2024
The impact of preoperative spinal injection timing on the postoperative complications of lumbar fusion
Mirpuri P, Khalid S, Colliander R, King P, Tao X, Elsamadicy A, Mehta A, Adogwa O. The impact of preoperative spinal injection timing on the postoperative complications of lumbar fusion. World Neurosurgery 2024 PMID: 39002778, DOI: 10.1016/j.wneu.2024.07.050.Peer-Reviewed Original ResearchTransforaminal lumbar interbody fusionCSF leakSurgical complicationsComplication rateIncidence of CSF leakRate of CSF leakSecondary outcomesRate of surgical complicationsSurgical complication ratePostoperative surgical complicationsSurgical site infectionDay of surgeryLumbar interbody fusionPostoperative complicationsSite infectionWound disruptionPostoperative rateAdult patientsLumbar fusionInterbody fusionIncreased riskPrimary outcomePatientsSurgeryPrimary analysis
2023
Assessment of the impact of frailty on adverse surgical outcomes in patients undergoing surgery for intracranial tumors using modified frailty index: A systematic review and meta-analysis
Aghajanian S, Shafiee A, Ahmadi A, Elsamadicy A. Assessment of the impact of frailty on adverse surgical outcomes in patients undergoing surgery for intracranial tumors using modified frailty index: A systematic review and meta-analysis. Journal Of Clinical Neuroscience 2023, 114: 120-128. PMID: 37390775, DOI: 10.1016/j.jocn.2023.06.013.Peer-Reviewed Original ResearchConceptsImpact of frailtyFrailty indexMFI scoreAdverse outcomesReoperation rateIntracranial tumorsNon-frail participantsAdverse surgical outcomesNeuro-oncological surgeryWeb of SciencePerioperative outcomesComplication rateIndependent predictorsSurgical outcomesWorse prognosisMean ageObservational studySurgical pathologyMixed-effects multilevel modelsPrimary analysisSystematic reviewNeurosurgical proceduresFrailtySurgical operationSurgeryAssociation Between Intravenous to Oral Opioid Transition Time and Length of Hospital Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.
Hengartner A, Havlik J, David W, Reeves B, Freedman I, Sarkozy M, Maloy G, Fernandez T, Craft S, Koo A, Tuason D, DiLuna M, Elsamadicy A. Association Between Intravenous to Oral Opioid Transition Time and Length of Hospital Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. The International Journal Of Spine Surgery 2023, 17: 468-476. PMID: 37076256, PMCID: PMC10312154, DOI: 10.14444/8448.Peer-Reviewed Original ResearchPosterior spinal fusionAdolescent idiopathic scoliosisExtended LOSSpinal fusionIdiopathic scoliosisMultivariate analysisMultilevel posterior spinal fusionLength of hospitalPostoperative complication rateMajor academic institutionOral opioidsHospital LOSStudy patientsDischarge dispositionHospital lengthPostoperative complicationsPostoperative courseComplication rateIntraoperative variablesLonger LOSPatient demographicsReadmission ratesMedical recordsUnivariate analysisOdds ratio
2022
134 Racial Disparities in Healthcare Resource Utilization After Pediatric Cervical and/or Thoracic Spinal Injuries: Is it Black and White?
