Lower complication rates for cranioplasty with peri-operative bundle

Systematic Review of Enhanced Recovery After Surgery in Patients Undergoing Cranial Surgery

BACKGROUND

Enhanced Recovery after Surgery (ERAS) pathways are increasingly being integrated in neurosurgical patient management. The full extent of ERAS in cranial surgery is not well studied. We performed a systematic review examining ERAS in cranial surgery patients to 1) identify the extent to which ERAS is integrated in cranial neurosurgical procedures and 2) assess effectiveness of ERAS interventions for patients undergoing these procedures.

METHODS

A systematic review of MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Scopus, PsychInfo, and Google Scholar was conducted according to PRISMA guidelines (CRD42020197187). Studies eligible for inclusion assessed patients undergoing any cranial surgical procedure using an ERAS or ERAS-like pathway, defined by ≥2 ERAS protocol elements per the ERAS Society's RECOvER Checklist and the recommendations of Hagan et al. 2016 (not including patient education, criteria for discharge, or tracking of postdischarge outcomes).

RESULTS

Nine studies were included in qualitative synthesis, 2 of which were randomized controlled trials. All studies showed a moderate risk of bias. The most common ERAS elements used were screening and/or optimization and formal discharge criteria. The least common ERAS elements used were fasting/carbohydrate loading and antithrombotic prophylaxis. Complication rates were similar in studies comparing ERAS with non-ERAS groups. ERAS interventions were associated with reduced length of stay, with comparable and/or improved patient satisfaction.

CONCLUSIONS

ERAS is a safe and potentially favorable perioperative pathway for select patients undergoing cranial surgery. Future studies of ERAS in cranial surgery patients should emphasize postoperative optimizations and patient-reported outcome measures as key features.

Cranioplasty

Calvarial defects are commonly encountered after neurosurgical procedures, trauma, and ablative procedures of advanced head neck cancers. The goals of cranioplasty are to provide a protective barrier for the intracranial contents, to restore form, and prevent syndrome of the trephined. Autologous and alloplastic techniques are available, each with their advantages and drawbacks. A multitude of materials are available for cranioplasty, and proper timing of reconstruction with attention to the overlying skin envelope is important in minimizing complications.

Immunopathogenesis of Craniotomy Infection and Niche-Specific Immune Responses to Biofilm

Bacterial infections in the central nervous system (CNS) can be life threatening and often impair neurological function. Biofilm infection is a complication following craniotomy, a neurosurgical procedure that involves the removal and replacement of a skull fragment (bone flap) to access the brain for surgical intervention. The incidence of infection following craniotomy ranges from 1% to 3% with approximately half caused by Staphylococcus aureus (S. aureus). These infections present a significant therapeutic challenge due to the antibiotic tolerance of biofilm and unique immune properties of the CNS. Previous studies have revealed a critical role for innate immune responses during S. aureus craniotomy infection. Experiments using knockout mouse models have highlighted the importance of the pattern recognition receptor Toll-like receptor 2 (TLR2) and its adaptor protein MyD88 for preventing S. aureus outgrowth during craniotomy biofilm infection. However, neither molecule affected bacterial burden in a mouse model of S. aureus brain abscess highlighting the distinctions between immune regulation of biofilm vs. planktonic infection in the CNS. Furthermore, the immune responses elicited during S. aureus craniotomy infection are distinct from biofilm infection in the periphery, emphasizing the critical role for niche-specific factors in dictating S. aureus biofilm-leukocyte crosstalk. In this review, we discuss the current knowledge concerning innate immunity to S. aureus craniotomy biofilm infection, compare this to S. aureus biofilm infection in the periphery, and discuss the importance of anatomical location in dictating how biofilm influences inflammatory responses and its impact on bacterial clearance.

Cranial Surgical Site Infection Interventions and Prevention Bundles: A Systematic Review of the Literature

BACKGROUND

Cranial surgical site infections (cSSIs) are associated with significant morbidity. Measures to reduce cSSI are necessary to reduce patient morbidity as well as hospital costs and resource utilization.

OBJECTIVE

To identify and characterize interventions or bundled interventions aimed at reduction of the incidence of cranial surgical site infections.

METHODS

A systematic review of the literature was conducted according to the PRISMA guidelines. The search strategy included randomized trials, quasi-experimental studies, cohort studies, and case series published between 2000 and 2020 that evaluated interventions implemented to reduce cSSI. Bias assessments and data extraction were performed on included studies.

