Clinical and Radiologic Outcome of a Less Invasive, Low-Cost Surgical Technique of Osteoplastic Decompressive Craniectomy

Abstract

Background Decompressive craniectomy (DC) has many technical details with significant constraining logistic/economic considerations in low-resource practice areas. We present a less invasive, cost-saving, and evidence-based technique of DC evolving in our practice.

Methods Earlier, we reported a technique of hinge decompressive craniectomy (hDC), in which the frontotemporoparietal skull flap is hinged on the temporal muscle. In this article we describe further refinements of this temporal muscle hDC : The scalp flap is raised in a galeal-skeletonizing plane preserving the subgaleal fascia on the pericranium, ready for use for duraplasty after durotomy. We performed a descriptive analysis of the clinical outcome of this surgical technique in a prospective consecutive cohort of patients with traumatic brain injury (TBI). The primary and secondary clinical outcome measures were in-hospital mortality and survival, respectively, and the immediate as well as long-term surgical wound issues.

Results There were 40 cases, 38 men (95%) and 2 women over a 40-month period with a mild (n = 8), moderate (n = 17), or severe TBI (n = 15). As assessed by the computed tomography Rotterdam score, life-threatening significant brain injury was present in 90%. Poor clinical outcome occurred in about a third of cases (32.5%) mainly in the severe TBI group (77% of poor outcome) and not in the mild TBI group. Surgical site complications occurred in four patients (10%)

Conclusions The presented modified temporal muscle hDC technique offers significant economic advantages over the traditional surgical method of DC without added complications. Analysis of the clinical data in a consecutive prospective cohort of patients with potentially fatal TBI who underwent this surgical procedure showed a good outcome in at least two thirds.

Keywords

decompressive craniectomy - hinge decompressive craniectomy - low-resource practice - surgical technique - outcome study

Notes

Portions of this work were presented in part at the Bethune Roundtable in International Surgery, Office of International Surgery, University of Toronto, Toronto, ON, Canada, May 2012, and at the 99th annual clinical congress and centenary celebration of the American College of Surgeons, Washington DC, USA, October 5–10, 2013.

