Complications following pediatric cranioplasty after decompressive craniectomy: a multicenter retrospective study

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>In children, the repair of skull defects arising from decompressive craniectomy presents a unique set of challenges. Single-center studies have identified different risk factors for the common complications of cranioplasty resorption and infection. The goal of the present study was to determine the risk factors for bone resorption and infection after pediatric cranioplasty.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors conducted a multicenter retrospective case study that included all patients who underwent cranioplasty to correct a skull defect arising from a decompressive craniectomy at 13 centers between 2000 and 2011 and were less than 19 years old at the time of cranioplasty. Prior systematic review of the literature along with expert opinion guided the selection of variables to be collected. These included: indication for craniectomy; history of abusive head trauma; method of bone storage; method of bone fixation; use of drains; size of bone graft; presence of other implants, including ventriculoperitoneal (VP) shunt; presence of fluid collections; age at craniectomy; and time between craniectomy and cranioplasty.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>A total of 359 patients met the inclusion criteria. The patients’ mean age was 8.4 years, and 51.5% were female. Thirty-eight cases (10.5%) were complicated by infection. In multivariate analysis, presence of a cranial implant (primarily VP shunt) (OR 2.41, 95% CI 1.17–4.98), presence of gastrostomy (OR 2.44, 95% CI 1.03–5.79), and ventilator dependence (OR 8.45, 95% CI 1.10–65.08) were significant risk factors for cranioplasty infection. No other variable was associated with infection.</jats:p><jats:p>Of the 240 patients who underwent a cranioplasty with bone graft, 21.7% showed bone resorption significant enough to warrant repeat surgical intervention. The most important predictor of cranioplasty bone resorption was age at the time of cranioplasty. For every month of increased age the risk of bone flap resorption decreased by 1% (OR 0.99, 95% CI 0.98–0.99, p &lt; 0.001). Other risk factors for resorption in multivariate models were the use of external ventricular drains and lumbar shunts.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>This is the largest study of pediatric cranioplasty outcomes performed to date. Analysis included variables found to be significant in previous retrospective reports. Presence of a cranial implant such as VP shunt is the most significant risk factor for cranioplasty infection, whereas younger age at cranioplasty is the dominant risk factor for bone resorption.</jats:p></jats:sec>

Japanese National Questionnaire Survey in 2018 on Complications Related to Cranial Implants in Neurosurgery

“…A multicenter retrospective study reported an infection rate of 10.5% in 359 pediatric patients. 11) In a study on pediatric cranial reconstruction for craniosynostosis with resorbable plate system, the incidence of unplanned re-operation was 5.4%. 12) The relatively low incidences of complications in this study might be explained by the usage of a resorbable plate system and a procedure that does not involve dura opening.…”

Persistent Intracranial Hypertension in a Cranial Vault Remodeling Patient With Open Skull Fractures From Horse Kick

“…The possibility of underlying dural scarring or adhesions from prior surgery may have acted as a barrier to decompression of the cerebrum. Soft tissue adhesions between the dura, temporalis muscle, and galea have been noted by neurosurgeons in cranioplasties following decompressive craniectomies (Cemil et al, 2009; Rocque et al, 2018). Finally, the patient’s refractory ICPs may have been simply due to her severe cranial trauma from horse kick.…”

Prognostic and Risk Factors Analysis of 106 Patients Undergoing Ventriculoperitoneal Shunt Combined with Cranioplasty

“…In clinical practice, traditional large bone ap decompression is often used in the treatment of patients with a cerebral hernia, resulting in post-operative skull defects. Some patients experience complications with communicating hydrocephalus for various reasons and further develop brain swelling and encephalocele, which increases the risk of secondary damage to brain tissue, leading to poor prognosis in most of the cases 1,2,3 . In patients with acute hydrocephalus, external ventricular puncture and drainage, lumbar cisterna drainage, or repeated lumbar puncture can be used to release CSF, thus achieving temporary relief in the early stage; however, the longterm application may lead to tube blockage, infection and bleeding, etc.…”