Management of decompressive craniectomy defects: modern military treatment strategies.
Management of decompressive craniectomy defects: modern military treatment strategies.
- 2012
Available online from MWHC library: 2001 - present, Available in print through MWHC library:1999-2007
BACKGROUND: Decompressive craniectomy has become a critical and standard life-saving maneuver in the theater of war. The high number of patients returning with large cranial defects and complex craniofacial injuries often involving the upper orbits or associated with the sunken skin flaps are a reconstructive challenge. We present a review of our treatment protocol highlighting the evolution of decompressive craniectomy and the development of a modern cranial defect treatment algorithmic approach to reconstruct these difficult clinical cases. CONCLUSIONS: Warfare-related decompressive craniectomy defects can be safely reconstructed using custom alloplastic implants with low morbidity and mortality. Risk factors that increase the rate of infection and require implant removal included orbital extension of the craniectomy defect, proximity to facial sinuses, and large contour abnormalities with corresponding large dead spaces. Staging reconstruction of high-risk cranial defects followed by definitive cranial defect reconstruction improved the likelihood of implant retention and successful cranioplasty outcome. METHODS: A review of previously published data and current data from our warfare treatment unit that reported the treatment of decompressive cranial defects from 2004 to 2011 was performed. Reported data included mechanism of injury, evacuation time, initial Glasgow Coma Scale (GCS), GCS on arrival to the continental United States, type of decompressive craniectomy, type of implants used for reconstruction, and complications such as implant infections, exposures, and removals. Secondary reconstruction techniques used to salvage failed cranioplasty cases with free tissue transfers and cranial bone or dermal fat grafts as indicated were also reviewed and outcomes were reported. RESULTS: From March 2003 to July 2011, more than 200 patients were identified who underwent cranioplasty after decompressive craniectomy. Patient average age was approximately 25 years (range, 18-53 y), and all patients were male. Average follow-up was 870 days (2.4 y). Average GCS at initial presentation was 7 and was 9 on arrival to the continental United States. Average time to evacuation to the continental United States was 6 days. Of all injuries, 46% were associated with an improvised explosive device blast. Of the patients, 90% underwent hemicraniectomies with the remaining 10% having received bifrontal craniectomies. Successful reconstruction and retention of the implant was present in 95% of the overall cohort. Contour abnormalities were the most common adverse outcome encountered (10% of patients after cranioplasty), whereas infections resulting in implant loss (5%) and seizures (<5%) were the most common complications that occurred after cranioplasty reconstruction.
English
1049-2275
*Decompressive Craniectomy/mt [Methods]
*Military Personnel
Adipose Tissue/tr [Transplantation]
Adolescent
Adult
Algorithms
Blast Injuries/su [Surgery]
Bone Transplantation/mt [Methods]
Clinical Protocols
Cohort Studies
Device Removal
Facial Bones/in [Injuries]
Facial Bones/su [Surgery]
Follow-Up Studies
Free Tissue Flaps/tr [Transplantation]
Glasgow Coma Scale
Humans
Male
Middle Aged
Prostheses and Implants
Prosthesis-Related Infections/et [Etiology]
Reconstructive Surgical Procedures/is [Instrumentation]
Reconstructive Surgical Procedures/mt [Methods]
Reoperation
Retrospective Studies
Skull/in [Injuries]
Skull/su [Surgery]
Surgical Wound Dehiscence/et [Etiology]
Time Factors
Treatment Outcome
War
Young Adult
MedStar Washington Hospital Center
Radiology
Journal Article
Available online from MWHC library: 2001 - present, Available in print through MWHC library:1999-2007
BACKGROUND: Decompressive craniectomy has become a critical and standard life-saving maneuver in the theater of war. The high number of patients returning with large cranial defects and complex craniofacial injuries often involving the upper orbits or associated with the sunken skin flaps are a reconstructive challenge. We present a review of our treatment protocol highlighting the evolution of decompressive craniectomy and the development of a modern cranial defect treatment algorithmic approach to reconstruct these difficult clinical cases. CONCLUSIONS: Warfare-related decompressive craniectomy defects can be safely reconstructed using custom alloplastic implants with low morbidity and mortality. Risk factors that increase the rate of infection and require implant removal included orbital extension of the craniectomy defect, proximity to facial sinuses, and large contour abnormalities with corresponding large dead spaces. Staging reconstruction of high-risk cranial defects followed by definitive cranial defect reconstruction improved the likelihood of implant retention and successful cranioplasty outcome. METHODS: A review of previously published data and current data from our warfare treatment unit that reported the treatment of decompressive cranial defects from 2004 to 2011 was performed. Reported data included mechanism of injury, evacuation time, initial Glasgow Coma Scale (GCS), GCS on arrival to the continental United States, type of decompressive craniectomy, type of implants used for reconstruction, and complications such as implant infections, exposures, and removals. Secondary reconstruction techniques used to salvage failed cranioplasty cases with free tissue transfers and cranial bone or dermal fat grafts as indicated were also reviewed and outcomes were reported. RESULTS: From March 2003 to July 2011, more than 200 patients were identified who underwent cranioplasty after decompressive craniectomy. Patient average age was approximately 25 years (range, 18-53 y), and all patients were male. Average follow-up was 870 days (2.4 y). Average GCS at initial presentation was 7 and was 9 on arrival to the continental United States. Average time to evacuation to the continental United States was 6 days. Of all injuries, 46% were associated with an improvised explosive device blast. Of the patients, 90% underwent hemicraniectomies with the remaining 10% having received bifrontal craniectomies. Successful reconstruction and retention of the implant was present in 95% of the overall cohort. Contour abnormalities were the most common adverse outcome encountered (10% of patients after cranioplasty), whereas infections resulting in implant loss (5%) and seizures (<5%) were the most common complications that occurred after cranioplasty reconstruction.
English
1049-2275
*Decompressive Craniectomy/mt [Methods]
*Military Personnel
Adipose Tissue/tr [Transplantation]
Adolescent
Adult
Algorithms
Blast Injuries/su [Surgery]
Bone Transplantation/mt [Methods]
Clinical Protocols
Cohort Studies
Device Removal
Facial Bones/in [Injuries]
Facial Bones/su [Surgery]
Follow-Up Studies
Free Tissue Flaps/tr [Transplantation]
Glasgow Coma Scale
Humans
Male
Middle Aged
Prostheses and Implants
Prosthesis-Related Infections/et [Etiology]
Reconstructive Surgical Procedures/is [Instrumentation]
Reconstructive Surgical Procedures/mt [Methods]
Reoperation
Retrospective Studies
Skull/in [Injuries]
Skull/su [Surgery]
Surgical Wound Dehiscence/et [Etiology]
Time Factors
Treatment Outcome
War
Young Adult
MedStar Washington Hospital Center
Radiology
Journal Article