Elsamadicy A, Sandhu M, Freedman I, Koo A, Hengartner A, Reeves B, Havlik J, Sarkozy M, Kundishora A, Tuason D, DiLuna M. 134 Racial Disparities in Healthcare Resource Utilization After Pediatric Cervical and/or Thoracic Spinal Injuries: Is it Black and White? Neurosurgery 2022, 68: 39-39. DOI: 10.1227/neu.0000000000001880_134.Peer-Reviewed Original ResearchHealthcare resource utilizationAfrican American patientsMultivariate regression analysisAfrican American cohortHospital complicationsHospital LOSComplication ratePediatric patientsSpinal traumaRacial disparitiesGreater prevalenceLogistic multivariate regression analysisLength of ICUOverall complication rateThoracic spine injuriesAfrican American raceDiagnosis coding systemRegression analysisThoracic spinal injuryPaucity of dataAfrican American/BlackUnited States healthcare systemICU LOSHospital stayInjury presentationsGeographic variations in health care resource utilization following elective ACDF for cervical spondylotic myelopathy: A national trend analysis
Koo AB, Elsamadicy AA, Sarkozy M, Pathak N, David WB, Freedman IG, Reeves BC, Sciubba DM, Laurans M, Kolb L. Geographic variations in health care resource utilization following elective ACDF for cervical spondylotic myelopathy: A national trend analysis. North American Spine Society Journal (NASSJ) 2022, 9: 100099. PMID: 35141663, PMCID: PMC8819911, DOI: 10.1016/j.xnsj.2022.100099.Peer-Reviewed Original ResearchCervical spondylotic myelopathyLength of stayElective ACDFSpondylotic myelopathyAdult patientsPatient demographicsComplication rateRegional cohortElective anterior cervical discectomyHealth care resource utilizationNational Inpatient Sample databaseAnterior cervical discectomyMean total costHousehold income quartileHealth care deliveryHealth care expendituresNonroutine dischargePerioperative complicationsCervical discectomyDischarge dispositionFemale patientsElixhauser comorbiditiesSurgery variesPrimary diagnosisHospital costs
2021
Comparison of frailty metrics and the Charlson Comorbidity Index for predicting adverse outcomes in patients undergoing surgery for spine metastases.
Hersh AM, Pennington Z, Hung B, Patel J, Goldsborough E, Schilling A, Feghali J, Antar A, Srivastava S, Botros D, Elsamadicy AA, Lo SL, Sciubba DM. Comparison of frailty metrics and the Charlson Comorbidity Index for predicting adverse outcomes in patients undergoing surgery for spine metastases. Journal Of Neurosurgery Spine 2021, 36: 849-857. PMID: 34826820, DOI: 10.3171/2021.8.spine21559.Peer-Reviewed Original ResearchMetastatic spinal tumor frailty indexCharlson Comorbidity IndexLength of stayNonroutine dischargePostoperative complicationsMFI-5Frailty metricsComorbidity indexPostoperative outcomesFrailty indexSpine metastasis patientsAdverse postoperative outcomesPatient demographic characteristicsProspective multicenter cohortHigh complication rateComprehensive cancer centerRobust independent predictorOutcomes of interestMedical comorbiditiesMetastasis surgeryPostoperative morbidityComplication rateMetastasis patientsRetrospective cohortIndependent predictorsRacial Disparities in Health Care Resource Utilization After Pediatric Cervical and/or Thoracic Spinal Injuries
Elsamadicy AA, Sandhu MR, Freedman IG, Koo AB, Hengartner AC, Reeves BC, Havlik J, Sarkozy M, Hong CS, Kundishora AJ, Tuason DA, DiLuna M. Racial Disparities in Health Care Resource Utilization After Pediatric Cervical and/or Thoracic Spinal Injuries. World Neurosurgery 2021, 156: e307-e318. PMID: 34560297, DOI: 10.1016/j.wneu.2021.09.047.Peer-Reviewed Original ResearchMeSH KeywordsAdolescentAsianBlack or African AmericanCervical VertebraeChildChild, PreschoolCohort StudiesFemaleHealth Status DisparitiesHealthcare DisparitiesHispanic or LatinoHumansInfantLength of StayMalePostoperative ComplicationsRetrospective StudiesSocioeconomic FactorsSpinal InjuriesThoracic VertebraeUnited StatesWhite PeopleConceptsHealth care resource utilizationNon-Hispanic blacksNon-Hispanic AsiansHospital complicationsPediatric patientsMultivariate regression analysisNon-Hispanic whitesHospital LOSComplication rateGreater prevalenceICD-10-CM diagnosisLogistic multivariate regression analysisNational Trauma Data BankLonger hospital LOSOverall complication rateThoracic spine injuriesTrauma Data BankRegression analysisThoracic spinal injuryNHB patientsHospital lengthRetrospective cohortSpine injuriesThoracic injuriesRisk ratioIndependent Association of Obesity and Nonroutine Discharge Disposition After Elective Anterior Cervical Discectomy and Fusion for Cervical Spondylotic Myelopathy
