgical repair. Early surgical repair of facial fractures in these circumstances does not appear to have a negative impact on recovery. Facial fractures are commonly associated with cerebral injury. Approximately 52 percent of patients with facial fractures have an associated closed head injury (CHI),' with the greater the energy at impact (j.e., motor vehicle accidents versus falls or assault), the greater the likelihood of a closed head injury. Life-threatening cerebral injury may be associated with facial fractures in as much as 36 percent of high-velocity trauma. Recently, great emphasis has been placed on the immediate and full correction of facial frac- tures, because of the obviously improved aes- thetic and functional results obtained by this treatment approach compared with that of de- layed surgery.“ Despite the obvious benefits of From the Departments of Pati Sung early facial fracture reduction, it is clear that some individuals with combined facial bone and cerebral injuries may be placed at risk for further cerebral injury by early surgery. Supine position- ing, intraoperative fluid shifts, and cerebrovas- cular dilating anesthetics all may exacerbate cer- ebral edema and negatively affect outcome. This study seeks to identify factors that might be used at the time of initial evaluation to recognize those individuals who might be adversely affected by early surgical reduction of facial fractures. PATIENTS AND METHODS Patient Population Approximately 4000 patients were admitted to the University of Virginia Health Sciences Center between January of 1980 and July of 1987 with a history of, at a minimum, a loss of consciousness (concussion). Each patient was evaluated by the trauma and neurosurgical serv- ices and, on an alternating weekly schedule, the plastic surgery or otolaryngology surgery serv- ices. These patients’ case histories were retro- spectively analyzed to identify those patients with displaced facial fractures plus cerebral injury se- vere enough to require, at least, intracranial pres- sure (ICP) monitoring (ie., significant cerebral contusions or intracranial hemorrhage requiring operative intervention). Excluded were patients with isolated cerebral or cranial vault injury, patients with isolated facial fractures, patients with cerebral concussions (mild cerebral injury) combined with facial fractures, and patients with ry, Neurological Surgery. and Otolaryngology-Head and Neck Surgery atthe University of Virginia Health Sciences Cente. Received for publication Apri 10, 1980; revised July 26, 1080 38Vol. 86, No. 2 / CRANIOFACIAL TRAUMA any severity of cerebral injury associated with nondisplaced facial fractures. Data Collection Admission data collected included the mode and time of injury, the age and sex of the patient, the admission neurologic examination, and the Glasgow coma scale (GCS) score” as a standard- ized measure of neurologic injury (Table 1). A high postinjury GCS score is associated with a lesser degree of cerebral injury and greater like- lihood of good neurologic recovery, while a low score predicts a low probability of good neu logic outcome. Notation was made as well of the location and type of associated injuries to other body systems (pulmonary, gastrointestinal, and so on). Facial fractures were categorized as upper, middle, or lower face or any combination of the three regions (after Gentry et al.” and Lee et al.”), Briefly, fractures cephalad to the frontozy- gomatic sutures laterally and the nasoethmoid sutures medially (ie., supraorbital rim, frontal sinus fractures) were designated upper-level, fractures caudad to this level but cephalad to the interocclusal plane (ie., ethmoid, maxillary, zy- TABLE 1 Glasgow Coma Seale (GCS) Summates Responses to Three inical Observations—Eye Opening, Verbal Response, and Movement—to Give an Index of the Severity of Neurologic Injury (Higher numerical score indicates less severe neurologic injury.) Eyes: Open Spontancously a To verbal command 3 To pin 2 No response 1 Best motor re Toverbal Obese o sponee ‘command To painful Lacalizes pin 5 ssimulus® Hexion-witdrawal 4 Hlexionabnormal (des 3 corticate rigidity) Estension decerebrawe 2 visit) No tesponse Best verbal re Oriented and con sponse —— Disoriented and com Inappropriate words 8 Incomprehensible 2 No response 1 TOTAL 239 gomatic, and nasal fractures) were designated middle-level, and fractures caudad to the inter- occlusal plane (.e., mandibular fractures) were identified as lower-level facial fractures. Patients with frontal bone fractures that did not involve the frontal sinus or the supraorbital rim were excluded from this study. Fractures such as a Le Fort III fracture (including the nasoethmoid, orbital floor, maxilla, and so on) were counted singly as one fracture and not subdivided into component parts. CT scans of the face, panra- diography of the skull and face, and operative notes from the repair procedure were used to assign location, number, and nature to the frac- tures. ‘The