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Ren S, Luo Y, Shen X, Wu Q, Wu X, Ma C, Xiong Z, Gong R, Liu Z, Chen J, Wang W. Vacuum Sealing Drainage against Surgical Site Infection after Intracranial Neurosurgery. Surg Infect (Larchmt) 2024. [PMID: 39187266 DOI: 10.1089/sur.2024.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/28/2024] Open
Abstract
Background: Surgical site infections (SSIs) remain a conundrum for neurosurgeons. This study examines the efficacy and outcome of vacuum sealing drainage (VSD) in the treatment of pyogenic SSIs following intracranial neurosurgery. Methods: Twenty patients with SSIs, who received surgical intervention, were treated retrospectively with VSD during the past five years. Primary surgical procedure types, SSI types, VSD replacements, pathogenic germs, antibiotic therapy, and infection control were reviewed and discussed. Results: Of the 20 infections, 13 (65%) were extradural and 7 (35%) were extradural SSIs combined with intracranial infections (including 5 meningitis, 1 subdural abscess, and 1 brain abscess). All the patients consented to medical device implantation (including 5 titanium webs, 6 bone flap fixation devices, and 12 duraplasties), most of which were removed during debridement. The median duration from primary surgical procedure to an SSI diagnosis was 19 days (range: 7 to 365 d). All the patients also agreed to debridement and VSD treatment; VSD was replaced 0 to 5 times (median, one time) every 4 to 7 days and kept for 4 to 35 days (median, 14 d). Seven (35%) patients had defined bacterial infections, with Staphylococcus aureus being the dominant infection. The deployed standard VSD and antibiotic treatment ensured full recovery from SSIs, including from intracranial infections: 14 (70%) patients had recovered fully by follow-up, and no infection-associated death was registered; 6 (30%) patients died of severe primary affections. Conclusion: VSD-assisted therapy is safe and effective against SSIs after intracranial neurosurgery.
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Affiliation(s)
- Sen Ren
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yun Luo
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiaoyong Shen
- Hospital of Stomatology Wuhan University, Wuhan, China
| | - Qian Wu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiaohui Wu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chao Ma
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhongwei Xiong
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Rui Gong
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zheng Liu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wei Wang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
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Spake CSL, Beqiri D, Rao V, Crozier JW, Svokos KA, Woo AS. Subgaleal drains may be associated with decreased infection following autologous cranioplasty: a retrospective analysis. Br J Neurosurg 2024; 38:877-883. [PMID: 34751075 DOI: 10.1080/02688697.2021.1995588] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/04/2021] [Accepted: 10/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Autologous bone is often the first choice in cranioplasty following a decompressive craniectomy. However, infection is a common complication, with reported rates up to 25%. While the incidence and management of infection are well documented, the risk factors associated with infection remain less clear. The current study aims to identify predictors of infection risk following autologous cranioplasty. METHODS A retrospective analysis was conducted on patients who underwent decompressive craniectomy and cranioplasty using cryopreserved autologous bone flaps between 2010 and 2020. Patient demographics and factors related to both surgeries and infection rates were recorded from patient records. Logistic regressions were conducted to determine which factors were implicated in the development of infection. RESULTS In our cohort, 126 patients underwent autologous cranioplasty. A total of 10 patients (7.9%) developed an infection following reconstruction, with half resulting in implant failure. We did not identify any significant risk factors for infection. Regression analysis identified placement of subgaleal drain following cranioplasty as a protective factor against the development of infection (OR: 0.16, p = 0.007). On average, drains remained in for 3 days, with no difference between the length of drains for those with infection vs. those without (p = 0.757). CONCLUSIONS The current study demonstrates an infection rate of 7.9% in patients who receive an autologous cranioplasty following decompressive craniectomy, which is consistent with previous data. Half (4%) of patients who experienced an infection ultimately required removal of the implant. While it is common practice for neurosurgeons to use drains to prevent hematomas and fluid collections, we found that subgaleal drain placement following cranioplasty was associated with decreased infection, thus demonstrating another benefit of a commonly used tool.
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Affiliation(s)
- Carole S L Spake
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Dardan Beqiri
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Vinay Rao
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Joseph W Crozier
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Konstantina A Svokos
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Albert S Woo
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Park JB, Filo J, Rahmani B, Adebagbo OD, Lee D, Escobar-Domingo MJ, Garvey SR, Arnautovic A, Cauley RP, Vega RA. Cranial stair-step incision for minimizing postoperative complications in neuro-oncologic surgery: A propensity score-matched analysis. Acta Neurochir (Wien) 2024; 166:305. [PMID: 39046560 DOI: 10.1007/s00701-024-06207-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 07/19/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE Craniotomies for tumor resection can at times result in wound complications which can be devastating in the treatment of neuro-oncological patients. A cranial stair-step technique was recently introduced as an approach to mitigate these complications, especially in this patient population who often exhibit additional risk factors including steroids, chemoradiation, and VEGF inhibitor treatments. This study evaluates our cranial stair-step approach by comparing its postoperative complications using propensity score matching with those of a standard craniotomy wound closure. METHODS A retrospective chart review was conducted on patients with intracranial neoplasms undergoing primary craniotomy at a single institution. Patients with prior craniotomies and less than three months of follow-up were excluded. Analyses were performed using R Studio. RESULTS 383 patients were included in the study, 139 of whom underwent the stair-step technique while the rest underwent traditional craniotomy closures. The stair-step cohort was older, had higher ASA classes, and had a higher prevalence of coronary artery disease. The stair-step patients were administered fewer steroids before (40.29% vs. 56.56%, p < 0.01) and after surgery (87.05% vs. 94.26%, p = 0.02), fewer immunotherapy (12.95% vs. 20.90%, p = 0.05), but they received more radiation preoperatively (15.11% vs. 8.61%, p = 0.05). They also underwent fewer operations for recurrences and residuals (0.72% vs. 10.66%, p = 0.01). On propensity score matching, we found 111 matched pairs with no differences except follow-up duration (p < 0.01). The stair-step group had fewer soft tissue infections (0% vs. 3.60%, p = 0.04), fewer total wound complications (0% vs. 4.50%, p = 0.02), was operated on less for these complications (0% vs. 3.60%, p = 0.04), and had a shorter length of stay (6 vs. 9 days, p < 0.01). Notably, the average time to wound complication in our cohort was 44 days, well within our exclusion criteria and follow-up duration. CONCLUSION The cranial stair-step technique is safe and effective in reducing rates of wound complications and reoperation for neuro-oncologic patients requiring craniotomy.
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Affiliation(s)
- John B Park
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Jean Filo
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Benjamin Rahmani
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Oluwaseun D Adebagbo
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Daniela Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Maria J Escobar-Domingo
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Shannon R Garvey
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Aska Arnautovic
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Ryan P Cauley
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Rafael A Vega
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA.
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Sun D, Ma Z, Geng Y, Kong C, Li Z. A meta-analysis of the risk factors for neurosurgical surgical site infection following craniotomy. Int Wound J 2024; 21:e14542. [PMID: 38140754 PMCID: PMC10961046 DOI: 10.1111/iwj.14542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
The purpose of the meta-analysis was to evaluate and compare the risk factors for neurosurgical surgical site infection (SSI) after craniotomy. Using dichotomous or contentious random or fixed effect models, the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were computed based on the examination of the meta-analysis results. Eighteen analyses, covering 11 068 craniotomies between 2001 and 2023, were included in the current meta-analysis. Subjects with SSIs had a significantly younger age (MD, -2.49; 95% CI, -2.95 to -2.04, p < 0.001), longer operation duration (MD, 10.21; 95% CI, 6.49-13.94, p < 0.001) and longer length of postoperative hospital stay (MD, 1.52; 95% CI, 0.45-2.60, p = 0.006) compared to subjects with no SSI with craniotomy. However, no significant difference was found between craniotomy subjects with SSIs and with no SSI in gender (OR, 0.90; 95% CI, 0.76-1.07, p = 0.23), and combination with other infection (OR, 3.93; 95% CI, 0.28-56.01, p = 0.31). The data that were looked at showed that younger age, longer operation duration and longer length of postoperative hospital stay can be considered as risk factors of SSI in subjects with craniotomy; however, gender and combination with other infections are not. Nonetheless, consideration should be given to their values because several studies only involved a small number of patients, and there are not many studies available for some comparisons.
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Affiliation(s)
- Dechao Sun
- Department of NeurosurgeryHuaihe Hospital of Henan UniversityKaifengChina
| | - Zhuang Ma
- Department of NeurosurgeryHuaihe Hospital of Henan UniversityKaifengChina
| | - Yadong Geng
- Department of NeurosurgeryHuaihe Hospital of Henan UniversityKaifengChina
| | - Chenxu Kong
- Department of NeurosurgeryHuaihe Hospital of Henan UniversityKaifengChina
| | - Zhenjiang Li
- Department of NeurosurgeryHuaihe Hospital of Henan UniversityKaifengChina
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Pan HB, Cui Y, Wu ZH, Meng Y, Wang TM, Fu Q, Chen Q, Chen QX, Wang B. Effect of Different Local Antibiotic Regimens on Prevention of Postoperative Infection in Clean Surgical Wounds: A Systematic Review and Network Meta-analysis. Adv Skin Wound Care 2024; 37:216-223. [PMID: 38353666 DOI: 10.1097/asw.0000000000000094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
OBJECTIVE To compare the efficacy of several local antibiotic regimens in preventing surgical site infection (SSI) in clean surgical wounds. DATA SOURCES The authors searched CNKI (China National Knowledge Infrastructure), the VIP (VIP information resource integration service platform), Wanfang Data knowledge service platform (WANFANG), SinoMed, Cochrane Library, EMBASE, and PubMed. STUDY SELECTION A total of 20 randomized controlled trials published between January 1, 2000 and April 1, 2021 were included in this meta-analysis. DATA EXTRACTION Authors extracted the name of the first author, publication date, country, type of surgery, follow-up time, mean age of participants, sample size of each group, interventions, outcome indicators, and study type from each article. DATA SYNTHESIS The overall effectiveness of eight local managements in reducing the incidence of the SSI effect were compared through the SUCRA (surface under the cumulative ranking curve) probabilities. The results of a network meta-analysis demonstrated that gentamicin ointment (odds ratio [OR], 0.16; 95% CI, 0.04-0.60), mupirocin ointment (OR, 0.44; 95% CI, 0.21-0.94), and gentamicin soaking of the graft (OR, 0.63; 95% CI, 0.44-0.91) significantly reduced the incidence of SSI compared with control. Further, vancomycin soaking of the graft (86.7%) ranked first, followed by gentamicin ointment (81.1%), gentamicin irrigation (79.9%), mupirocin ointment (56.8%), triple antibiotic ointment (47.8%), gentamicin soaking of the graft (42.3%), and vancomycin powder (22.1%); ampicillin powder (17.8%) was the least effective drug. CONCLUSIONS The findings indicate that local antibiotics combined with conventional antibiotics in the wound before wound closure are effective in reducing the incidence of SSI in clean surgical wounds. Vancomycin inoculation of the graft exhibited the best effect.