Koo AB, Elsamadicy AA, Sarkozy M, David WB, Reeves BC, Hong CS, Boylan A, Laurans M, Kolb L. Independent Association of Obesity and Nonroutine Discharge Disposition After Elective Anterior Cervical Discectomy and Fusion for Cervical Spondylotic Myelopathy. World Neurosurgery 2021, 151: e950-e960. PMID: 34020060, DOI: 10.1016/j.wneu.2021.05.022.Peer-Reviewed Original ResearchConceptsCervical spondylotic myelopathyNonroutine discharge dispositionAnterior cervical discectomyElective anterior cervical discectomyDischarge dispositionSpondylotic myelopathyCervical discectomyElective ACDFComplication rateNational Inpatient Sample databaseElective spine surgeryOverall complication ratePrevalence of obesityShort-term outcomesLength of stayHospital bed sizeMultivariate regression analysisHealth care coverageMore comorbiditiesNonroutine dischargeDischarge weightIndependent predictorsElixhauser comorbiditiesGreater proportionPrimary diagnosisRace Is an Independent Predictor for Nonroutine Discharges After Spine Surgery for Spinal Intradural/Cord Tumors
Elsamadicy AA, Koo AB, David WB, Reeves BC, Freedman IG, Pennington Z, Ehresman J, Kolb L, Laurans M, Shin JH, Sciubba DM. Race Is an Independent Predictor for Nonroutine Discharges After Spine Surgery for Spinal Intradural/Cord Tumors. World Neurosurgery 2021, 151: e707-e717. PMID: 33940256, DOI: 10.1016/j.wneu.2021.04.085.Peer-Reviewed Original ResearchConceptsNonroutine discharge dispositionIndependent predictorsNonroutine dischargeDischarge dispositionCord tumorsAA raceSurgical interventionNational Inpatient Sample databaseMultivariable logistic regression analysisStepwise multivariable logistic regression analysisBackward stepwise multivariable logistic regression analysisAfrican AmericansPostoperative complication rateRetrospective cohort studyClinical Modification diagnosisLength of hospitalizationProcedural Coding SystemLogistic regression analysisHealth care costsRegression analysisMultivariate regression analysisAA/BlackPostoperative complicationsCohort studyComplication rateCost and Health Care Resource Utilization Differences After Spine Surgery for Bony Spine versus Primary Intradural Spine Tumors
Elsamadicy AA, Koo AB, Reeves BC, Freedman IG, Pennington Z, David WB, Ehresman J, Hengartner A, Laurans M, Kolb L, Shin JH, Sciubba DM. Cost and Health Care Resource Utilization Differences After Spine Surgery for Bony Spine versus Primary Intradural Spine Tumors. World Neurosurgery 2021, 151: e286-e298. PMID: 33866030, DOI: 10.1016/j.wneu.2021.04.015.Peer-Reviewed Original ResearchConceptsLength of stayPrimary intradural spinal tumorsIntradural spinal tumorsSpine tumorsSpine surgeryPerioperative complicationsSpinal tumorsNational Inpatient Sample databaseMultivariable logistic regression analysisStepwise multivariable logistic regression analysisBackward stepwise multivariable logistic regression analysisIntradural spinal neoplasmsIntradural spine tumorsRetrospective cohort studyLogistic regression analysisHealth care resourcesMore comorbiditiesAdult patientsCohort studyDischarge dispositionIntraoperative variablesPatient demographicsComplication rateHospital admissionIndependent predictors
2020
Impact of Preoperative Anemia on Outcomes After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis
Elsamadicy AA, Freedman IG, Koo AB, David WB, Havlik J, Kundishora AJ, Hong CS, Sciubba DM, Kahle KT, DiLuna M. Impact of Preoperative Anemia on Outcomes After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. World Neurosurgery 2020, 146: e214-e224. PMID: 33091648, DOI: 10.1016/j.wneu.2020.10.074.Peer-Reviewed Original ResearchConceptsPosterior spinal fusionAdolescent idiopathic scoliosisPreoperative anemiaAnemic cohortHospital stayReadmission ratesIndependent predictorsSpinal fusionIdiopathic scoliosisNational Surgical Quality Improvement Program Pediatric databaseSurgeons National Surgical Quality Improvement Program Pediatric databaseUnplanned reoperation rateLonger hospital stayRetrospective cohort studyThirty-day outcomesLonger operative timeLonger lengthPostoperative complicationsReoperation rateCohort studyDischarge dispositionComplication ratePediatric patientsTransfusion eventsOperative timePredictors of Extended Length of Stay Following Treatment of Unruptured Adult Cerebral Aneurysms: A Study of The National Inpatient Sample
Koo AB, Elsamadicy AA, Lin IH, David WB, Sujijantarat N, Santarosa C, Cord BJ, Zetchi A, Hebert R, Bahrassa F, Malhotra A, Matouk CC. Predictors of Extended Length of Stay Following Treatment of Unruptured Adult Cerebral Aneurysms: A Study of The National Inpatient Sample. Journal Of Stroke And Cerebrovascular Diseases 2020, 29: 105230. PMID: 33066916, DOI: 10.1016/j.jstrokecerebrovasdis.2020.105230.Peer-Reviewed Original ResearchMeSH KeywordsAgedComorbidityDatabases, FactualEndovascular ProceduresFemaleHospital CostsHumansInpatientsIntracranial AneurysmLength of StayMaleMicrosurgeryMiddle AgedOutcome and Process Assessment, Health CarePatient AdmissionPostoperative ComplicationsQuality Indicators, Health CareRisk AssessmentRisk FactorsTime FactorsTreatment OutcomeUnited StatesConceptsLOS cohortExtended LOSMultivariate logistic regressionUnruptured cerebral aneurysmsCerebral aneurysmsPreadmission comorbiditiesInpatient complicationsHospital stayMore patientsOdds ratioUnruptured aneurysmsHealthcare costsMultiple patient-specific factorsLogistic regressionOverall complication rateHospital-level factorsNon-routine dischargePatient-level factorsNational Inpatient SamplePatient-specific factorsOverall healthcare costsChoice of procedureIndex admissionPostoperative complicationsComplication rateRisk Factors Portending Extended Length of Stay After Suboccipital Decompression for Adult Chiari I Malformation
Elsamadicy AA, Koo AB, Lee M, David WB, Kundishora AJ, Freedman IG, Zogg CK, Hong CS, DeSpenza T, Sarkozy M, Kahle KT, DiLuna M. Risk Factors Portending Extended Length of Stay After Suboccipital Decompression for Adult Chiari I Malformation. World Neurosurgery 2020, 138: e515-e522. PMID: 32147550, PMCID: PMC7379177, DOI: 10.1016/j.wneu.2020.02.158.Peer-Reviewed Original ResearchConceptsPatient-level factorsMultivariate logistic regressionExtended LOSLOS cohortSurgical decompressionDecompression surgeryOdds ratioGreater overall complication ratesMultiple patient-level factorsLogistic regressionChiari malformation type IAdult Chiari I malformationPatient's baseline comorbidityOverall complication rateRetrospective cohort studyChiari I malformationRisk-adjusted LOSPostoperative complicationsAdult patientsCohort studyComplication ratePatient demographicsSuboccipital decompressionElectrolyte disordersObstructive hydrocephalusGeographic Variation in Outcomes and Costs After Spinal Fusion for Adolescent Idiopathic Scoliosis
Koo AB, Elsamadicy AA, Kundishora AJ, David WB, Lee M, Hong CS, Lee V, Kahle KT, DiLuna M. Geographic Variation in Outcomes and Costs After Spinal Fusion for Adolescent Idiopathic Scoliosis. World Neurosurgery 2020, 136: e347-e354. PMID: 31917315, DOI: 10.1016/j.wneu.2019.12.175.Peer-Reviewed Original ResearchConceptsAdolescent idiopathic scoliosisLength of surgeryAdolescent patientsSpinal fusionIdiopathic scoliosisMultilevel posterior spinal fusionHealth care resource utilizationGreater complication ratePosterior spinal fusionPosterior spinal surgeryPostoperative complicationsComplication ratePrimary outcomeAIS patientsSpinal surgeryPatientsSurgeryAdmissionRegional variationComplicationsFurther studiesOutcomesCohortScoliosisTotal cost
2019
Reduced influence of affective disorders on perioperative complication rates, length of hospital stay, and healthcare costs following spinal fusion for adolescent idiopathic scoliosis.