admission cerebral CT scan was inter- preted by the radiology or neurological surgery staff. Information gathered from these scans in- cluded the degree of shift of normally midline cerebral structures; the number, location, and nature of high-density lesions (i.e., epidural, sub- dural, or intracerebral hematom: ence of compress brospinal fluid cisterns (as an indication of intra- cranial spatial decompensation and_ incipient cerebral herniation). The facial CT scan was interpreted by the plastic surgery or otolaryn- gology-head and neck surgery staff to note the location and degree of displacement of the facial fractures. Neurosurgical procedures were carried out as indicated by the clinical findings supported by the CT scan. Facial fractures were managed by the plastic surgery or the otolaryngology-head and neck surgery services on a rotating weekly schedule. The timing of the facial fracture repair was determined by the preference of the con- sultant, except when contraindicated by the fol- lowing clinical situations 1. Elevated intracranial pressure (ICP) arbi- trarily set at 15 mmHg on admission (all patients undergoing early facial fracture reduction had placement of ICP monitors; normal ICP in a supine patient may be as high as 12 mmHg) 2. Severe associated injury (such as massive pulmonary contusion) 3. Severe medical conditions (such as dissem- inated intravascular coagulation) 4. Obvious poor prognosis for survival due to cerebral injury (clinical criteria for brain death or severe brainstem level dysfunc- tion)240 PLASTIC AND RECONSTRUCTIVE SURGERY, August 1990 ‘The timing of facial fracture repair was divided into three groups: 1, Early (0 to 3 days) 2. Middle (4 to 7 days) 3. Late (after 7 days) ‘The operative notes from all procedures per- formed were reviewed, and data were collected regarding date and length of each procedure (neurosurgical and facial fracture repair), the type of procedures, and the total of perioperative fluids administered. The preoperative and post- operative GCS scores were obtained from the hospital record. Outcome data collected included the date of discharge, the discharge GCS score, and if appro- priate, the date and time of death. Glasgow out- come score (GOS)"” was computed from the chart and reflects an objective measure of the degree of impairment of patients following re- covery from head injury (Table II). Outcome was divided into two categories: 1. Good recovery with (GOS 5) 2. Moderate to severe disability or death (GOS <4) val disability Statistical analysis of the data was performed using either chi-square analysis or Fisher's exact, test TABLE Il Glasgow Outcome Scale (Abbreviated Scale), A Measure of Function Following Cerebral Injury Pan can Dead a Fall and independent life ‘with or without min inal neurologic def ‘GOS Moderate recovers! Patient has neurologic ‘or intellect in Pairment but is inde- ene ‘GOSS: Severely dimblede —__ Gonscions patent, but {otally dependent on others to get {hrough the activities forthe day OS 8: Vegetative warvial TABLE U1 iphies of Combined Craniofacial Trauma Patient Population Demogr Percent of 1 2 5 31 27 55 5 10 1 2 ‘Mate 43 88 Female 6 i Mechanism of injury wa 2 86 csw 2 4 ‘Asc 1 2 Fall 4 8 Resutts Population Forty-nine patients were admitted during 1980-1987 with a combined facial fracture and neurologic injury requiring operative interven- tion, or approximately 1 percent of this head- injury population. As with most head-injury se- ries, the majority of patients injured were male, aged 21 to 40 years, who had been involved ina motor vehicle accident (Table II1). ‘The admission GCS score of the 49 patients for study demonstrates a nearly even distribution between severe (GCS 3 to 5), moderate (GCS 6 to 8), and relatively mild (GCS 9 to 14) neuro- logic injury (Table IV), Fractures of the craniofacial skeleton were dis- tributed as listed in Table V. Overall, the injuries were severe, with a majority of the patients hav- ing an average of four to six fractures per patient. Patients undergoing early surgery (0 to 3 days after injury) generally had a higher GCS score (less severe injury) (Table V1). Patients with more severe injury tended to be delayed owing to the initial recording of ICP being greater than 15 TABLE 1V Admission GCS Scores of Patients with Combined Craniofacial Trauma, Indicating Severity of Cerebral Injury GCS Score Frequcny x 1% 6x 20 9-14 4Vol. 86, No. 2 / CRANIOFACIAL TRAUMA TABLE V Fracture Frequency and Distribution in Patients with ‘Combined Craniofacial Trauma 241 TABLE VU Severity of Neurologic Injury (GCS Score) on Admission Compared with Ourcome (Note that lower GCS scores are associated with poorer prognosis.) Upper face roma bone * Frat ane sinus 5 Front post sinus 7 Orbital tot 5 Orbit mea wall 0 Nasocthonoid * Middle ace Orbital floor 1 Levent 7 ‘Zygon 9 LeFort ll 10 ‘sgomatic aren S LeFort Nasal 6 Palate 2 Manilla Lower face ‘Mandible mmHg. Finally, 12 patients with the most severe head injuries were not operated on