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Affiliation(s)
- Hai Bang Pan
- At First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou City, Gansu Province, China, Hai Bang Pan, MD, is Associate Professor, and Yan Cui, MM, and Zhi Hang Wu, MM, are Graduate Students in Surgery. Ying Meng, MM, is Primary Pharmacist, Zibo City, Shandong Province, China. Also at the First Clinical Medical College, Gansu University of Chinese Medicine, Tian Ming Wang, MM; Qi Fu, MM; Qian Chen, MM; and Quan Xin Chen, MM, are Graduate Students in Surgery. Bo Wang, MM, is Associate Professor, School of Nursing, Gansu University of Traditional Chinese Medicine
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Gu Z, Tu C, Song D, Yang Z, Xia J. Comprehensive analysis of risk factors and pathogenetic characteristics associated with surgical site infections following craniotomy procedures. Int Wound J 2024; 21:e14550. [PMID: 38069518 PMCID: PMC10961042 DOI: 10.1111/iwj.14550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/19/2023] [Accepted: 11/23/2023] [Indexed: 03/25/2024] Open
Abstract
Craniotomies are intricate neurosurgical procedures susceptible to post-operative complications, among which surgical site infections (SSIs) are particularly concerning. This study sought to elucidate the potential risk factors and pathogenetic characteristics associated with SSIs following craniotomy procedures in a clinical setting. A retrospective study was conducted from May 2020 to May 2023, examining patients subjected to elective or emergency craniotomies. The cohort underwent post-operative surveillance for SSIs, facilitating patient classification into SSI and Non-SSI groups based on infection occurrence. Data collection encapsulated demographic and clinical parameters, including American Society of Anesthesiologists (ASA) classifications, and operative factors. SSIs were diagnosed via an integrated approach combining clinical symptoms, microbiological culture findings and pertinent laboratory tests. A rigorous statistical methodology employing IBM's SPSS version 27.0 was utilised for data analysis. In a univariate analysis, significant risk factors for post-craniotomy SSIs were identified, with patients aged over 60 displaying a pronounced susceptibility. Moreover, surgeries exceeding a duration of 4 h heightened infection risks. Elevated ASA grades denoted an increased prevalence of SSIs, as did emergency procedures and higher National Nosocomial Infections Surveillance scores. Multivariate analysis pinpointed epidural/subdural drainage as a protective measure against SSIs, whereas emergency surgeries, operative times beyond 4 h and subsequent surgeries within the hospital stay amplified infection risks. Notably, coagulase-negative Staphylococcus dominated the identified pathogens at 28.09%, followed by Escherichia coli (17.98%), Klebsiella pneumoniae (10.11%) and Staphylococcus aureus (11.24%), underscoring the need for diverse prophylactic measures. SSIs following craniotomies present a multifaceted challenge influenced by a confluence of patient-related, operative and post-operative determinants. Understanding these risk factors is paramount in refining surgical protocols and post-operative care strategies to mitigate SSI incidence.
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Affiliation(s)
- Zhiwei Gu
- Department of NeurosurgeryThe Central Hospital Affiliated to Shaoxing UniversityShaoxingZhejiang ProvinceChina
| | - Chuanjian Tu
- Department of NeurosurgeryThe Central Hospital Affiliated to Shaoxing UniversityShaoxingZhejiang ProvinceChina
| | - Dagang Song
- Department of NeurosurgeryThe Central Hospital Affiliated to Shaoxing UniversityShaoxingZhejiang ProvinceChina
| | - Zhihao Yang
- Department of NeurosurgeryThe Central Hospital Affiliated to Shaoxing UniversityShaoxingZhejiang ProvinceChina
| | - Jiajie Xia
- Department of NeurosurgeryThe Central Hospital Affiliated to Shaoxing UniversityShaoxingZhejiang ProvinceChina
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7
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Gu Z, Wang Q, Chen J, Zhu Y. Predicted factors of surgical site infection in glioblastoma patients: A meta-analysis. Int Wound J 2024; 21:e14504. [PMID: 38044279 PMCID: PMC10898386 DOI: 10.1111/iwj.14504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/08/2023] [Indexed: 12/05/2023] Open
Abstract
Surgical site infection (SSI) is one of the common postoperative complications after craniotomy for glioblastoma patients. Previous studies have investigated the risk factors for SSI in patients with glioblastoma. Whereas big differences in research results exist, and the correlation coefficients of different research results are quite different. A meta-analysis was conducted to examine the risk factors related to surgical site infection in patients with glioblastoma. We searched English databases to collect case-control studies or cohort studies published before 15 October 2023 including PubMed, Web of Science, Embase. The risk of bias of the included studies was assessed via Newcastle-Ottawa Scale. The analysis was performed using RevMan 5.4.1 tool. A total of 4 articles (n = 2222) were selected in this meta-analysis. The following risk factors were presented to be correlated with SSI in glioblastoma: irradiation (OR = 1.88, 95% CI [0.46, 7.60]), more than 3 surgeries (OR = 2.99, 95% CI [1.47, 6.08]). Occurrence of SSI is influenced by a variety of factors. Thus, we should pay close attention to high-risk subjects and take crucial targeted interventions to lower the SSI risk following craniotomy. Owing to the limited quality and quantity of the included studies, more rigorous studies with adequate sample sizes are needed to verify the conclusion.
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Affiliation(s)
- Zhaowen Gu
- Department of NeurosurgeryThe Second Affiliated Hospital of Zhejiang University School of MedicineHangzhouChina
| | - Qiangwei Wang
- Department of NeurosurgeryThe Second Affiliated Hospital of Zhejiang University School of MedicineHangzhouChina
| | - Jiarui Chen
- Department of NeurosurgeryThe Second Affiliated Hospital of Zhejiang University School of MedicineHangzhouChina
| | - Yongjian Zhu
- Department of NeurosurgeryThe Second Affiliated Hospital of Zhejiang University School of MedicineHangzhouChina
- Clinical Research Center for Neurological Diseases of Zhejiang ProvinceHangzhouChina
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Rae AI, O'Neill BE, Godil J, Fecker AL, Ross D. Low-Cost Wound Healing Protocol Reduces Infection and Reoperation Rates After Cranioplasty: A Retrospective Cohort Study. Neurosurgery 2023; 93:1220-1227. [PMID: 37319382 DOI: 10.1227/neu.0000000000002563] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/14/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Cranioplasty infections are a common and expensive problem associated with significant morbidity. Our objective was to determine whether a wound healing protocol after cranioplasty reduced the rate of infections and to determine the value of this intervention. METHODS This is a single-institution retrospective chart review of 2 cohorts of cranioplasty patients over 12 years. The wound healing protocol, consisting of vitamin and mineral supplementation, fluid supplementation, and oxygen support, was instituted for all patients aged older than 15 years undergoing cranioplasty. We retrospectively reviewed the charts of all patients over the study period and compared outcomes before and after protocol institution. Outcomes included surgical site infection, return to operating room within 30 days, and cranioplasty explant. Cost data were collected from the electronic medical record. We included 291 cranioplasties performed before the wound healing protocol and 68 postprotocol. RESULTS Baseline demographics and comorbidities were comparable between preprotocol and postprotocol groups. Odds of takeback to operating room within 30 days were the same before and after the wound healing protocol (odds ratio [OR] 2.21 [95% CI 0.76-6.47], P = .145). Odds of clinical concern for surgical site infection were significantly higher in the preprotocol group (OR 5.21 [95% CI 1.22-22.17], P = .025). Risk of washout was higher in the preprotocol group (HR 2.86 [95% CI 1.08-7.58], P = .035). Probability of cranioplasty flap explant was also significantly higher in the preprotocol group (OR 4.70 [95% CI 1.10-20.05], P = .036). The number needed to treat to prevent 1 cranioplasty infection was 24. CONCLUSION A low-cost wound healing protocol was associated with reduced rate of infections after cranioplasty with concomitant reduction in reoperations for washout, saving the health care system more than $50,000 per 24 patients. Prospective study is warranted.
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Affiliation(s)
- Ali I Rae
- Department of Neurological Surgery, Oregon Health & Science University, Portland , Oregon , USA
| | - Brannan E O'Neill
- Department of Neurological Surgery, Oregon Health & Science University, Portland , Oregon , USA
| | - Jamila Godil
- Department of Neurological Surgery, Oregon Health & Science University, Portland , Oregon , USA
| | - Adeline L Fecker
- Department of Neurological Surgery, Oregon Health & Science University, Portland , Oregon , USA
| | - Donald Ross
- Department of Neurological Surgery, Oregon Health & Science University, Portland , Oregon , USA
- Operative Care Division, Portland Veterans Administration Medical Center, Portland , Oregon , USA
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Youn SB, Hwang G, Kim HG, Kang JS, Kim HC, Oh SH, Kim MK, Chung BS, Rhim JK, Sheen SH. Intrawound Vancomycin Powder Application for Preventing Surgical Site Infection Following Cranioplasty. J Korean Neurosurg Soc 2023; 66:536-542. [PMID: 37032483 PMCID: PMC10483168 DOI: 10.3340/jkns.2023.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 04/11/2023] Open
Abstract
OBJECTIVE Surgical site infection is the most detrimental complication following cranioplasty. In other surgical fields, intrawound vancomycin powder application has been introduced to prevent surgical site infection and is widely used based on results in multiple studies. This study evaluated the effect of intrawound vancomycin powder in cranioplasty compared with the conventional method without topical antibiotics. METHODS This retrospective study included 580 patients with skull defects who underwent cranioplasty between August 1, 1998 and December 31, 2021. The conventional method was used in 475 (81.9%; conventional group) and vancomycin powder (1 g) was applied on the dura mater and bone flap in 105 patients (18.1%; vancomycin powder group). Surgical site infection was defined as infection of the incision, organ, or space that occurred after cranioplasty. Surgical site infection within 1-year surveillance period was compared between the conventional and vancomycin powder groups with logistic regression analysis. Penalized likelihood estimation method was used in logistic regression to deal with zero events. All local and systemic adverse events associated with topical vancomycin application were also evaluated. RESULTS Surgical site infection occurred in 31 patients (5.3%) and all were observed in the conventional group. The median time between cranioplasty and detection of surgical site infection was 13 days (range, 4-333). Staphylococci were the most common organisms and identified in 25 (80.6%) of 31 cases with surgical site infections. The surgical site infection rate in the vancomycin powder group (0/105, 0.0%) was significantly lower than that in the conventional group (31/475, 6.5%; crude odds ratio [OR], 0.067; 95% confidence interval [CI], 0.006-0.762; adjusted OR, 0.068; 95% CI, 0.006-0.731; p=0.026). No adverse events associated with intrawound vancomycin powder were observed during the follow-up. CONCLUSION Intrawound vancomycin powder effectively prevented surgical site infections following cranioplasty without local or systemic adverse events. Our results suggest that intrawound vancomycin powder is an effective and safe strategy for patients undergoing cranioplasty.
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Affiliation(s)
- Seong Bin Youn
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Hyun-Gon Kim
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Jae Seong Kang
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Hyung Cheol Kim
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Sung Han Oh
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Mi-Kyung Kim
- Department of Neurosurgery, Myongji St Mary’s Hospital, Seoul, Korea
| | - Bong Sub Chung
- Department of Neurosurgery, Anyang Sam Hospital, Anyang, Korea
| | - Jong Kook Rhim
- Department of Neurosurgery, Jeju National University Hospital, Jeju, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang CHA Medical Center, CHA University, Seongnam, Korea
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Deora H, Nagesh M, Garg K, Singh M, Chandra SP, Kale SS. Topical Vancomycin for Prevention of Surgical Site Infection in Cranial Surgeries: Results of an Updated Systematic Review, Meta-Analysis and Meta-Regression. Neurol India 2023; 71:875-883. [PMID: 37929420 DOI: 10.4103/0028-3886.388107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Background Surgical site infection (SSI) rates (1-9%) remain high despite the widespread adoption of infection control bundles. Topical vancomycin has emerged as an effective strategy to reduce the rate of SSI in patients undergoing spinal surgery including instrumentation. However, its use and efficiency in cranial neurosurgery is not well established. The aim of this study is to study the efficacy of topical vancomycin in cranial neurosurgery. Methods A systematic search was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Data regarding type of surgery, use of implants, the dose of vancomycin, technique of administration in each study, outcomes, rate of SSI, and the interval between surgery and SSI; possible complications related to antibiotic use were collected. Results A total of 12 studies were included in the qualitative analysis with 3,446 patients. SSI developed in 1.6% of the patients in the vancomycin group as compared to 5.28% in the control group. The pooled risk ratio was 0.24 with 95% CI: 0.12-0.51 (P-value: <0.00001). The difference between the subgroups was significant (P-value: < 0.00001). The number needed to treat (NNT) was 27.2. The studies showed low heterogeneity with an I2 of 24%. Meta-regression analysis showed that the number of patients in a study, duration of follow-up, and year of publication did not contribute significantly to effect size. Conclusion The limited systemic absorption of vancomycin and broad-spectrum led to its widespread applicability in the prevention of SSI in all types of cranial neurosurgery. Cases with implantable pulse generators, cranioplasty, and cerebrospinal fluid (CSF) diversion procedures have all demonstrated their unequivocal effectiveness.
