Quantifying the risks: a systematic review and proportional meta-analysis of the perioperative complications of posterior cranial vault distraction osteogenesis in patients with craniosynostosis.

OBJECTIVE

Posterior cranial vault distraction osteogenesis (PCVDO) is a well-established surgical technique for increasing intracranial volume and correcting cranial deformities in children with craniosynostosis. Despite its efficacy, PCVDO is associated with the risk for several perioperative complications. In this systematic review and proportional meta-analysis, the authors aimed to estimate the pooled prevalence of complications associated with PCVDO, including overall complications, infection, CSF leakage, device-related complications, premature device removal, and unplanned returns to the operating room. Additionally, they sought to identify sources of heterogeneity among the studies and evaluate the influence of key clinical and surgical moderators-such as patient age, syndromic status, distraction parameters, elevated intracranial pressure, hydrocephalus, Chiari malformation, syrinx, and prior surgical interventions-on complication rates.

METHODS

A systematic review and proportional meta-analysis were conducted, following the PRISMA guidelines. The MEDLINE/PubMed database was reviewed for English-language, peer-reviewed studies published between 2009 and 2025 that reported perioperative complications in pediatric patients (age < 18 years) with craniosynostosis who had undergone PCVDO and included at least 2 patients. Excluded publications were single case reports, editorials, technical notes, reviews, preclinical or animal studies, and studies not meeting these criteria. Data from the included studies were compiled into a comprehensive spreadsheet to facilitate qualitative and quantitative analyses. A quality assessment of all studies was conducted utilizing the Newcastle-Ottawa Scale. The primary outcome was the proportion of patients experiencing any complication. Secondary outcomes comprised rates of infection and wound-related events, CSF leakage, device-related complications, premature device removal, and unplanned returns to the operating room.

RESULTS

Thirty-three studies were included in this analysis. The pooled overall complication rate was 26.3%. Infection and wound-related complications were most common (10.4%), followed by CSF leakage (6.7%) and device-related complications (6.0%). Premature device removal and return to the operating room occurred in 4.0% and 9.9% of patients, respectively. Meta-regression analysis revealed that younger age was significantly associated with an increased risk of CSF leakage and premature device removal. Shorter latency periods were associated with a higher risk of CSF leakage and return to the operating room.

CONCLUSIONS

While PCVDO is effective in managing craniosynostosis, it is associated with a considerable risk of complications. Age and latency period are significant predictors of adverse outcomes. Innovations in device design and surgical protocols are warranted to optimize the safety and efficacy of the procedure.