because of evidence of severe brainstem-level dysfunction or brain death at the time of initial evaluation. Outcome ‘The GCS score accurately predicted outcome (Table VI). Those patients with a GCS score of less than 5 uniformly did poorly, all patients cither expiring or having severe disability, whereas the patients with a high GCS score (9 to 14) did well, 86 percent achieving a good recov- ery statu CT scan findings also accurately predicted sur- vival. The presence of intracranial hemorrhage and/or shift of midline cerebral structures was associated with a statistically significant poorer prognosis (Tables VIII and IX). The presence of basal CSF cistern effacement showed a tendency to be associated with a poor prognosis, but this difference was not statistically significant (Table X). There were, however, 10 CT scans that were TABLE VI Severity of Neurologic Injury (GCS Score) Compared with Timing of Facial Fracture Surgery (Note that less severely injured patients are operated on earl than more severely GS Score Ded Dabied Good Revoery * 7 ° 68 7 n oa 2 2 unavailable for analysis because they were either technically inadequate to determine obliteration of the cistern or they were physically purged from radiographic files. The small numbers of available scans for review also affected our ability to further characterize the prognostic effect of the type (epidural, subdural, intracranial), loca tion, and size of cranial hemorrhage. The level of facial fracture affected survival, with patients having fractures located in the up- per level combined with patients having upper- and middle-level facial injuries faring statistically more poorly (p< 0.05) than patients with lower- level lesions (Table X1). Moreover, patients ex- hibiting an additional body system trauma (e. pulmonary, cardiac, gastrointestinal) did statisti- cally more poorly (p < 0.05) than patients who did not. Effects of Surgery Of the 49 patients fulfilling the criteria for combined cerebral and facial trauma, 12 died or remained in a “vegetative” state prior to repair of the facial fracture. All these patients had an admission GCS score of less than 5. Thirty-seven patients underwent repair of their facial frac- tures. The patient groups that underwent early, middle, and late surgery did not differ signifi- cantly between groups with respect to age, sex, type of neurologic procedure (i.e., cerebral in- TABLE VIL Frequency of CT-Demonstrated Intracranial Hemorrhage Compared with Outcome (Note the statistically significant less frequent hemorrhage present in patients with good recovery.) injured patients.) GG sore ine Nowe ___Hemorrage __—_Dese/Diabled Goad Recovery z 2 Absent T B 5 0 Present 6 7 9 6 peour242 PLASTIC AND RECONSTRUCTIVE SURGERY, August 1990 TABLE IX Shift of the Normally Midline Septum Pellucidum Compared with Outcome (Note the statistically significant poorer outcome associated with shift of the septum pellucidum.) TABLE XI Location of Facial Fracture Compared with Outcome (Note that upper-level fractures are associated with poorer ‘Absent 15 28 Prevent 7 2 peo0s jury), number of associated system injuries, num- ber of facial fractures, length of operative pro- cedure, or fluid replacement. Likewise, the three groups of patients did not differ statistically with respect to admission GCS scores, though a trend toward early surgery for patients with less severe cerebral injury was evi- dent (Table X11). Likewise, a nonstatistically sig- nificant trend toward improved survival was doc- umented in the patients who had early repair of facial fractures compared with those who under- went late repair. From a statistical standpoint, no patient oper- ated on in any time period showed a decrement in GCS score. The majority of patients’ GCS scores were unchanged from the time of surgery to the date of discharge approximately 1 month later. There were individuals, particularly those operated on in the early surgery category, dem- onstrating improved neurologic outcome (higher GCS scores) following surgery. This is probably due to the fact that they were operated on during the stage of rapid neurologic recovery, soon after trauma, before stabilization had taken place, rather than due to any beneficial effect of the surgery itself (Fig. 1). ‘Two patients in the series of operated patients died. Their numerical GCS scores were not wors- TABLE X Status of Cerebrospinal Fluid Cisterns Compared with ‘Outcome (Note that deformity of cisterns is more common in patients with poor outcome, but the difference does not achieve statistical significance.) outcome.) Reon Ded/Diabled Good Roney U+UM 12 4 L+ML+ UML+M 4 Ig 7 opper Me mde Lower ened by surgery; on admission, they already had as low a GCS score as was possible (ie., GCS 3). One underwent facial fracture repair 10 days after admission (j.e., late) and died of pulmonary- induced sepsis 107 days later. The second patient underwent early repair (24 hours after injury), with death occurring on the first postoperative day. This