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Affiliation(s)
- Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Madhusudhan Nagesh
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sarat P Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank S Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Christianson D, Seaman SC, Ray E, Li L, Zanaty M, Lemoine P, Wilson G, Grimm D, Park BJ, Gold C, Andrews B, Grady S, Dlouhy K, Howard MA. The Adjustable Cranial Plate: A Novel Implant Designed to Eliminate the Need for Cranioplasty Surgery Following a Hemicraniectomy Operation. World Neurosurg 2023; 173:e306-e320. [PMID: 36804433 DOI: 10.1016/j.wneu.2023.02.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) is performed to relieve life-threatening intracranial pressure elevations. After swelling abates, a cranioplasty is performed for mechanical integrity and cosmesis. Cranioplasty is costly with high complication rates. Prior attempts to obviate second-stage cranioplasty have been unsuccessful. The Adjustable Cranial Plate (ACP) is designed for implantation during DHC to afford maximal volumetric expansion with later repositioning without requiring a second major operation. METHODS The ACP has a mobile section held by a tripod fixation mechanism. Centrally located gears adjust the implant between the up and down positions. Cadaveric ACP implantation was performed. Virtual DHC and ACP placement were done using imaging data from 94 patients who had previously undergone DHC to corroborate our cadaveric results. Imaging analysis methods were used to calculate volumes of cranial expansion. RESULTS The ACP implantation and adjustment procedures are feasible in cadaveric testing without wound closure difficulties. Results of the cadaveric study showed total volumetric expansion achieved was 222 cm3. Results of the virtual DHC procedure showed the volume of cranial expansion achieved by removing a standardized bone flap was 132 cm3 (range, 89-171 cm3). Applied to virtual craniectomy patients, the total volume of expansion achieved with the ACP implantation operation was 222 cm3 (range, 181-263 cm3). CONCLUSIONS ACP implantation during DHC is technically feasible. It achieves a volume of cranial expansion that will accommodate that observed following survivable hemicraniectomy operations. Moving the implant from the up to the down position can easily be performed as a simple outpatient or inpatient bedside procedure, thus potentially eliminating second-stage cranioplasty procedures.
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Affiliation(s)
- David Christianson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Scott C Seaman
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Emanuel Ray
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Luyuan Li
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | | | - Daniel Grimm
- Karl Leibinger Medizintechnik GmbH & Co. KG, Mühlheim an der Donau, Germany
| | - Brian J Park
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Colin Gold
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Brian Andrews
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Sean Grady
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen Dlouhy
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
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12
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Ebel F, Schön S, Sharma N, Guzman R, Mariani L, Thieringer FM, Soleman J. Clinical and patient-reported outcome after patient-specific 3D printer-assisted cranioplasty. Neurosurg Rev 2023; 46:93. [PMID: 37074490 PMCID: PMC10115682 DOI: 10.1007/s10143-023-02000-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/16/2023] [Accepted: 04/08/2023] [Indexed: 04/20/2023]
Abstract
Various cranioplasty techniques exist for the reconstruction of cranial bone defects. Patient-specific implants can be produced in-house using a recently developed 3D printer-assisted cranioplasty technique. However, the resulting cosmetic outcomes from the patient's perspective are underreported. With our case series, we aim to present the clinical outcome, morbidity rate, patient-reported cosmetic results, and cost-effectiveness of patient-specific3D printer-assisted cranioplasty technique. This is a consecutive retrospective case series of adult patients undergoing cranioplasty using the patient-specific 3D printer-assisted technique. As primary endpoint, the functional outcome based on modified Rankin scale (mRS) at discharge and follow-up was assessed. A prospective telephone survey was conducted to collect and provide patient-reported outcomes. Thirty-one patients underwent patient-specific 3D printer-assisted cranioplasty, mostly to reconstruct frontotemporoparietal (61.3%) and frontotemporal defects with orbital involvement (19.4%). Good functional outcome (mRS ≤ 2) at discharge and during the last follow-up was achieved in 54.8% (n = 17) and 58.1% (n = 18) patients. Overall, the rate of clinically relevant surgery-related complications was 35.5% (n = 11). Postoperative epidural hematoma/collection (16.1%) and infections (12.9%) were the most frequent complications. Permanent morbidity occurred in one patient (3.2%) with postoperative acute ipsilateral vision loss after frontotemporal cranioplasty with orbital involvement. No surgery-related mortality occurred. The mean patient-reported cosmetic satisfaction score was 7.8 ± 1.5, with 80% of patients reporting satisfying or very satisfying cosmetic results. No significant differences were seen between the different defect localization regarding the cosmetic outcome. The mean manufacturing costs of a patient-specific 3D printer-assisted implant ranged from 748 to 1129 USD. Based on our case series, patient-specific 3D printer-assisted cranioplasty is cost-effective and leads to satisfying cosmetic results, especially in large defects and/or defects with complex geometry.
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Affiliation(s)
- Florian Ebel
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland.
| | - Stephan Schön
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Neha Sharma
- Department of Oral & Cranio-Maxillo-Facial Surgery and 3D Print Lab, University Hospital of Basel, Basel, Switzerland
- Medical Additive Manufacturing Research Group (Swiss MAM/Smart Implants), Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Florian M Thieringer
- Department of Oral & Cranio-Maxillo-Facial Surgery and 3D Print Lab, University Hospital of Basel, Basel, Switzerland
- Medical Additive Manufacturing Research Group (Swiss MAM/Smart Implants), Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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13
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Tian B, He Y, Han Z, Liu T, Zhang X. Effect of powdered vancomycin on stopping surgical site wound infections in neurosurgery: A meta-analysis. Int Wound J 2023; 20:1139-1150. [PMID: 36237125 PMCID: PMC10031230 DOI: 10.1111/iwj.13973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/15/2022] [Accepted: 09/27/2022] [Indexed: 11/28/2022] Open
Abstract
We performed a meta-analysis to evaluate the effect of powdered vancomycin on stopping surgical site wound infections in neurosurgery. A systematic literature search up to July 2022 was performed and 24 137 subjects with neurosurgery at the baseline of the studies; 10 496 of them were using the powdered vancomycin, and 13 641 were not using the powdered vancomycin as a control. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of powdered vancomycin on stopping surgical site wound infections in neurosurgery using dichotomous methods with a random or fixed-effect model. The powdered vancomycin had significantly lower surgical site wound infections after spinal surgery (OR, 0.53; 95% CI, 0.41-0.70, P < .001), deep surgical site wound infections after spinal surgery (OR, 0.45; 95% CI, 0.35-0.57, P < .001), superficial surgical site wound infections after spinal surgery (OR, 0.60; 95% CI, 0.43-0.83, P = .002), and surgical site wound infections after cranial surgery (OR, 0.37; 95% CI, 0.22-0.61, P < .001) compared to control in subjects with neurosurgery. The powdered vancomycin had significantly lower surgical site wound infections after spinal surgery, deep surgical site wound infections after spinal surgery, superficial surgical site wound infections after spinal surgery, and surgical site wound infections after cranial surgery compared to control in subjects with neurosurgery. The analysis of outcomes should be done with caution even though the low number of studies with low sample size, 3 out of the 42 studies, in the meta-analysis, and a low number of studies in certain comparisons.
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Affiliation(s)
- Bo Tian
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Yanli He
- Department of Radiology, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Zian Han
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Tianjing Liu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Xingye Zhang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
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14
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Do TH, Lu J, Palzer EF, Cramer SW, Huling JD, Johnson RA, Zhu P, Jean JN, Howard MA, Sabal LT, Hanson JT, Jonason AB, Sun KW, McGovern RA, Chen CC. Rates of operative intervention for infection after synthetic or autologous cranioplasty: a National Readmissions Database analysis. J Neurosurg 2023; 138:514-521. [PMID: 35901766 DOI: 10.3171/2022.4.jns22301] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/05/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to characterize the clinical utilization and associated charges of autologous bone flap (ABF) versus synthetic flap (SF) cranioplasty and to characterize the postoperative infection risk of SF versus ABF using the National Readmissions Database (NRD). METHODS The authors used the publicly available NRD to identify index hospitalizations from October 2015 to December 2018 involving elective ABF or SF cranioplasty after traumatic brain injury (TBI) or stroke. Subsequent readmissions were further characterized if patients underwent neurosurgical intervention for treatment of infection or suspected infection. Survey Cox proportional hazards models were used to assess risk of readmission. RESULTS An estimated 2295 SF and 2072 ABF cranioplasties were performed from October 2015 to December 2018 in the United States. While the total number of cranioplasty operations decreased during the study period, the proportion of cranioplasties utilizing SF increased (p < 0.001), particularly in male patients (p = 0.011) and those with TBI (vs stroke, p = 0.012). The median total hospital charge for SF cranioplasty was $31,200 more costly than ABF cranioplasty (p < 0.001). Of all first-time readmissions, 20% involved surgical treatment for infectious reasons. Overall, 122 SF patients (5.3%) underwent surgical treatment of infection compared with 70 ABF patients (3.4%) on readmission. After accounting for confounders using a multivariable Cox model, female patients (vs male, p = 0.003), those discharged nonroutinely (vs discharge to home or self-care, p < 0.001), and patients who underwent SF cranioplasty (vs ABF, p = 0.011) were more likely to be readmitted for reoperation. Patients undergoing cranioplasty during more recent years (e.g., 2018 vs 2015) were less likely to be readmitted for reoperation because of infection (p = 0.024). CONCLUSIONS SFs are increasingly replacing ABFs as the material of choice for cranioplasty, despite their association with increased hospital charges. Female sex, nonroutine discharge, and SF cranioplasty are associated with increased risk for reoperation after cranioplasty.