• References

• 1 Honeybul S. Decompressive craniectomy: a new complication. J Clin Neurosci 2009; 16 (5) 727-729
• 2 Cooper DJ, Rosenfeld JV, Murray L , et al; DECRA Trial Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 2011; 364 (16) 1493-1502
• 3 Stiver SI. Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus 2009; 26 (6) E7
• 4 Guerra WK, Gaab MR, Dietz H, Mueller JU, Piek J, Fritsch MJ. Surgical decompression for traumatic brain swelling: indications and results. J Neurosurg 1999; 90 (2) 187-196
• 5 Bhaskar IP, Zaw NN, Zheng M, Lee GY. Bone flap storage following craniectomy: a survey of practices in major Australian neurosurgical centres. ANZ J Surg 2011; 81 (3) 137-141
• 6 Chibbaro S, Marsella M, Romano A, Ippolito S, Benericetti E. Combined internal uncusectomy and decompressive craniectomy for the treatment of severe closed head injury: experience with 80 cases. J Neurosurg 2008; 108 (1) 74-79
• 7 Chibbaro S, Tacconi L. Role of decompressive craniectomy in the management of severe head injury with refractory cerebral edema and intractable intracranial pressure. Our experience with 48 cases. Surg Neurol 2007; 68 (6) 632-638
• 8 Kakar V, Nagaria J, John Kirkpatrick P. The current status of decompressive craniectomy. Br J Neurosurg 2009; 23 (2) 147-157
• 9 Schirmer CM, Ackil Jr AA, Malek AM. Decompressive craniectomy. Neurocrit Care 2008; 8 (3) 456-470
• 10 Adeleye AO. Decompressive craniectomy for traumatic brain injury in a developing country: an initial observational study. Ind J Neurotrauma 2010; 7 (1) 41-46
• 11 Kersh AM, El-Gendy HH. Unilateral decompressive craniectomy in traumatic brain injury patients with poor Glasgow Coma Scale as an intraoperative decision after evacuation of focal lesion; outcome in 30 consecutive cases. Med J Cairo Univ 2012; 80: 143
• 12 Mracek J, Choc M, Mork J, Vacek P, Mracek Z. Osteoplastic decompressive craniotomy—an alternative to decompressive craniectomy. Acta Neurochir (Wien) 2011; 153 (11) 2259-2263
• 13 Piek J. Decompressive surgery in the treatment of traumatic brain injury. Curr Opin Crit Care 2002; 8 (2) 134-138
• 14 Adeleye AO, Azeez AL. Decompressive craniectomy bone flap hinged on the temporalis muscle: a new inexpensive use for an old neurosurgical technique. Surg Neurol Int 2011; 2: 150
• 15 Ito H, Kimura T, Sameshima T , et al. Reinforcement of pericranium as a dural substitute by fibrin sealant. Acta Neurochir (Wien) 2011; 153 (11) 2251-2254
• 16 Adeleye AO. Surgical repair of cerebrospinal rhinorrhea in a resource-poor practice: a low-cost surgical technique with case illustrations. Neurosurg Q 2013; 23 (2) 127-132
• 17 Adeleye A, Ukachukwu A. The simple urine bag as wound drain post-craniotomy in a low-resource neurosurgical practice: a personal 4-year prospective cohort study. East Cent Africa J Surg 2014; 19 (1) 67-72
• 18 Maas AI, Hukkelhoven CW, Marshall LF, Steyerberg EW. Prediction of outcome in traumatic brain injury with computed tomographic characteristics: a comparison between the computed tomographic classification and combinations of computed tomographic predictors. Neurosurgery 2005; 57 (6) 1173-1182 ; discussion 1173–1182
• 19 Marshall LF, Marshall SB, Klauber MR , et al. The diagnosis of head injury requires a classification based on computed axial tomography. J Neurotrauma 1992; 9 (Suppl. 01) S287-S292
• 20 Baldo S, Tacconi L. Effectiveness and safety of subcutaneous abdominal preservation of autologous bone flap after decompressive craniectomy: a prospective pilot study. World Neurosurg 2010; 73 (5) 552-556
• 21 Ko K, Segan S. In situ hinge craniectomy. Neurosurgery 2007; 60 (4) (Suppl. 02) 255-258 ; discussion 258–259
• 22 Schmidt III JH, Reyes BJ, Fischer R, Flaherty SK. Use of hinge craniotomy for cerebral decompression. Technical note. J Neurosurg 2007; 107 (3) 678-682
• 23 Goettler CE, Tucci KA. Decreasing the morbidity of decompressive craniectomy: the Tucci flap. J Trauma 2007; 62 (3) 777-778
• 24 Kenning TJ, Gandhi RH, German JW. A comparison of hinge craniotomy and decompressive craniectomy for the treatment of malignant intracranial hypertension: early clinical and radiographic analysis. Neurosurg Focus 2009; 26 (6) E6
• 25 Burger R, Duncker D, Uzma N, Rohde V. Decompressive craniotomy: durotomy instead of duroplasty to reduce prolonged ICP elevation. Acta Neurochir Suppl (Wien) 2008; 102: 93-97
• 26 Missori P, Polli FM, Peschillo S, D'Avella E, Paolini S, Miscusi M. Double dural patch in decompressive craniectomy to preserve the temporal muscle: technical note. Surg Neurol 2008; 70 (4) 437-439 ; discussion 439
• 27 Miyake S, Fujita A, Aihara H, Kohmura E. New technique for decompressive duraplasty using expanded polytetrafluoroethylene dura substitute—technical note. Neurol Med Chir (Tokyo) 2006; 46 (2) 104-106 ; discussion 106