patient, with an admission GCS score of 8, also had a CT demonstration of basal cistern effacement indicating incipient transtentorial herniation. He died the day following surgery as a result of uncontrolled ICP. Although it is dif- ficult to implicate surgical treatment as affecting outcome in the patient undergoing late surgery, the patient undergoing surgery within 24 hours of injury and subsequently dying due to in- creased intracranial pressure most likely was neg- atively affected. There were no significant differences in the number of postoperative complications experi- enced between the groups undergoing carly, middle, and late surgery (Table XID). Discussion In this preliminary study, our data indicate that low GCS score, upper-level facial fracture, CT evidence of intracranial hemorrhage, and shift of midline cerebral structures are associated with a poor prognosis. Additionally, evidence for basal CSF cistern effacement on CT scan may TABLE XI ing of Surgery Compared with Outcome (A trend toward early surgery in patients with less severe neurologic injury is seen.) CSFCicrint —_—_Dead/Disbied Good Recovery Deed/Diabled Goad Reorery Nan 10 7 Ean 4 2 Mild 1 1 Middle 3 5 B A Lae 8 7 : . Nondisplaced 4 5 NMI porma il il deforony del deine dori pas rn 4 ahersp= 0088: p= 0.087Vol. 86, No. 2 / CRANIOFACIAL TRAUMA POSTOPERATIVE CHANGE IN GCS Eon (0-3 0098) Di Lote attr 7 0045) dale (5-7 Days) Number g yi y Vy, ) y @ | @ $a 5 oes, Fig. 1. Histogram demonstrating change in GCS score in patients undergoing early, middle, and late period surgery No patient demonstrated & worsening of GCS score. MN TABLE XII Comparison of Different Systems Injury ($1) Frequency with Timing of Facial Fracture Repair (No significant differences were appreciated between groups undergoing early, middle, late, or no surgery.) w ° ® 5 1 4 4 2 3 3 1 > 1 6 4 2 indicate a poor prognosis, but statistical support for this statement is lacking. Patients who underwent early surgical reduc- tion of their facial fractures demonstrated a non- statistically significant improvement in survival. ‘The improvement is probably artifactual, since this is a retrospective study with a preselection bias inherent in the treatment of these patients: a greater number of patients with lesser cerebral injury (high GCS scores) were selected for early surgery. It is interesting to note, however, that when the early, middle, and late surgery groups are compared relative to major prognostic fac- tors and demographic characteristics, they are similar with no appreciable or statistically signif- icant differences. These data suggest that, at least, early surgery does not appear to worsen survival when compared to the middle and later surgical groups if one of the selection criteria for surgery is an ICP of less than 15 mmHg. Because early surgical treatment of facial fractures can 243 provide a better aesthetic result and it does not appear to worsen survival, support for the early surgery recommendation is given by this study. Early surgery for facial trauma, as stated pre- viously by Manson et al.,* Gruss and Mackinnon,* and others, is appealing because the techniques of direct exposure of fracture fragments with anatomic reduction and interfragment bone fix- ation largely obviate the need for precise intra- operative soft-tissue contour assessment, which ordinarily is distorted due to edema. Addi- tionally, since fracture reduction may be achieved prior to fibroblast ingrowth into and collagen production in the traumatized area, sec- ondary abnormal distortion of facial structures by scar is potentially reduced. Proponents of delayed surgery for neurologically unstable pa- tients rightfully do exist, however. Patients with extensive facial fractures who are apparently “fit” by neurologic examination criteria preopera- tively have sustained immediate unexplained worsening in neurologic status postoperatively.” Although vasospasm of basal cerebral vessels is suspected, documentation is lacking. In the present study, the finding of a poorer prognosis with upper facial fractures is coin dent with previously published data by Lee et al.’ They found upper-level facial injury most frequently associated with closed head injury (CHD), contrasted with isolated mandible frac- tures with a low association with closed head injury. Midfacial fractures with mandible frac- ture (i.c., multiple fractures) in their data analysis were associated with a low incidence of associated closed head injury, invoking the idea of a protec- tive cushioning effect of the facial fracture for the brain, Data analysis in this study was unable to substantiate this, although the trend was in the same direction. The predictive value of the GCS score is well established by previous investigations.