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Affiliation(s)
- Truong H Do
- 1Department of Neurological Surgery, University of Minnesota
| | - Jinci Lu
- 3University of Minnesota Medical School, Minneapolis, Minnesota
| | - Elise F Palzer
- 2School of Public Health, Division of Biostatistics, University of Minnesota; and
| | - Samuel W Cramer
- 1Department of Neurological Surgery, University of Minnesota
| | - Jared D Huling
- 2School of Public Health, Division of Biostatistics, University of Minnesota; and
| | - Reid A Johnson
- 3University of Minnesota Medical School, Minneapolis, Minnesota
| | - Ping Zhu
- 1Department of Neurological Surgery, University of Minnesota
| | - James N Jean
- 1Department of Neurological Surgery, University of Minnesota
| | | | - Luke T Sabal
- 3University of Minnesota Medical School, Minneapolis, Minnesota
| | - Jacob T Hanson
- 1Department of Neurological Surgery, University of Minnesota
| | - Alec B Jonason
- 1Department of Neurological Surgery, University of Minnesota
| | - Kevin W Sun
- 1Department of Neurological Surgery, University of Minnesota
| | | | - Clark C Chen
- 1Department of Neurological Surgery, University of Minnesota
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15
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Sakata T, Tanikawa M, Yamada H, Fujinami R, Nishikawa Y, Yamada S, Mase M. Minimally invasive treatment for glioblastoma through endoscopic surgery including tumor embolization when necessary: a technical note. Front Neurol 2023; 14:1170045. [PMID: 37153685 PMCID: PMC10160401 DOI: 10.3389/fneur.2023.1170045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/03/2023] [Indexed: 05/10/2023] Open
Abstract
Background Although there have been some reports on endoscopic glioblastoma surgery, the indication has been limited to deep-seated lesions, and the difficulty of hemostasis has been a concern. In that light, we attempted to establish an endoscopic procedure for excision of glioblastoma which could be applied even to hypervascular or superficial lesions, in combination with pre-operative endovascular tumor embolization. Methods Medical records of six consecutive glioblastoma patients who received exclusive endoscopic removal between September and November 2020 were analyzed. Preoperative tumor embolization was performed in cases with marked tumor stain and proper feeder arteries having an abnormal shape, for instance, tortuous or dilated, without passing through branches to the normal brain. Endoscopic tumor removal through a key-hole craniotomy was performed by using an inside-out excision for a deep-seated lesion, with the addition of an outside-in extirpation for a shallow portion when needed. Results Endoscopic removal was successfully performed in all six cases. Before resection, endovascular tumor embolization was performed in four cases with no resulting complications, including ischemia or brain swelling. Gross total resection was achieved in three cases, and near total resection in the other three cases. Intraoperative blood loss exceeded 1,000 ml in only one case, whose tumor showed a prominent tumor stain but no proper feeder artery for embolization. In all patients, a smooth transition to adjuvant therapy was possible with no surgical site infection. Conclusion Endoscopic removal for glioblastoma was considered to be a promising procedure with minimal invasiveness and a favorable impact on prognosis.
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16
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Zeng X, Yang B, Zhang B, Xu B, Rong C, She J, Guo W, Kong J, Liu Y, Zhao D, Xu X. A meta‐analysis examined the effect of intrawound vancomycin on surgical site wound infections in non‐spinal neurosurgical operation. Int Wound J 2022; 20:1584-1590. [PMID: 36424840 PMCID: PMC10088818 DOI: 10.1111/iwj.14014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 11/26/2022] Open
Abstract
To assess the impact of intrawound vancomycin on surgical site wound infections in non-spinal neurosurgical operations, we conducted a meta-analysis. A thorough review of the literature up to September 2022 showed that 4286 participants had a non-spinal neurosurgical operation at the start of the investigations; 1975 of them used intrawound vancomycin, while 2311 were control. Using dichotomous or contentious methods and a random or fixed-effect model, odds ratios (OR) and mean difference (MD) with 95% confidence intervals (CIs) were estimated to evaluate the impact of intrawound vancomycin on surgical site wound infections in non-spinal neurosurgical operation. The intrawound vancomycin had significantly lower surgical site wound infections (OR, 0.28; 95% CI, 0.19-0.40; P < .001) with low heterogeneity (I2 = 32%) compared with the control in non-spinal neurosurgical operation. The intrawound vancomycin had significantly lower surgical site wound infections compared with control in non-spinal neurosurgical operation. The low sample size of 2 out of 13 researches in the meta-analysis calls for care when analysing the results.
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Affiliation(s)
- Xiangwu Zeng
- Department of Brain The Second People's Hospital of Zhangye City Zhangye Gansu China
| | - Bo Yang
- Department of Pharmacy The Second People's Hospital of Zhangye City Zhangye Gansu China
| | - Baiming Zhang
- Department of Pharmacy The Second People's Hospital of Zhangye City Zhangye Gansu China
| | - Buxuan Xu
- Department of Brain The Second People's Hospital of Zhangye City Zhangye Gansu China
| | - Congxue Rong
- Department of Brain The Second People's Hospital of Zhangye City Zhangye Gansu China
| | - Jianhu She
- Department of Brain The Second People's Hospital of Zhangye City Zhangye Gansu China
| | - Wanliang Guo
- Department of Brain The Second People's Hospital of Zhangye City Zhangye Gansu China
| | - Jianlong Kong
- Department of Brain The Second People's Hospital of Zhangye City Zhangye Gansu China
| | - Yangzi Liu
- Department of Brain The Second People's Hospital of Zhangye City Zhangye Gansu China
| | - Dianfan Zhao
- Department of Brain The Second People's Hospital of Zhangye City Zhangye Gansu China
| | - Xiuzhen Xu
- Department of Pharmacy The Second People's Hospital of Zhangye City Zhangye Gansu China
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Wathen C, Yang AI, Hitti FL, Henry L, Chaibainou H, Baltuch GH. Feasibility of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Essential Tremor in the Setting of Prior Craniotomy. Oper Neurosurg (Hagerstown) 2022; 22:61-65. [PMID: 35007218 DOI: 10.1227/ons.0000000000000012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Magnetic resonance imaging-guided focused ultrasound (MRgFUS) thalamotomy is a rapidly evolving therapy for the treatment of essential tremor. Although the skull is a major determinant of the delivery of acoustic energy to the target, how the presence of a prior craniotomy must be accounted for during lesioning is unclear. OBJECTIVE To demonstrate novel application of this therapeutic option in a patient with a history of prior craniotomies for unrelated intracranial pathologies. METHODS A 55-yr-old man with a history of right frontal craniotomy for resection of a colloid cyst underwent a left ventrointermedius nucleus thalamotomy through MRgFUS. The prior craniotomy flap was not excluded in the treatment plan; however, all bony defects and hardware were marked as "no-pass" regions. Clinical outcomes were collected at the 6-mo follow-up. RESULTS Transducer elements whose acoustic paths would have been altered by the craniotomy defect were turned off. Sonications reaching lesional temperatures of up to 56°C were successfully delivered. The procedure was well-tolerated, without any persistent intra-ablation or postablation adverse effects. The presence of a lesion was confirmed on MRI, which was associated with a significant reduction in the patient's tremor that was sustained at the 6-mo follow-up. CONCLUSION This case demonstrates the safety and efficacy of MRgFUS thalamotomy in a patient with prior craniotomies and highlights our strategy for acoustic lesioning in this setting.
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Affiliation(s)
- Connor Wathen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew I Yang
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frederick L Hitti
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Hanane Chaibainou
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gordon H Baltuch
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Huang X, Zhang X, Zhou J, Li G, Zheng G, Peng L, Yan Z, Chen S. Analysis of risk factors and preventive strategies for intracranial infection after neuroendoscopic transnasal pituitary adenoma resection. BMC Neurosci 2022; 23:1. [PMID: 34979913 PMCID: PMC8725403 DOI: 10.1186/s12868-021-00688-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 12/28/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To analyse the risk factors for intracranial infection after neuroendoscopic transnasal pituitary adenoma resection (NTPAR) to provide a reference for the prevention and treatment of postoperative intracranial infection. METHODS The clinical data of 387 patients who underwent NTPAR in the Department of Neurosurgery of the First People's Hospital of Yichang from March 2013 to March 2021 were retrospectively analysed. The patients were divided into an infected group and a noninfected group according to the occurrence of intracranial infection. The detailed clinical data of the two groups were collected. Univariate and multivariate logistic regression was used to analyse the risk factors for intracranial infection after NTPAR. RESULTS Among the 387 surgical patients, 32 patients (8.27%) were in the intracranially infected group and 355 patients (91.73%) were in the noninfected group. The results of the univariate analysis suggested that age > 45 years, tumour size > 1 cm, operation time > 240 min, blood loss > 400 ml, Kelly Grade of cerebrospinal fluid (CSF) leakage > Grade 2, postoperative CSF leakage, lumbar cistern drainage and blood transfusion were the influencing factors for postoperative intracranial infection, while the results of multivariate logistic regression analysis implied that intraoperative CSF leakage (Kelly Grade > 2) and postoperative CSF leakage were independent influencing factors for intracranial infection after NTPAR, and perioperative use of antibiotics was an independent protective factor for postoperative intracranial infection. CONCLUSIONS There are a variety of risk factors for intracranial infection after NTPAR, which indicates that it is necessary to develop different repair strategies for CSF leakage according to the Kelly Grade, timely treatment of postoperative CSF leakage and perioperative use of antibiotics. These measures have been shown to effectively reduce the probability of intracranial infection after NTPAR.
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Affiliation(s)
- Xin Huang
- Department of Neurosurgery, The People's Hospital of China Three Gorges University, Yichang, 443000, China
| | - Xuejun Zhang
- Department of Neurosurgery, Dangyang People's Hospital, Yichang, China
| | - Jian Zhou
- Department of Neurosurgery, The People's Hospital of China Three Gorges University, Yichang, 443000, China
| | - Gang Li
- Department of Neurosurgery, The People's Hospital of China Three Gorges University, Yichang, 443000, China
| | - Gang Zheng
- Department of Neurosurgery, The People's Hospital of China Three Gorges University, Yichang, 443000, China
| | - Lei Peng
- Department of Neurosurgery, The People's Hospital of China Three Gorges University, Yichang, 443000, China
| | - Ziwei Yan
- Department of Ultrasound Diagnostics, The People's Hospital of China Three Gorges University, Yichang, China
| | - Shaojun Chen
- Department of Neurosurgery, The People's Hospital of China Three Gorges University, Yichang, 443000, China.
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Overview and risk factors for postcraniotomy surgical site infection: A four-year experience. ANTIMICROBIAL STEWARDSHIP AND HEALTHCARE EPIDEMIOLOGY 2022; 2:e14. [PMID: 36310773 PMCID: PMC9615103 DOI: 10.1017/ash.2021.258] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/14/2021] [Accepted: 12/17/2021] [Indexed: 12/02/2022]
Abstract
Objective: Despite evidence favoring perioperative antibiotic prophylaxis (ABP) use in patients undergoing craniotomy to reduce rates of surgical site infections (SSIs), standardized protocols are lacking. We describe demographic characteristics, risk factors, and ABP choice in patients with craniotomy complicated with SSI. Design: Retrospective case series from January 1, 2017, through December 31, 2020. Setting: Tertiary-care referral center. Patients: Adults who underwent craniotomy and were diagnosed with an SSI. Methods: Logistic regression to estimate odds ratios and 95% confidence intervals to identify factors associated with SSIs. Results: In total, 5,328 patients undergoing craniotomy were identified during the study period; 59 (1.1%) suffered an SSI. Compared with non-SSI cases, patients with SSI had a significantly higher frequency of emergency procedures: 13.5% versus 5.8% (P = .02; odds ratio [OR], 2.52; 95% confidene interval [CI], 1.10–5.06; P = .031). Patients with SSI had a higher rate of a dirty (5.1% vs 0.9%) and lower rate of clean-contaminated (3.3% vs 14.5%) wound class than those without infection (P = .002). Nearly all patients received ABP before craniotomy (98.3% in the SSI group vs 99.6% in the non-SSI group; P = .10). Combination of vancomycin and cefazolin as dual therapy was more prevalent in the group of patients without infection (n = 1,761, 34.1%) than those with SSI (n = 4, 6.8%) (P < .001), associated with decreased odds for SSI (OR, 0.17; 95% CI, 0.005–0.42; P ≤ .001). Conclusions: SSI are frequently seen after an emergent neurosurgical procedure and a dirty wound classification. Combination of prophylactic cefazolin and vancomycin is associated with decreased risk for SSI.
