School of Medicine and Health Sciences Poster Presentations

Title

Cranial bone grafting in the setting of infection: is it an absolute contraindication?

Document Type

Poster

Keywords

Intracranial empyema; Craniotomy; Bone Flap; Cranioplasty

Publication Date

Spring 2017

Abstract

Cranial bone grafting in the setting of infection: is it an absolute contraindication?

Background

Surgical treatment of intracranial empyema often necessitates craniotomy with removal of a bone “flap” in order to allow exposure to the affected site, debride necrotic tissue, and drain loculated pockets of purulent fluid. After removal, the bone is avascular, rendering it more susceptible to bacterial infection and subsequent necrosis. Consequently, standard practices are to bank the bone flap in an ectopic subcutaneous site (e.g., abdominal wall) or cryopreservation for future re-implantation. Disadvantages to this include an obligatory secondary operation, as well as relegating the patient to a protective helmet. Here we report on a unique approach, with primary re-implantation of the bone flap at the time of initial craniotomy, with the hypothesis that a substantial proportion may have successful bony reconstruction without infection or loss of the bone flap.

Methods

An institutional-review board approved retrospective review was performed of patients undergoing craniotomy for intracranial empyema at Children’s National Medical Center between 1997-2014. Those who had immediate bone flap re-implantation were included for study. Outcomes were determined by 1) persistent or recurrent infection/osteomyelitis, 2) long term bone healing versus resorption, and 3) requirement for future cranioplasty.

Results

23 bone flaps in 21 patients were included for study. Average age was 10.7 years at craniotomy. Average follow up was 22.2 months. Average bone flap surface area was 36.1±34.3 cm2. The majority of the empyemas were secondary to sinusitis (82.6%). Patients were treated with an average of 5.4 weeks of susceptibility-targeted antibiotic therapy after drainage.

Of the 23 replaced bone flaps, 21 (91.3%) were successfully replaced. 15 (65.2%) required a single craniotomy in conjunction with antibiotic therapy to treat the empyema. An additional 6 (26.1%) required an average of 1.4±0.7 (range: 1-3) intraoperative washouts with eventual clearance of infection. No patients developed clinical evidence of osteomyelitis. In the long-term, 2 patients (9.5%) developed partial bony resorption necessitating further reconstruction with autogenous split calvarium bone graft to restore continuity of the calvarium.

Conclusion

Immediate rigid replacement of the bone flap after craniectomy for drainage of intracranial empyemas is a reliable technique to provide autogenous reconstruction while minimizing bony resorption and the requirement for secondary cranioplasties, and carries a low complication profile.

Creative Commons License

Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

Open Access

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Comments

Poster to be presented at GW Annual Research Days 2017.

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Cranial bone grafting in the setting of infection: is it an absolute contraindication?

Cranial bone grafting in the setting of infection: is it an absolute contraindication?

Background

Surgical treatment of intracranial empyema often necessitates craniotomy with removal of a bone “flap” in order to allow exposure to the affected site, debride necrotic tissue, and drain loculated pockets of purulent fluid. After removal, the bone is avascular, rendering it more susceptible to bacterial infection and subsequent necrosis. Consequently, standard practices are to bank the bone flap in an ectopic subcutaneous site (e.g., abdominal wall) or cryopreservation for future re-implantation. Disadvantages to this include an obligatory secondary operation, as well as relegating the patient to a protective helmet. Here we report on a unique approach, with primary re-implantation of the bone flap at the time of initial craniotomy, with the hypothesis that a substantial proportion may have successful bony reconstruction without infection or loss of the bone flap.

Methods

An institutional-review board approved retrospective review was performed of patients undergoing craniotomy for intracranial empyema at Children’s National Medical Center between 1997-2014. Those who had immediate bone flap re-implantation were included for study. Outcomes were determined by 1) persistent or recurrent infection/osteomyelitis, 2) long term bone healing versus resorption, and 3) requirement for future cranioplasty.

Results

23 bone flaps in 21 patients were included for study. Average age was 10.7 years at craniotomy. Average follow up was 22.2 months. Average bone flap surface area was 36.1±34.3 cm2. The majority of the empyemas were secondary to sinusitis (82.6%). Patients were treated with an average of 5.4 weeks of susceptibility-targeted antibiotic therapy after drainage.

Of the 23 replaced bone flaps, 21 (91.3%) were successfully replaced. 15 (65.2%) required a single craniotomy in conjunction with antibiotic therapy to treat the empyema. An additional 6 (26.1%) required an average of 1.4±0.7 (range: 1-3) intraoperative washouts with eventual clearance of infection. No patients developed clinical evidence of osteomyelitis. In the long-term, 2 patients (9.5%) developed partial bony resorption necessitating further reconstruction with autogenous split calvarium bone graft to restore continuity of the calvarium.

Conclusion

Immediate rigid replacement of the bone flap after craniectomy for drainage of intracranial empyemas is a reliable technique to provide autogenous reconstruction while minimizing bony resorption and the requirement for secondary cranioplasties, and carries a low complication profile.