Elsamadicy AA, Koo AB, Lee M, Kundishora AJ, Hong CS, Hengartner AC, Camara-Quintana J, Kahle KT, DiLuna ML. Reduced influence of affective disorders on perioperative complication rates, length of hospital stay, and healthcare costs following spinal fusion for adolescent idiopathic scoliosis. Journal Of Neurosurgery Pediatrics 2019, 24: 722-727. PMID: 31491756, DOI: 10.3171/2019.7.peds19223.Peer-Reviewed Original ResearchLength of stayPerioperative complication ratePosterior spinal fusionElective posterior spinal fusionMajority of patientsDischarge dispositionComplication rateQuality of careAffective disordersAdolescent patientsIdiopathic scoliosisPostoperative complicationsInpatient DatabaseSpinal fusionNonroutine discharge dispositionHospital-level factorsProportion of patientsOverall patient satisfactionKids' Inpatient DatabaseNumber of complicationsConcurrent affective disorderAdolescent idiopathic scoliosisHospital stayPatient comorbiditiesPatient demographicsReduced Influence of Affective Disorders on 6-Week and 3-Month Narcotic Refills After Primary Complex Spinal Fusions for Adult Deformity Correction: A Single-Institutional Study
Elsamadicy AA, Charalambous L, Adil SM, Drysdale N, Lee M, Koo AB, Chouairi F, Kundishora AJ, Camara-Quintana J, Qureshi T, Kolb L, Laurans M, Abbed K, Karikari IO. Reduced Influence of Affective Disorders on 6-Week and 3-Month Narcotic Refills After Primary Complex Spinal Fusions for Adult Deformity Correction: A Single-Institutional Study. World Neurosurgery 2019, 129: e311-e316. PMID: 31132486, DOI: 10.1016/j.wneu.2019.05.135.Peer-Reviewed Original ResearchConceptsPrimary complex spinal fusionComplex spinal fusionNarcotic refillsPain scoresSpinal fusionAffective disordersDeformity correctionNarcotic useDeformity patientsAD cohortPatient-reported pain scoresAdult spine deformity patientsAdult deformity correctionPostoperative pain scoresPostoperative complication ratePreoperative narcotic useHigher pain scoresSpinal deformity patientsSpine deformity patientsMajor academic institutionAmbulatory statusComplication ratePatient demographicsPrimary outcomePostoperative perceptionAssociation Between Preoperative Narcotic Use with Perioperative Complication Rates, Patient Reported Pain Scores, and Ambulatory Status After Complex Spinal Fusion (≥5 Levels) for Adult Deformity Correction
Elsamadicy AA, Drysdale N, Adil SM, Charalambous L, Lee M, Koo A, Freedman IG, Kundishora AJ, Camara-Quintana J, Qureshi T, Kolb L, Laurans M, Abbed K, Karikari IO. Association Between Preoperative Narcotic Use with Perioperative Complication Rates, Patient Reported Pain Scores, and Ambulatory Status After Complex Spinal Fusion (≥5 Levels) for Adult Deformity Correction. World Neurosurgery 2019, 128: e231-e237. PMID: 31009775, DOI: 10.1016/j.wneu.2019.04.107.Peer-Reviewed Original ResearchMeSH KeywordsAdultAgedBone TransplantationDepressionFemaleHumansIntraoperative Neurophysiological MonitoringLaminectomyLength of StayMaleMiddle AgedMobility LimitationNarcoticsOsteotomyPainPain MeasurementPain, PostoperativePatient ReadmissionPatient Reported Outcome MeasuresPostoperative ComplicationsPreoperative PeriodSpinal DiseasesSpinal FusionConceptsComplex spinal fusionPain scoresPerioperative complication ratePreoperative narcotic useComplication rateSpinal fusionAmbulatory statusNarcotic usePatient demographicsDeformity correctionPatient-reported pain scoresPrimary complex spinal fusionAdult deformity correctionLast pain scoreNon-user cohortsPostoperative pain scoresPostoperative complication rateHigher pain scoresPhysical therapy regimensPrevalence of depressionGreater mean ageUse of narcoticsMajor academic institutionAmbulatory dayPreoperative useReduced Impact of Obesity on Short-Term Surgical Outcomes, Patient-Reported Pain Scores, and 30-Day Readmission Rates After Complex Spinal Fusion (≥7 Levels) for Adult Deformity Correction