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Kondapavulur S, Burke J, Volz M, Wang DD, Starr PA. Use of Topical Vancomycin Powder to Reduce Surgical Site Infections after Deep Brain Stimulation Surgery: UCSF Experience and Meta-Analysis. Stereotact Funct Neurosurg 2022; 100:130-139. [PMID: 34839296 PMCID: PMC8917085 DOI: 10.1159/000520197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/17/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Surgical site infection (SSI) is the most common serious complication of deep brain stimulation (DBS) implantation surgery. Here, we report a single-surgeon experience on the efficacy of topical, intrawound vancomycin powder (VP) in reducing SSI for DBS surgery and present the first systematic review and meta-analysis examining the effect of topical vancomycin on SSI in patients after DBS surgery. METHODS For the retrospective review, all unique patients undergoing DBS surgery at UCSF for new hardware implantation or internal pulse generator (IPG) replacement by a single surgeon from September 2013 to March 2019, with at least 1 year of follow-up data, were included. For the meta-analysis, we included all primary studies that compared SSIs with and without application of topical vancomycin in DBS surgeries. RESULTS 368 unique patients met inclusion criteria; 195 patients received topical VP (VP group) and 173 did not (control). 99/195 patients in the VP group underwent new DBS implantation and 96/195 had IPG replacement. 71/173 patients in the control group had new DBS implantation and 102/173 had IPG replacement. There were 10 total cases of SSI: 4 patients from the VP group (3 new implants and 1 IPG replacement) and 6 patients from the control group (3 new implants and 3 IPG replacements), resulting in SSI rates of 2.1 and 3.5%, respectively (p value = 0.337). Including our retrospective analysis, 6 studies met inclusion criteria for the systematic review and meta-analysis. In the 4 studies that examined primary DBS implants, 479 total patients received topical VP and 436 did not; mean odds ratio for SSI with topical vancomycin was 0.802 (95% confidence interval [CI] 0.175-3.678). Across the 5 studies that examined IPG implantations or replacements, 606 total patients received topical VP while 1,173 patients did not; mean odds ratio for SSI with topical vancomycin was 0.492 (95% CI 0.164-1.475). In either case, topical VP application did not significantly decrease risk of SSI. CONCLUSION Surgical infections after DBS surgery are uncommon events, with studies demonstrating mixed results on whether topical vancomycin reduces this risk. Our single-institution retrospective analysis and systematic review of prior studies both demonstrated no significant SSI rate reduction with topical VP. This is likely due to low baseline SSI rates, resulting in a small effect size for prevention. Given the cost-effectiveness, simplicity, and low risk, topical, intrawound VP remains a treatment option to further reduce risk of SSI, particularly in settings with higher baseline infection rates.
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Affiliation(s)
| | - John Burke
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
| | - Monica Volz
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
| | - Doris D. Wang
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
| | - Philip A. Starr
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
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21
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Ammanuel SG, Edwards CS, Chan AK, Mummaneni PV, Kidane J, Vargas E, D’Souza S, Nichols AD, Sankaran S, Abla AA, Aghi MK, Chang EF, Hervey-Jumper SL, Kunwar S, Larson PS, Lawton MT, Starr PA, Theodosopoulos PV, Berger MS, McDermott MW. Are preoperative chlorhexidine gluconate showers associated with a reduction in surgical site infection following craniotomy? A retrospective cohort analysis of 3126 surgical procedures. J Neurosurg 2021; 135:1889-1897. [PMID: 33930864 PMCID: PMC9448162 DOI: 10.3171/2020.10.jns201255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 10/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical site infection (SSI) is a complication linked to increased costs and length of hospital stay. Prevention of SSI is important to reduce its burden on individual patients and the healthcare system. The authors aimed to assess the efficacy of preoperative chlorhexidine gluconate (CHG) showers on SSI rates following cranial surgery. METHODS In November 2013, a preoperative CHG shower protocol was implemented at the authors' institution. A total of 3126 surgical procedures were analyzed, encompassing a time frame from April 2012 to April 2016. Cohorts before and after implementation of the CHG shower protocol were evaluated for differences in SSI rates. RESULTS The overall SSI rate was 0.6%. No significant differences (p = 0.11) were observed between the rate of SSI of the 892 patients in the preimplementation cohort (0.2%) and that of the 2234 patients in the postimplementation cohort (0.8%). Following multivariable analysis, implementation of preoperative CHG showers was not associated with decreased SSI (adjusted OR 2.96, 95% CI 0.67-13.1; p = 0.15). CONCLUSIONS This is the largest study, according to sample size, to examine the association between CHG showers and SSI following craniotomy. CHG showers did not significantly alter the risk of SSI after a cranial procedure.
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Affiliation(s)
- Simon G. Ammanuel
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Caleb S. Edwards
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Andrew K. Chan
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V. Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Joseph Kidane
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Enrique Vargas
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Sarah D’Souza
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Amy D. Nichols
- Department of Hospital Epidemiology and Infection Control, University of California, San Francisco, California
| | - Sujatha Sankaran
- Department of Hospital Medicine, University of California, San Francisco, California
| | - Adib A. Abla
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Manish K. Aghi
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Edward F. Chang
- Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Sandeep Kunwar
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Paul S. Larson
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael T. Lawton
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Philip A. Starr
- Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Mitchel S. Berger
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael W. McDermott
- Department of Neurological Surgery, University of California, San Francisco, California
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22
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Jiménez-Martínez E, Cuervo G, Carratalà J, Hornero A, Ciercoles P, Gabarrós A, Cabellos C, Pelegrin I, Domínguez-Luzón MA, Càmara J, Moreno-Fuentes R, Adamuz J, Pujol M. Economic impact of a care bundle to prevent surgical site infection after craniotomy: a cost-analysis study. Antimicrob Resist Infect Control 2021; 10:146. [PMID: 34645525 PMCID: PMC8513215 DOI: 10.1186/s13756-021-01016-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/27/2021] [Indexed: 11/15/2022] Open
Abstract
Background Surgical site infections after craniotomy (SSI-CRAN) significantly impact patient outcomes and healthcare costs by increasing length of stay and readmission and reoperation rates. However, to our knowledge, no study has yet analysed the economic impact of a surgical care bundle for preventing SSI-CRAN. The aim is to analyse the hospital cost saving after implementation of a care bundle for the prevention of SSI-CRAN. Methods A retrospective cost-analysis was performed, considering two periods: pre-care bundle (2013–2015) and care bundle (2016–2017). A bottom-up approach was used to calculate the costs associated with infection in patients who developed a SSI-CRAN in comparison to those who did not, in both periods and on a patient-by-patient basis. The derived cost of SSI-CRAN was calculated considering: (1) cost of the antibiotic treatment, (2) cost of length of stay in the neurosurgery ward within the 1-year follow up period, (3) cost of the re-intervention, and (4) cost of the implant for cranial reconstruction, when necessary. Results A total of 595 patients were included in the pre-care bundle period and 422 in the care bundle period. Mean cost of a craniotomy procedure was approximately €8000, rising to €24,000 in the case of SSI-CRAN. Mean yearly hospital costs fell by €502,857 in the care bundle period (€714,886 vs. €212,029). Extra costs between periods were mainly due to increased length of hospital stay (€573,555.3 vs. €183,958.9; difference: €389,596.4), followed by the cost of implant for cranial reconstruction (€69,803.4 vs. €9,936; difference: €59,867.4). Overall, implementation of the care bundle saved the hospital €500,844.3/year. Conclusion The implementation of a care bundle for SSI-CRAN had a significant economic impact. Hospitals should consider the deployment of this multimodal preventive strategy to reduce their SSI-CRAN rates, and also their costs. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-01016-4.
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Affiliation(s)
- Emilio Jiménez-Martínez
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Guillermo Cuervo
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain. .,Spanish Network for Research in Infectious Diseases (REIPI), Instituto Carlos III, Madrid, Spain.
| | - Jordi Carratalà
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.,University of Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto Carlos III, Madrid, Spain
| | - Ana Hornero
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Pilar Ciercoles
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Andreu Gabarrós
- Neurosurgery Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Carmen Cabellos
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto Carlos III, Madrid, Spain
| | - Ivan Pelegrin
- Infectious Diseases Department, Parc de Salut Mar, Barcelona, Spain
| | - Maria Angeles Domínguez-Luzón
- Microbiology Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.,Research Network for Respiratory Diseases (CIBERES), ISCIII, Madrid, Spain
| | - Jordi Càmara
- Microbiology Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.,Research Network for Respiratory Diseases (CIBERES), ISCIII, Madrid, Spain
| | - Ramon Moreno-Fuentes
- Finance Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Jordi Adamuz
- Nursing Information Systems Department Support, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
| | - Miquel Pujol
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto Carlos III, Madrid, Spain
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23
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Meyer H, Khalid SI, Dorafshar AH, Byrne RW. The Materials Utilized in Cranial Reconstruction: Past, Current, and Future. Plast Surg (Oakv) 2021; 29:184-196. [PMID: 34568234 PMCID: PMC8436325 DOI: 10.1177/2292550320928560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Cranioplasty (CP) is associated with high complication rates compared to other common neurosurgical procedures. Several graft materials are used for CP, which may contribute to the high complication rates, but data in the literature regarding the influence of graft material on post-CP outcomes are inconsistent making it difficult to determine if, when, and to what extent the graft material impacts the rate of perioperative complications. There is an increased demand to identify and develop superior graft materials. OBJECTIVE To review and compare the indications, risks, complications, and patient results associated with the use of different graft materials for cranial reconstructions. DESIGN A search through EBSCOhost was conducted using the keywords "craniectomy" or "decompressive craniectomy," "cranioplasty," and "materials." The search was limited to literature published in the English language from 2005 until the present. Ultimately, 69 articles were included in this review. Due to the heterogeneity of the study populations, results, statistical analyses, and collecting methods, no statistical analyses could be performed. CONCLUSIONS Several graft materials have been adapted for use in cranial reconstructions with inconsistent results making it unclear if or when one material may be indicated over others. Advances in computer-aided design have led to improved patient-specific implants, but the ideal graft material is still being sought after in ongoing research efforts. Reviewing materials currently available, as well as those in clinical trials, is important to identify the limitations associated with different implants and to guide future research.
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Affiliation(s)
- Haley Meyer
- Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, IL, USA
| | - Syed I. Khalid
- Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, IL, USA
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Amir H. Dorafshar
- Department of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL
| | - Richard W. Byrne
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL
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24
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Surgical Site Infection After Autologous Cranioplasty for Decompressive Craniectomy in Traumatic Brain Injury: A Retrospective Review of Two Level 1 Trauma Centers. J Craniofac Surg 2021; 32:2728-2731. [PMID: 34260461 DOI: 10.1097/scs.0000000000007830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECT Surgical site infection (SSI) after cranioplasty can result in unnecessary morbidity. This analysis was designed to determine the risk factors of SSI after cranioplasty in patients who received a decompressive craniectomy with the autologous bone for traumatic brain injury (TBI). METHODS A retrospective review was performed at two level 1 academic trauma centers for adult patients who underwent autologous cranioplasty after prior decompressive craniectomy for TBI. Demographic and procedural variables were collected and analyzed for associations with an increased incidence of surgical site infection with two-sample independent t tests and Mann Whitney U tests, and with a Bonferroni correction applied in cases of multiple comparisons. Statistical significance was reported with a P value of < 0.05. RESULTS A total of 71 patients were identified. The mean interval from craniectomy to cranioplasty was 99 days (7-283), and 3 patients developed SSIs after cranioplasty (4.2%). Postoperative drain placement (P > 0.08) and administration of intrawound vancomycin powder (P = 0.99) were not predictive of infection risk. However, a trend was observed suggesting that administration of prophylactic preoperative IV vancomycin is associated with a reduced infection rate. CONCLUSIONS The SSI rate after autologous cranioplasty in TBI patients is lower than previously reported for heterogeneous groups and indications, and the infection risk is comparable to other elective neurosurgical procedures. As such, the authors recommend attempting to preserve native skull and perform autologous cranioplasty in this population whenever possible.