°""'* In the present study, further support comes in the finding of no “good recovery” in patients with a GCS score of less than 5, whereas 61 percent of those with GCS score of 6 to 8 recovered with nal disability and 85 percent of those with a GCS score of greater than 9 made a good recovery. The CT scan data have proved invaluable, as noted by previous authors, in that the presence of intracranial hemorrhage is recognized as a poor prognostic sign.'” Likewise in this study, the presence of a shift of intracranial midline struc- tures is associated with a poor prognosis. Lipper244 PLASTIC AND RECONSTRUCTIVE SURGERY, August 1990 etal."® previously noted that a shift of intracranial midline structures of more than 3.8 mm correctly predicted poor outcome in 63 percent of severely head-injured patients. Others have shown an in- verse relationship between the degree of basal cistern effacement and survival.!7 Intracranial hemorrhage in this study was as- sociated with a poorer survival rate. However, questions regarding the size and location of hem- orthage affecting survival are left unanswered. Previous data in patients with isolated cerebral and cranial vault injury indicate that the larger the hemorrhage, the worse is the prognosis, by indirect measures such as shift of midline cere- bral structures. Delayed intracranial hemorrhage was not seen in the present study but should be considered in the overall treatment plans of patients with se- vere head injury.'® These hemorrhages by defi- nition are not present on initial CT scan study but develop 1 to 24 days following trauma, the greatest number being diagnosed as an abrupt ge in ICP 24 to 48 hours after injury. De- layed hemorrhages are more likely to be seen in more severe head injuries and lower GCS scores. Special consideration should be given in the severely brain-injured patient (low GCS score) with facial fractures to ICP monitor- ing intraoperatively during facial fracture reduc- tion at least in the early treatment phase to be able to diagnose and treat this possi promptly as possible. Monitoring of intracranial pressure has been shown to be an effective adjunct in determining the severity and treatment of cerebral injury. Because of this, in the present study, no patient with an ICP of more than 15 mmElg on initial reading underwent early surgical reduction of facial fractures. It is believed that the relative supine head position intraoperatively, the ex- pected blood loss and fluid replacement, and the need for cerebral vasodilating inhalation anes- thetics contribute to the possibility of increasing cerebral edema. In these cases, we recommend surgery be delayed. Additionally, the observation of an ICP of less than 15 mmHg on admission should not be the sole guide to determining the feasibility of early surgery. Fracture of the ante- rior cranial base may result in dural tears and CSF leaks, falsely lowering the ICP and masking the degree of cerebral edema present. The best treatment regimen for the combined facial fracture and cerebral injury patient is yet to be defined, and the relatively small number of patients in this study disallows implementation of rigid guidelines. These data should be consid- ered preliminary pending completion of a larger- scale multicenter study of this issue. However, because of the relative frequency of these pa- tients needing care nationwide, we offer these early recommendations: enlist the early consul- tation of the neurologic and trauma surgeon, obtain appropriate radiologic studies to include CT scans of the craniofacial skeleton, and record the ICP to help determine the appropriate timing of facial fracture reduction surgery. We believe that the patient with a GCS score of 6 or higher, no evidence of intracranial hemorrhage, midline cranial shift, or basal cistern effacement, and an ICP of less than 15 mmHg without an obvious CSF leak is a good candidate for early facial fracture reduction. Alternatively, the patient with a GCS score of 5 or lower, evidence of intracranial hemorrhage, midline cranial shift, or basal cistern effacement, and an ICP of more than 15 mmflg is a poor candidate for early fracture reduction. Consideration should be given to delayed surgical treatment. However, even those patients with a low likelihood for neurologic recovery (unless they are clinically brain dead) still should be considered for delayed surgical reduction of facial fractures, when ICP reduction permits, to avoid the later develop- ment of grotesque facial deformity. Restoration of correct facial anatomy may be of benefit not only to the patient with the unexpected and surprisingly good recovery, but as well to the family of the patient with persistent severe brain injury, since it may reduce their tendency toward “familial” social isolation as a result of the pa- tient’s facial deformity. John A. Persing, M.D. Division of Craniofacial Surgery Box 376 University of Virginia Health Sciences Center Charlottesville, Va. 22908 ACKNOWLEDGMENTS ‘Theauthors wish to thank Jeff Adams and Nancy Tisdale, R. N,, for assistance in data organization and retrieval and Debra Shaffer for excellent editorial assistance. REFERENCES 1. 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