Elsamadicy AA, Camara-Quintana J, Kundishora AJ, Lee M, Freedman IG, Long A, Qureshi T, Laurans M, Tomak P, Karikari IO. Reduced Impact of Obesity on Short-Term Surgical Outcomes, Patient-Reported Pain Scores, and 30-Day Readmission Rates After Complex Spinal Fusion (≥7 Levels) for Adult Deformity Correction. World Neurosurgery 2019, 127: e108-e113. PMID: 30876992, DOI: 10.1016/j.wneu.2019.02.165.Peer-Reviewed Original ResearchMeSH KeywordsAdultAgedBody Mass IndexComorbidityDiabetes MellitusDyslipidemiasElective Surgical ProceduresFemaleHeart DiseasesHumansHypertensionLaminectomyLength of StayMaleMiddle AgedObesityPain, PostoperativePatient ReadmissionPatient Reported Outcome MeasuresPostoperative ComplicationsPrevalencePulmonary Disease, Chronic ObstructiveRetrospective StudiesSpinal DiseasesSpinal FusionTreatment OutcomeUnited StatesYoung AdultConceptsPatient-reported pain scoresComplex spinal fusionPain scoresImpact of obesityReadmission ratesSurgical outcomesDeformity correctionSpinal fusionAmbulatory statusPatient demographicsComplication ratePreoperative body mass indexPrimary complex spinal fusionShort-term surgical outcomesAdult deformity correctionInferior surgical outcomesPostoperative complication profileLength of surgeryPostoperative complication ratePrevalence of obesityBody mass indexPatient-reported outcomesComplex spinal surgeryPaucity of dataMajor academic institutionRate of instrumentation changes on postoperative and follow-up radiographs after primary complex spinal fusion (five or more levels) for adult deformity correction.
Elsamadicy AA, Lubkin DT, Sergesketter AR, Adil SM, Charalambous LT, Drysdale N, Williamson T, Camara-Quintana J, Abd-El-Barr MM, Goodwin CR, Karikari IO. Rate of instrumentation changes on postoperative and follow-up radiographs after primary complex spinal fusion (five or more levels) for adult deformity correction. Journal Of Neurosurgery Spine 2019, 30: 376-381. PMID: 30641841, DOI: 10.3171/2018.9.spine18686.Peer-Reviewed Original ResearchConceptsPrimary complex spinal fusionComplex spinal fusionSpinal fusionSpine surgeryDeformity correctionAdult deformity correctionCost-conscious healthcareMethodsThe medical recordsPostoperative complication rateMean lengthBody mass indexFollow-up radiographsRevision of surgeryComplex spine surgeryMajor academic institutionHospital stayAdult patientsComplication ratePatient demographicsReadmission ratesBlood lossPrimary outcomeMass indexEarly radiographsPostoperative radiographs
2018
Socioeconomic Factors, Perioperative Complications, and 30-Day Readmission Rates Associated With Delayed Cranial Vault Reconstruction for Craniosynostosis
Sergesketter AR, Elsamadicy AA, Lubkin DT, Kemeny H, Harward SC, Krucoff KB, Krucoff MO, Fuchs H, Thompson EM, Allori AC, Marcus JR, Muh CR. Socioeconomic Factors, Perioperative Complications, and 30-Day Readmission Rates Associated With Delayed Cranial Vault Reconstruction for Craniosynostosis. Journal Of Craniofacial Surgery 2018, 29: 1767-1771. PMID: 30059426, DOI: 10.1097/scs.0000000000004787.Peer-Reviewed Original ResearchMeSH KeywordsChild, PreschoolCraniosynostosesDevelopmental DisabilitiesFemaleHealthcare DisparitiesHumansIncidenceInfantIntracranial HypertensionLanguageMalePatient ReadmissionPlastic Surgery ProceduresPostoperative ComplicationsRacial GroupsRetrospective StudiesRisk FactorsSkullSocioeconomic FactorsTime-to-TreatmentConceptsCranial vault reconstructionNon-English primary languageReadmission ratesMonths of ageMedicaid insurancePrimary cranial vault reconstructionCraniosynostosis patientsPerioperative complication ratePerioperative complicationsPrimary surgeryPatient demographicsComplication ratePatient barriersMedical recordsFirst consultIntracranial pressureSurgeryPatientsEsthetic consequencesPrimary languagePremature fusionDevelopmental disabilitiesSocioeconomic factorsComplicationsChildren