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25
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Extensive Convexity Flattening of a Synthetic Skull Implant the Overcome Major Scalp Deficiency After Multiple Craniotomies. J Craniofac Surg 2021; 32:2532-2535. [PMID: 34172675 PMCID: PMC8478319 DOI: 10.1097/scs.0000000000007750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Multiple craniofacial surgeries and postoperative recalcitrant infections frequently can lead to secondary scalp tissue scarring and skin retraction. Although there are different methods of reducing and optimizing scalp skin tension, the authors describe a last resort treatment method of cranioplastic procedure, which despite of its unfavorable cosmetic outcome, relieves the skin tension through extensive flattening of the polyetheretherketone curvature. Thereby, a custom-made cranioplastic bone flap was extensively flattened in the curvature of the fronto-parietal area with consideration of the related brain hemisphere extension. The extent of bone curvature flatting reduced the skin tension significantly and allowed for plain and simple tension-free wound closure in a chronic smoker patient with poor skin quality and brain atrophy. Although brain extension was sufficient, the cosmetic outcome was unfavorable with regard to skull symmetry, but well accepted and satisfactory for the patient due to preoperative discussion outcome expectation from surgery. Thus, extensive polyetheretherketone curvature flattening is a straightforward and simple last resort treatment option for tension-free skin closure in high-risk patients with extensive skin scarring and retraction and previous reconstructive plastic skin relief procedures. However, this method is limited in patients with normal brain hemisphere extension.
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26
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Shepetovsky D, Mezzini G, Magrassi L. Complications of cranioplasty in relationship to traumatic brain injury: a systematic review and meta-analysis. Neurosurg Rev 2021; 44:3125-3142. [PMID: 33686551 PMCID: PMC8592959 DOI: 10.1007/s10143-021-01511-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Abstract
Despite being a common procedure, cranioplasty (CP) is associated with a variety of serious, at times lethal, complications. This study explored the relationship between the initial injury leading to decompressive craniectomy (DC) and the rates and types of complications after subsequent CP. It specifically compared between traumatic brain injury (TBI) patients and patients undergoing CP after DC for other indications.A comprehensive search of PubMed, Scopus, and the Cochrane Library databases using PRISMA guidelines was performed to include case-control studies, cohorts, and clinical trials reporting complication data for CP after DC. Information about the patients' characteristics and the rates of overall and specific complications in TBI and non-TBI patients was extracted, summarized, and analyzed.A total of 59 studies, including the authors' institutional experience, encompassing 9264 patients (4671 TBI vs. 4593 non-TBI) met the inclusion criteria; this total also included 149 cases from our institutional series. The results of the analysis of the published series are shown both with and without our series 23 studies reported overall complications, 40 reported infections, 10 reported new-onset seizures, 13 reported bone flap resorption (BFR), 5 reported post-CP hydrocephalus, 10 reported intracranial hemorrhage (ICH), and 8 reported extra-axial fluid collections (EFC). TBI was associated with increased odds of BFR (odds ratio [OR] 1.76, p < 0.01) and infection (OR 1.38, p = 0.02). No difference was detected in the odds of overall complications, seizures, hydrocephalus, ICH, or EFC.Awareness of increased risks of BFR and infection after CP in TBI patients promotes the implementation of new strategies to prevent these complications especially in this category of patients.
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Affiliation(s)
- David Shepetovsky
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Viale Brambilla 74, 27100, Pavia, Italy
| | - Gianluca Mezzini
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Viale Brambilla 74, 27100, Pavia, Italy
| | - Lorenzo Magrassi
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Viale Brambilla 74, 27100, Pavia, Italy. .,IRCCS Fondazione Policlinico S. Matteo, Pavia, Italy.
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27
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Veldeman M, Daleiden L, Hamou H, Höllig A, Clusmann H. An altered posterior question-mark incision is associated with a reduced infection rate of cranioplasty after decompressive hemicraniectomy. J Neurosurg 2021; 134:1262-1270. [PMID: 32330877 DOI: 10.3171/2020.2.jns193335] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/04/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Performing a cranioplasty (CP) after decompressive craniotomy is a straightforward neurosurgical procedure, but it remains associated with a high complication rate. Surgical site infection (SSI), aseptic bone resorption (aBR), and need for a secondary CP are the most common complications. This observational study aimed to identify modifiable risk factors to prevent CP failure. METHODS A retrospective analysis was performed of all patients who underwent CP following decompressive hemicraniectomy (DHC) between 2010 and 2018 at a single institution. Predictors of SSI, aBR, and need for allograft CP were evaluated in a univariate analysis and multivariate logistic regression model. RESULTS One hundred eighty-six patients treated with CP after DHC were included. The diagnoses leading to a DHC were as follows: stroke (83 patients, 44.6%), traumatic brain injury (55 patients, 29.6%), subarachnoid hemorrhage (33 patients, 17.7%), and intracerebral hemorrhage (15 patients, 8.1%). Post-CP SSI occurred in 25 patients (13.4%), whereas aBR occurred in 32 cases (17.2%). An altered posterior question-mark incision, ending behind the ear, was associated with a significantly lower infection rate and CP failure, compared to the classic question-mark incision (6.3% vs 18.4%; p = 0.021). The only significant predictor of aBR was patient age, in which those developing resorption were on average 16 years younger than those without aBR (p < 0.001). CONCLUSIONS The primary goal of this retrospective cohort analysis was to identify adjustable risk factors to prevent post-CP complications. In this analysis, a posterior question-mark incision proved beneficial regarding infection and CP failure. The authors believe that these findings are caused by the better vascularized skin flap due to preservation of the superficial temporal artery and partial preservation of the occipital artery. In this trial, the posterior question-mark incision was identified as an easily and costless adaptable technique to reduce CP failure rates.
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Affiliation(s)
- Michael Veldeman
- 1Department of Neurosurgery, RWTH Aachen University Hospital, Aachen; and
| | - Lorina Daleiden
- 1Department of Neurosurgery, RWTH Aachen University Hospital, Aachen; and
- 2Department of Neurosurgery, Military Hospital Koblenz, Germany
| | - Hussam Hamou
- 1Department of Neurosurgery, RWTH Aachen University Hospital, Aachen; and
| | - Anke Höllig
- 1Department of Neurosurgery, RWTH Aachen University Hospital, Aachen; and
| | - Hans Clusmann
- 1Department of Neurosurgery, RWTH Aachen University Hospital, Aachen; and
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28
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Paredes I, Lagares A, San-Juan R, Castaño-León AM, Gómez PA, Jimenez-Roldán L, Panero I, Eiriz C, García-Perez D, Moreno LM, Perez-Nuñez A, Gonzalez-León P, Alén JAF. Reduction in the infection rate of cranioplasty with a tailored antibiotic prophylaxis: a nonrandomized study. Acta Neurochir (Wien) 2020; 162:2857-2866. [PMID: 32720014 DOI: 10.1007/s00701-020-04508-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/20/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Cranioplasty carries a high risk of surgical site infections (SSIs) for a scheduled procedure, particularly with antibiotic-resistant bacteria. METHODS The goal of this retrospective study was to measure the effect of tailored antibiotic prophylaxis on SSIs resulting from cranioplasties. The authors collected a prospective database of cranioplasties from 2009 to 2018. Risk factors for SSI were registered, as well as infection occurring during the first year postoperatively. A new protocol was initiated in 2016 consisting of antibiotic prophylaxis tailored to the colonizing flora of the skin of the scalp and decolonization of patients who were nasal carriers of methicillin-resistant S. aureus (MRSA); infection rates were compared. RESULTS One hundred nine cranioplasties were identified, 64 in the old protocol and 45 in the new protocol. Of the 109 cranioplasties, 16 (14.7%) suffered an infection, 14 (21.9%) in the old protocol group and 2 (4.4%) in the new protocol group (OR for the new protocol 0.166, 95% CI 0.036-0.772). Multiple surgeries (OR 3.44), Barthel ≤ 70 (OR 3.53), and previous infection (OR 3.9) were risk factors for SSI. Of the bacteria identified in the skin of the scalp, 22.2% were resistant to routine prophylaxis (cefazoline). Only one patient was identified as a nasal carrier of MRSA and was decolonized. CONCLUSIONS A high percentage of bacteria resistant to routine prophylaxis (cefazoline) was identified in the skin of these patients' scalps. The use of tailored antibiotic prophylaxis reduced significantly the infection rate in this particular set of patients.
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Affiliation(s)
- Igor Paredes
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain.
| | - Alfonso Lagares
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Rafael San-Juan
- Unit of Infectious Diseases, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Ana María Castaño-León
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Pedro-Antonio Gómez
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Luis Jimenez-Roldán
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Irene Panero
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Carla Eiriz
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Daniel García-Perez
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Luis Miguel Moreno
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Angel Perez-Nuñez
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Pedro Gonzalez-León
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - José Antonio F Alén
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
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29
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Cranial bone flap resorption-pathological features and their implications for clinical treatment. Neurosurg Rev 2020; 44:2253-2260. [PMID: 33047218 PMCID: PMC8338853 DOI: 10.1007/s10143-020-01417-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/03/2020] [Accepted: 10/08/2020] [Indexed: 10/26/2022]
Abstract
Cranioplasty following decompressive craniectomy (DC) has a primary complication when using the autologous bone: aseptic bone resorption (ABR). So far, risk factors such as age, number of fragments, and hydrocephalus have been identified but a thorough understanding of the underlying pathophysiology is still missing. The aim of this osteopathological investigation was to gain a better understanding of the underlying processes. Clinical data of patients who underwent surgical revision due to ABR was collected. Demographics, the time interval between craniectomy and cranioplasty, and endocrine serum parameters affecting bone metabolism were collected. Removed specimens underwent qualitative and quantitative histological examination. Two grafts without ABR were examined as controls. Compared to the controls, the typical layering of the cortical and cancellous bone was largely eliminated in the grafts. Histological investigations revealed the coexistence of osteolytic and osteoblastic activity within the necrosis. Bone appositions were distributed over the entire graft area. Remaining marrow spaces were predominantly fibrotic or necrotic. In areas with marrow cavity fibrosis, hardly any new bone tissue was found in the adjacent bone, while there were increased signs of osteoclastic resorption. Insufficient reintegration of the flap may be due to residual fatty bone marrow contained in the bone flap which seems to act as a barrier for osteogenesis. This may obstruct the reorganization of the bone structure, inducing aseptic bone necrosis. Following a path already taken in orthopedic surgery, thorough lavage of the implant to remove the bone marrow may be a possibility, but will need further investigation.
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Salle H, Deluche E, Couvé-Deacon E, Beaujeux AC, Pallud J, Roux A, Dagain A, de Barros A, Voirin J, Seizeur R, Belmabrouk H, Lemnos L, Emery E, Fotso MJ, Engelhardt J, Jecko V, Zemmoura I, Le Van T, Berhouma M, Cebula H, Peyre M, Preux PM, Caire F. Surgical Site Infections after glioblastoma surgery: results of a multicentric retrospective study. Infection 2020; 49:267-275. [PMID: 33034890 DOI: 10.1007/s15010-020-01534-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/28/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The effects of surgical site infections (SSI) after glioblastoma surgery on patient outcomes are understudied. The aim of this retrospective multicenter study was to evaluate the impact of SSI on the survival of glioblastoma patients. METHODS Data from SSI cases after glioblastoma surgeries between 2009 and 2016 were collected from 14 French neurosurgical centers. Collected data included patient demographics, previous medical history, risk factors, details of the surgical procedure, radiotherapy/chemotherapy, infection characteristics, and infection management. Similar data were collected from gender- and age-paired control individuals. RESULTS We used the medical records of 77 SSI patients and 58 control individuals. 13 were excluded. Our analyses included data from 64 SSI cases and 58 non-infected glioblastoma patients. Infections occurred after surgery for primary tumors in 38 cases (group I) and after surgery for a recurrent tumor in 26 cases (group II). Median survival was 381, 633, and 547 days in patients of group I, group II, and the control group, respectively. Patients in group I had significantly shorter survival compared to the other two groups (p < 0.05). The one-year survival rate of patients who developed infections after surgery for primary tumors was 50%. Additionally, we found that SSIs led to postoperative treatment discontinuation in 30% of the patients. DISCUSSION Our findings highlighted the severity of SSIs after glioblastoma surgery, as they significantly affect patient survival. The establishment of preventive measures, as well as guidelines for the management of SSIs, is of high clinical importance.
