HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Annals of Plastic Surgery • Volume 83, Number 1, July 2019

Postoperative CT Use in Orbital Floor Fractures

TABLE 4. Number and Cost of Postoperative Imaging That Led to Changed Management in Patients With Orbital Floor Fracture Repair

Procedure

No. Patients

No. CT Scans*

No. MRI Scans †

No. X-ray Scans ‡

Total Cost§

Postoperative CT scans Change in care

4

5

0 0

0 0

$719.20 $7048.16

No change in care

43

49

Postoperative alternative imaging Change in care

0

0 0

0 2

0

$0

No change in care

25

23

$5496.52

Postoperative CT scan + alternative imaging Change in care 2

12 10

1 1

1 8

$2276.90 $3454.18

No change in care

9

*Orbit, face, and neck CT scan without contrast, $143.84. † Orbit, face, and neck MRI with and without contrast, $341.54. ‡ X-ray facial bones complete, $209.28. §2017 UCI Health Revenue Cycle.

Our study possesses a variety of limitations, stemming from its retrospective, single-site study design; one must be cautious in applying our findings to other patient populations or institutions. As a retrospec- tive study, archived medical records did not maintain uniformity in their reporting, and we acknowledge that a prospective assessment of radio- graphic efficacy would be preferred. Specifically, the size of orbital floor deficits was at times reported quantitatively (ie, in millimeters or centimeters), but other times qualitatively (ie, small, moderate, signifi- cant), requiring us to instead gauge severity of injury by the presence of concomitant orbital injuries. Moreover, at our institution, surgeons from different departments perform orbital floor fracture repairs, leading to dif- ferences in approach, materials (Synthes and Stryker titanium meshed plates were most commonly used), and postoperative management. Our institution does not have routine access to intraoperative CTor navigation tools to check implants; thus, implant placement confirmation is achieved by clinical testing only. We also defined a change in management as a need for reoperation. It is possible that postoperative CT scans provided the surgeon with information that impacted clinical management in a small way other than supporting surgical revision. Lastly, the pres- ence or absence of additional imaging modalities may have affected a surgeon's decision to pursue reoperation, but this was not a focus in our analysis. CT scans for recently repaired orbital fracture patients. However, the large number ordered and high cost of CT scans used for the assessment of these patients in our institution suggest that careful physical examina- tion may be more clinically beneficial than routine postoperative imag- ing. Because of this study's limitations, more exploration is required before applying this conclusion to other institutions; however, our re- sults clearly display one example of the surplus nature of postoperative CT scans. REFERENCES 1. Brenner DJ . Should we be concerned about the rapid increase in CT usage? Rev Environ Health . 2010;25:63 – 68. CONCLUSIONS Currently, there are no clear guidelines regarding postoperative

2. de González AB , Darby S. Risk of cancer from diagnostic x-rays: estimates for the UK and 14 other countries. Lancet . 2004;363:345 – 351. 3. Diaz L , Mady LJ, Mendelson ZS, et al. Endoscopic ventral skull base surgery: is early postoperative imaging warranted for detecting complications? Laryngo- scope . 2015;125:1072 – 1076. 4. Wang S , Xiao J, Liu L, et al. Orbital floor reconstruction: a retrospective study of 21 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod . 2008;106: 324 – 330. 5. Nadimi S , Caballero N, Carpenter P, et al. Immediate postoperative imaging after uncomplicated endoscopic approach to the anterior skull base: is it necessary. Int Forum Allergy Rhinol . 2014;4:1024 – 1029. 6. Jung H , Byun JY, Kim H-J, et al. Prognostic CT findings of diplopia after surgical repair of pure orbital blowout fracture. J Craniomaxillofac Surg . 2016;44: 1479 – 1484. 7. Mendelson ZS , Echanique KA, Crippen MM, et al. Utility of early postoperative imaging after combined endoscopic and open ventral skull base surgery. Am J Rhinol Allergy . 2017;31:186 – 189. 8. AlHilli MM , El-Nashar SA, Garrett AT, et al. Use of computed tomography in the diagnosis of bowel complications after gynecologic surgery. Obstet Gynecol . 2013;122:1255 – 1262. 9. Nayeri A , Prablek MA, Brinson PR, et al. Short-term postoperative surveillance imaging may be unnecessary in elderly patients with resected WHO grade I me- ningiomas. J Clin Neurosci . 2016;26:101 – 104. 10. Zygourakis CC , Winkler E, Pitts L, et al. Clinical utility and cost analysis of rou- tine postoperative head CT in elective aneurysm clippings. J Neurosurg . 2017; 126:558 – 563. 11. Blumer M , Gander T, Kruse Gujer A, et al. Influence of mirrored computed tomo- grams on decision-making for revising surgically treated orbital floor fractures. J Oral Maxillofac Surg . 2015;73:1982.e1 – 1982.e9. 12. Shah S , Uppal SK, Mittal RK, et al. Diagnostic tools in maxillofacial fractures: is there really a need of three-dimensional computed tomography? Indian J Plast Surg . 2016;49:225 – 233. 13. Schouman T , Courvoisier DS, Van Issum C, et al. Can systematic computed tomo- graphic scan assessment predict treatment decision in pure orbital floor blowout fractures? J Oral Maxillofac Surg . 2012;70:1627 – 1632. 14. Manchio JV , Sati S, Rosman DA, et al. Role of sagittal reformatted computed to- mographic images in the evaluation of orbital floor fractures. J Craniofac Surg . 2010;21:1153 – 1157. 15. Prokop M . New challenges in MDCT. Eur Radiol . 2005;15(suppl 5):E35 – E45. 16. Khaldi A , Prabhu VC, Anderson DE, et al. The clinical significance and optimal timing of postoperative computed tomography following cranial surgery. J Neurosurg . 2010;113:1021 – 1025. 17. Baerlocher MO , Detsky AS. Discussing radiation risks associated with CT scans with patients. JAMA . 2010;304:2170.

www.annalsplasticsurgery.com

© 2019 Wolters Kluwer Health, Inc. All rights reserved.

41