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Affiliation(s)
- Henri Salle
- Neurochirurgie, CHU de Limoges, Limoges, France. .,CAPTuR, EA 3842, Université de Limoges, Limoges, France.
| | | | | | | | - Johan Pallud
- Neurochirurgie, GHU Paris - Hôpital Sainte-Anne, Paris, France.,IMA-BRAIN, UMR1266, Inserm, Paris, France
| | - Alexandre Roux
- Neurochirurgie, GHU Paris - Hôpital Sainte-Anne, Paris, France.,IMA-BRAIN, UMR1266, Inserm, Paris, France
| | - Arnaud Dagain
- Neurochirurgie, BCRM Toulon, HIA Sainte-Anne, Toulon, France
| | - Amaury de Barros
- Neurochirurgie, CHU de Toulouse, Hopital Pierre-Paul Riquet, Toulouse, France
| | - Jimmy Voirin
- Neurochirurgie, Hôpitaux Civils de Colmar, Colmar, France.,Neurochirurgie, CHU de Strasbourg, Strasbourg, France
| | - Romuald Seizeur
- Neurochirurgie, Hôpital de La Cavale Blanche, CHU de Brest, Brest, France.,Université de BREST, LaTIM INSERM UMR 1101, Brest, France
| | - Houda Belmabrouk
- Neurochirurgie, Hôpital de La Cavale Blanche, CHU de Brest, Brest, France
| | | | - Evelyne Emery
- Neurochirurgie, CHU Caen Normandie, Caen, France.,Université CAEN Normandie, Inserm U 12 37, Cycéron, Caen, France
| | | | | | - Vincent Jecko
- Neurochirurgie, CHU de Bordeaux, Bordeaux, France.,INCIA, UMR 5287, Université de Bordeaux, CNRS, Bordeaux, France
| | - Ilyess Zemmoura
- Neurochirurgie, CHU de Tours, Tours, France.,iBrain, UMR 1253, Université de Tours, Inserm, Tours, France
| | | | - Moncef Berhouma
- Neurochirurgie, CHU de Lyon, Hôpital Neurologique Pierre Wertheimer, Lyon, France.,Creatis Laboratory, , CNRS UMR 5220, INSERM U1206, Université Lyon 1/INSA, Lyon, France
| | - Hélène Cebula
- Neurochirurgie, CHU de Strasbourg, Strasbourg, France
| | - Matthieu Peyre
- Neurochirurgie, APHP, Groupe Hospitalier Pitié Salpêtrière, Paris, France.,Genetics and Development of Brain Tumors - CRICM INSERM U1127 CNRS UMR 7225, Paris, France
| | - Pierre-Marie Preux
- Centre d'Epidémiologie, CHU de Limoges, de Biostatistiques Et de Méthodologie de La Recherche CEBIMER, Limoges, France
| | - François Caire
- Neurochirurgie, CHU de Limoges, Limoges, France.,XLIM, UMR 7252, Université de Limoges, CNRS, Limoges, France
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Abstract
INTRODUCTION Cranioplasty (CP) is a multifaceted procedure in a heterogenous patient population, with a high risk for complication. However, no previous large-scale studies have compared outcomes in primary (ie, first attempt) CP versus revision CP (ie, following previous attempts). The authors, therefore, analyzed long-term outcomes of 506 consecutive primary and revision CPs, performed by a single surgeon. METHODS All CPs performed between 2012 and 2019 were analyzed under IRB protocol approval. Surgeries were categorized as either primary (no previous CP; n = 279) or revision CP (at least one previous CP; n = 227). Complications were defined as either major or minor. Subgroup analyses investigated whether or not CP complication risk directly correlated with the number of previous neuro-cranial surgeries and/or CP attempts. RESULTS The primary CP group experienced a major complication rate of 9% (26/279). In comparison, the revision CP group demonstrated a major complication rate of 32% (73/227). For the revision CP group, the rate of major complications rose with each additional surgery, from 4% (1 prior surgery) to 17% (2 prior surgeries) to 39% (3-4 prior surgeries) to 47% (≥5 prior surgeries). CONCLUSION In a review of 506 consecutive cases, patients undergoing revision CP had a 3-fold increase in incidence of major complications, as compared to those undergoing primary CP. These results provide critical insight into overall CP risk stratification and may guide preoperative risk-benefit discussions. Furthermore, these findings may support a center-of-excellence care model, particularly for those patients with a history of previous neuro-cranial surgeries and/or CP attempts.
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Jiménez-Martínez E, Cuervo G, Carratalà J, Hornero A, Ciercoles P, Gabarrós A, Cabellos C, Pelegrin I, Dominguez Luzón MA, García-Somoza D, Càmara J, Tebé C, Adamuz J, Pujol M. A Care Bundle Intervention to Prevent Surgical Site Infections after a Craniotomy. Clin Infect Dis 2020; 73:e3921-e3928. [PMID: 32594119 DOI: 10.1093/cid/ciaa884] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/22/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Although surgical site infections after a craniotomy (SSI-CRAN) are a serious problem involving significant morbidity and costs, information on their prevention is scarce. We aimed to assess whether the implementation of a care bundle was effective in preventing SSI-CRANs. METHODS A historical control study was used to evaluate the care bundle, which included a preoperative shower with 4% chlorhexidine soap, appropriate hair removal, adequate preoperative systemic antibiotic prophylaxis, the administration of 1 g of vancomycin powder into the subgaleal space before closing, and a post-operative dressing of the incisional surgical wound with a sterile absorbent cover. Patients were divided into 2 groups: pre-intervention (January 2013 to December 2015) and intervention (from January 2016 to December 2017). The primary study endpoint was the incidence of SSI-CRANs within a year post-surgery. Propensity score matching was performed and differences between the two study periods were assessed using Cox regression models. RESULTS A total of 595 and 422 patients were included in the pre-intervention and intervention periods, respectively. The incidence of SSI-CRANs was lower in the intervention period (15.3% vs. 3.5%; p < 0.001). Using a propensity score model, 421 pairs of patients were matched. The care bundle intervention was independently associated with a reduced incidence of SSI-CRANs (AOR: 0.23, 95% CI: 0.13-0.40; p < 0.001). CONCLUSION The care bundle intervention was effective in reducing SSI-CRAN rates. The implementation of this multimodal preventive strategy should be considered in centers with high SSI-CRAN incidences.
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Affiliation(s)
- Emilio Jiménez-Martínez
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Guillermo Cuervo
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto Carlos III, Madrid, Spain
| | - Jordi Carratalà
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.,University of Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto Carlos III, Madrid, Spain
| | - Ana Hornero
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Pilar Ciercoles
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Andres Gabarrós
- Neurosurgery Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Carmen Cabellos
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto Carlos III, Madrid, Spain
| | - Ivan Pelegrin
- Infectious Diseases Department, Hospital Parc Taulí, Fundació Institut d'Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain
| | - Maria Angeles Dominguez Luzón
- Microbiology Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.,University of Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto Carlos III, Madrid, Spain
| | - Dolores García-Somoza
- Microbiology Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Jordi Càmara
- Microbiology Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.,Nursing Information Systems Department Support, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.,University of Barcelona, Barcelona, Spain.,Biostatistics Unit, IDIBELL, L'Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto Carlos III, Madrid, Spain.,Research Network for Respiratory Diseases (CIBERES), ISCIII, Madrid, Spain
| | - Cristian Tebé
- Biostatistics Unit, IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Jordi Adamuz
- Nursing Information Systems Department Support, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
| | - Miquel Pujol
- Infectious Diseases Department, Hospital Universitari de Bellvitge - Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto Carlos III, Madrid, Spain
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Abstract
BACKGROUND Infection may complicate the outcome of cranial repair with significant additional morbidity, related to hospitalization, surgery and long antibiotic therapy, that may become even dramatic in case of multi-resistant germs and in particular in the paediatric population. Additionally, the economic costs for the health system are obvious. Moreover, surgical decisions concerning the timing of cranioplasty and choice of the material may be strongly affected by the risk of infection. Despite, management and prevention of cranioplasty infections are not systematically treated through the literature so far. METHODS We reviewed pertinent literature dealing with cranioplasty infection starting from the diagnosis to treatment options, namely conservative versus surgical ones. Our institutional bundle, specific to the paediatric population, is also presented. This approach aims to significantly reduce the risk of infection in first-line cranioplasty and redo cranioplasty after previous infection. CONCLUSIONS A thorough knowledge and understanding of risk factors may lead to surgical strategies and bundles, aiming to reduce infectious complications of cranioplasty. Finally, innovation in materials used for cranial repair should also aim to enhance the antimicrobial properties of these inert materials.
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Chen Y, Zhang L, Qin T, Wang Z, Li Y, Gu B. Evaluation of neurosurgical implant infection rates and associated pathogens: evidence from 1118 postoperative infections. Neurosurg Focus 2019; 47:E6. [DOI: 10.3171/2019.5.focus18582] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 05/22/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVEVarious implanted materials are used in neurosurgery; however, there remains a lack of pooled data on infection rates (IRs) and infective bacteria over past decades. The goal of this study was to investigate implant infections in neurosurgical procedures in a longitudinal retrospective study and to evaluate the IRs of neurosurgically implanted materials and the distribution of pathogenic microorganisms.METHODSA systematic literature search was conducted using PubMed and Web of Science databases for the time period between 1968 and 2018. Neurosurgical implant infections were studied in 5 subgroups, including operations or diseases, implanted materials, bacteria, distribution by country, and time periods, which were obtained from the literature and statistically analyzed. In this meta-analysis, statistical heterogeneity across studies was tested by using p values and I2 values between studies of associated pathogens. Egger’s test was used for assessing symmetries of funnel plots with Stata 11.0 software. Methodological quality was assessed to judge the risk of bias according to the Cochrane Handbook.RESULTSA total of 22,971 patients from 227 articles satisfied the study’s eligibility criteria. Of these, 1118 cases of infection were reported, and the overall IR was 4.87%. In this study, the neurosurgical procedures or disorders with the top 3 IRs included craniotomy (IR 6.58%), cranioplasty (IR 5.89%), and motor movement disorders (IR 5.43%). Among 13 implanted materials, the implants with the top 3 IRs included polypropylene-polyester, titanium, and polyetheretherketone (PEEK), which were 8.11%, 8.15%, and 7.31%, respectively. Furthermore, the main causative pathogen was Staphylococcus aureus and the countries with the top 3 IRs were Denmark (IR 11.90%), Korea (IR 10.98%), and Mexico (IR 9.26%). Except for the low IR from 1998 to 2007, the overall implant IR after neurosurgical procedures was on the rise.CONCLUSIONSIn this study, the main pathogen in neurosurgery was S. aureus, which can provide a certain reference for the clinic. In addition, the IRs of polypropylene-polyester, titanium, and PEEK were higher than other materials, which means that more attention should be paid to them. In short, the total IR was high in neurosurgical implants and should be taken seriously.
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Affiliation(s)
- Ying Chen
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
| | - Linyan Zhang
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
| | - Tingting Qin
- 2Clinical Microbiology Laboratory, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhenzhen Wang
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
| | - Ying Li
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
| | - Bing Gu
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
- 2Clinical Microbiology Laboratory, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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Jiménez-Martínez E, Cuervo G, Hornero A, Ciercoles P, Gabarrós A, Cabellos C, Pelegrin I, García-Somoza D, Adamuz J, Carratalà J, Pujol M. Risk factors for surgical site infection after craniotomy: a prospective cohort study. Antimicrob Resist Infect Control 2019; 8:69. [PMID: 31073400 PMCID: PMC6498621 DOI: 10.1186/s13756-019-0525-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/29/2019] [Indexed: 12/16/2022] Open
Abstract
Background Although surgical site infection after craniotomy (SSI-CRAN) is a serious complication, risk factors for its development have not been well defined. We aim to identify the risk factors for developing SSI-CRAN in a large prospective cohort of adult patients undergoing craniotomy. Methods A series of consecutive patients who underwent craniotomy at a university hospital from January 2013 to December 2015 were prospectively assessed. Demographic, epidemiological, surgical, clinical and microbiological data were collected. Patients were followed up in an active post-discharge surveillance programm e for up to one year after surgery. Multivariate analysis was carried out to identify independent risk factors for SSI-CRAN. Results Among the 595 patients who underwent craniotomy, 91 (15.3%) episodes of SSI-CRAN were recorded, 67 (73.6%) of which were organ/space. Baseline demographic characteristics were similar among patients who developed SSI-CRAN and those who did not. The most frequent causative Gram-positive organisms were Cutibacterium acnes (23.1%) and Staphylococcus epidermidis (23.1%), whereas Enterobacter cloacae (12.1%) was the most commonly isolated Gram-negative agent. In the univariate analysis the factors associated with SSI-CRAN were ASA score > 2 (48.4% vs. 35.5% in SSI-CRAN and no SSI-CRAN respectively, p = 0.025), extrinsic tumour (28.6% vs. 19.2%, p = 0.05), and re-intervention (4.4% vs. 1.4%, p = < 0.001). In the multivariate analysis, ASA score > 2 (AOR: 2.26, 95% CI: 1.32-3.87; p = .003) and re-intervention (OR: 8.93, 95% CI: 5.33-14.96; p < 0.001) were the only factors independently associated with SSI-CRAN. Conclusion The risk factors and causative agents of SSI-CRAN identified in this study should be considered in the design of preventive strategies aimed to reduce the incidence of this serious complication.
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Affiliation(s)
- Emilio Jiménez-Martínez
- Infectious Diseases Department, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Bellvitge University Hospital, Feixa Llarga s/n, 08907, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Guillermo Cuervo
- Infectious Diseases Department, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Bellvitge University Hospital, Feixa Llarga s/n, 08907, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Ana Hornero
- Infectious Diseases Department, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Bellvitge University Hospital, Feixa Llarga s/n, 08907, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Pilar Ciercoles
- Infectious Diseases Department, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Bellvitge University Hospital, Feixa Llarga s/n, 08907, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Andres Gabarrós
- Neurosurgery Department, Bellvitge University Hospital-Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Carmen Cabellos
- Infectious Diseases Department, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Bellvitge University Hospital, Feixa Llarga s/n, 08907, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Ivan Pelegrin
- Infectious Diseases Department, H. Parc Taulí, Sabadell, Spain
| | - Dolores García-Somoza
- Microbiology Department, Bellvitge University Hospital-Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Jordi Adamuz
- Nursing Information Systems Department Support, Bellvitge University Hospital-Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Jordi Carratalà
- Infectious Diseases Department, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Bellvitge University Hospital, Feixa Llarga s/n, 08907, L’Hospitalet de Llobregat, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Miquel Pujol
- Infectious Diseases Department, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Bellvitge University Hospital, Feixa Llarga s/n, 08907, L’Hospitalet de Llobregat, Barcelona, Spain
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Abode-Iyamah KO, Chiang HY, Woodroffe RW, Park B, Jareczek FJ, Nagahama Y, Winslow N, Herwaldt L, Greenlee JD. Deep brain stimulation hardware-related infections: 10-year experience at a single institution. J Neurosurg 2019; 130:629-638. [PMID: 29521584 PMCID: PMC6858932 DOI: 10.3171/2017.9.jns1780] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 09/25/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Deep brain stimulation is an effective surgical treatment for managing some neurological and psychiatric disorders. Infection related to the deep brain stimulator (DBS) hardware causes significant morbidity: hardware explantation may be required; initial disease symptoms such as tremor, rigidity, and bradykinesia may recur; and the medication requirements for adequate disease management may increase. These morbidities are of particular concern given that published DBS-related infection rates have been as high as 23%. To date, however, the key risk factors for and the potential preventive measures against these infections remain largely uncharacterized. In this study, the authors endeavored to identify possible risk factors for DBS-related infection and analyze the efficacy of prophylactic intrawound vancomycin powder (VP). METHODS The authors performed a retrospective cohort study of patients who had undergone primary DBS implantation at a single institution in the period from December 2005 through September 2015 to identify possible risk factors for surgical site infection (SSI) and to assess the impact of perioperative (before, during, and after surgery) prophylactic antibiotics on the SSI rate. They also evaluated the effect of a change in the National Healthcare Safety Network's definition of SSI on the number of infections detected. Statistical analyses were performed using the 2-sample t-test, the Wilcoxon rank-sum test, the chi-square test, Fisher's exact test, or logistic regression, as appropriate for the variables examined. RESULTS Four hundred sixty-four electrodes were placed in 242 adults during 245 primary procedures over approximately 10.5 years; most patients underwent bilateral electrode implantation. Among the 245 procedures, 9 SSIs (3.7%) occurred within 90 days and 16 (6.5%) occurred within 1 year of DBS placement. Gram-positive bacteria were the most common etiological agents. Most patient- and procedure-related characteristics did not differ between those who had acquired an SSI and those who had not. The rate of SSIs among patients who had received intrawound VP was only 3.3% compared with 9.7% among those who had not received topical VP (OR 0.32, 95% CI 0.10-1.02, p = 0.04). After controlling for patient sex, the association between VP and decreased SSI risk did not reach the predetermined level of significance (adjusted OR 0.32, 95% CI 0.10-1.03, p = 0.06). The SSI rates were similar after staged and unstaged implantations. CONCLUSIONS While most patient-related and procedure-related factors assessed in this study were not associated with the risk for an SSI, the data did suggest that intrawound VP may help to reduce the SSI risk after DBS implantation. Furthermore, given the implications of SSI after DBS surgery and the frequency of infections occurring more than 90 days after implantation, continued follow-up for at least 1 year after such a procedure is prudent to establish the true burden of these infections and to properly treat them when they do occur.
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Affiliation(s)
- Kingsley O. Abode-Iyamah
- Departments of Neurosurgery, The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Hsiu-Yin Chiang
- Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Royce W. Woodroffe
- Departments of Neurosurgery, The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Brian Park
- The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | | | - Yasunori Nagahama
- Departments of Neurosurgery, The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Nolan Winslow
- The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Loreen Herwaldt
- Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
- Program of Hospital Epidemiology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
- Department of Epidemiology, The University of Iowa College of Public Health, Iowa City, IA 55242, USA
| | - Jeremy D.W. Greenlee
- Departments of Neurosurgery, The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
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Jiang Y, Hu R, Zhu G. Top 100 cited articles on infection in orthopaedics: A bibliometric analysis. Medicine (Baltimore) 2019; 98:e14067. [PMID: 30633210 PMCID: PMC6336590 DOI: 10.1097/md.0000000000014067] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 07/22/2018] [Accepted: 12/18/2018] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The infection is an essential problem in the clinical practice in orthopedics. The bibliometric analysis was conducted to evaluate the top 100 cited articles on infection in orthopaedics. METHODS The Web of Science (WoS) Core Database was comprehensively searched from 1975 to 2017, and the literature search was limited in Science Citation Index Expanded (SCI-E). The subject terms included "infection", "infectious", and "infect*". All retrieved articles were filtrated by selecting the subspecialty of "Orthopedics". The searching results were listed by citation times to identify the top 100 cited articles. Significant information was elicited, including the authors, journals, countries, institutions, published year, and types of publication. RESULTS A significant increase was observed in the number of annual publications focusing on infection in orthopedics worldwide. Each of the top 100 cited articles was cited more than 150 times. Total citation times was positively associated with citation times in 2016 (P <.01) and mean citation times per year (P <.01). Conversely, age of the article was negatively associated with citation times in 2016 (P <.01) and mean citation times per year (P <.01). Besides, citation times in 2016 was positively related to mean citation times per year (P <.01). The United States was the most productive country, surgery was the most popular subspecialty and Journal of Bone and Joint Surgery American Volume was the most popular journal. CONCLUSION Infection in orthopaedics has attracted more and more researchers' concern. As for the top 100 cited articles, there were significant relationships among total citation times, citation times in 2016 and mean citation times per year as well as age of the article. The United States was the most productive country, surgery was the most popular subspecialty and Journal of Bone and Joint Surgery American Volume was the most popular journal.
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Affiliation(s)
| | - Renjing Hu
- Department of Clinical Laboratory, Nanjing Medical University Affiliated Wuxi Second Hospital, Wuxi, China
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Still M, Kane A, Roux A, Zanello M, Dezamis E, Parraga E, Sauvageon X, Meder JF, Pallud J. Independent Factors Affecting Postoperative Complication Rates After Custom-Made Porous Hydroxyapatite Cranioplasty: A Single-Center Review of 109 Cases. World Neurosurg 2018; 114:e1232-e1244. [PMID: 29625304 DOI: 10.1016/j.wneu.2018.03.181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/24/2018] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Cranioplasties are an important neurosurgical procedure not only for improved cosmesis but also for improved functional recovery after craniectomy with a large cranial defect. The aim of this study was to identify predictive factors of postcranioplasty complications using custom-made porous hydroxyapatite cranioplasty. METHODS Retrospective review was performed of all patients who underwent a reconstructive cranioplasty using custom-made hydroxyapatite at our institution between February 2008 and September 2017. Postoperative complications considered included bacterial infection, seizures, hydrocephalus requiring ventricular shunt placement, and cranioplasty-to-bone shift. Variables associated at P < 0.1 level in unadjusted analysis were entered into backward stepwise logistic regression models. RESULTS Of 109 patients included, 15 (13.8%) experienced postoperative infection, with craniectomy performed at an outside institution (adjusted odds ratio [OR] 10.37 [95% confidence interval [CI], 2.03-75.27], P = 0.012) and a previous infection at the surgical site (adjusted OR 6.15 [95%CI, 1.90-19.92], P = 0.003) identified as independent predictors. Six patients (5.5%) experienced postoperative seizures, with stroke (ischemic and hemorrhagic) as a reason for craniectomy (adjusted OR 11.68 [95% CI, 2.56-24.13], P < 0.001) and the presence of seizures in the month before cranioplasty (adjusted OR 9.39 [95% CI, 2.04-127.67], P = 0.002) identified as independent predictors. Four patients (3.7%) experienced postcranioplasty hydrocephalus necessitating shunt placement, and 5 patients (4.6%) experienced cranioplasty-to-bone shift ≥5 mm, but no significant predictive factors were identified for either complication. CONCLUSIONS This study identified possible predictive factors for postcranioplasty complications to help identify at-risk patients, guide prophylactic care, and improve morbidity of this important surgical procedure.
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Affiliation(s)
- Megan Still
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Abdoulaye Kane
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Alexandre Roux
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; IMABRAIN Team, Inserm, U894, Centre Psychiatrie et Neurosciences, Paris, France
| | - Marc Zanello
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Edouard Dezamis
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Eduardo Parraga
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Xavier Sauvageon
- Department of Neuro-Anaesthesia and Neuro-Intensive Care, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Jean-François Meder
- Department of Neuroradiology, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; IMABRAIN Team, Inserm, U894, Centre Psychiatrie et Neurosciences, Paris, France
| | - Johan Pallud
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; IMABRAIN Team, Inserm, U894, Centre Psychiatrie et Neurosciences, Paris, France.
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