RESULTS

The initial search generated 1249 studies. Application of inclusion and exclusion criteria and review of references yielded 15 single-intervention and 6 bundled-intervention studies. The single interventions included handwashing protocols, use of vancomycin powder, hair washing and clipping practices, and incision closure techniques. Bundled interventions addressed a variety of preoperative, intraoperative, and postoperative changes. Despite a lack of strong evidence to support the adoption of statistically significant interventions, the use of vancomycin powder may be effective in reducing cSSI. In addition, bundled interventions that involved cultural changes, such as increased teaching/education, personal accountability, direct observation, and feedback, showed some success in decreasing SSI rates.

CONCLUSIONS

The strength of the conclusions is limited by small sample sizes, study heterogeneity, relatively low cSSI incidence, and high case variability. Some evidence supports the use of intraoperative vancomycin powder in adult noncranioplasty cases and the application of accountability, teaching, and surveillance of faculty, particularly those early in training.

Reduction in the infection rate of cranioplasty with a tailored antibiotic prophylaxis: a nonrandomized study

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.

A 10-Year Analysis of 3693 Craniotomies during a Transition to Multidisciplinary Teams, Protocols, and Pathways

INTRODUCTION

A Cochrane review of teams, protocols, and pathways demonstrated improved care efficiency and outcomes over a traditional model. Little is known about this approach for craniotomy.

METHODS

This observational study involved sequential implementation of a multidisciplinary team, protocols, and a craniotomy pathway. Data on 3693 admissions were retrospectively reviewed at a tertiary care neurosurgery center from 2008 to 2017 for the top 6 diagnosis-related group codes. In June 2016, a searchable discharge summary template in the electronic medical record was implemented to capture data regarding quality, efficiency, and outcomes.

RESULTS

Staffing transitioned to a team of neurosurgeons, neurointensivists, neurohospitalists, and midlevel practitioners. Order sets, protocols, and pathways were developed. Quality improvements were observed for craniotomy and cranioplasty surgical site infections, ventriculitis, coagulopathy reversal, and decompressive hemicraniectomy rates for stroke. Case volume increased 73%, yet craniotomy hospital days decreased from 2768 in 2008 to 2599 in 2017 because of reduced length of stay. We accommodated service line growth without hospital expansion or case backlogs. With an average California hospital day rate of $3341, the improved length of stay decreased costs by $14,666,990/y. We also present outcomes data, including craniotomy indications, operative timing, complications, functional outcomes, delays in discharge, and discharge destinations using the craniotomy discharge summary.

CONCLUSION

Multidisciplinary teams, protocols, and pathways reduced craniotomy complication rates, improved hospital length of stay by 63%, reduced costs, and increased professional collegiality and satisfaction. A searchable craniotomy discharge summary is an important tool for continuous monitoring of quality and efficiency of care.

Management and prevention of cranioplasty infections

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.

Infection Prevention in the Neurointensive Care Unit: A Systematic Review

Hospital-acquired infections are common in neurointensive care units. We sought to review interventions which may reduce infection rates in neurocritically ill populations. We conducted a systematic review of studies targeting adult patients in neuro-intensive care units (neuro-ICUs) with an intervention designed to prevent ICU-acquired infections. Our outcome of interest was change in the prevalence or rates of infection between active and control arms of these studies. We excluded studies based on the following criteria: no English full-text version available; pediatric population; non-neurosciences ICU population; pre- or intraoperative methods to prevent infection; lack of discrete data for infection rates/prevalence; studies that were purely observational in nature and did not test an intervention; and studies performed in resource limited settings. We initially retrieved 3716 results by searching the following databases: PubMed/MEDLINE, EMBASE via Ovid, and Cochrane CENTRAL via Ovid. No date or language limits were used in the search. Computerized deduplication was conducted using EndNote followed by a confirmatory manual review resulting in 3414 citations. An additional 19 manuscripts were identified through review of references. The screening process followed a standard protocol, using two screeners at the title/abstract level to determine relevance and at the full-text level to determine eligibility for inclusion. The 3427 titles/abstracts were independently screened by two board-certified neurointensivists to determine relevance for full-text review, and 3248 were rejected. The remaining 179 abstracts were reviewed in full text using predetermined inclusion/exclusion criteria. Ultimately, 75 articles met our inclusion criteria and were utilized in the final analysis. The reviewed literature highlights the need for collaborative, multi-disciplinary, and multi-pronged approaches to reduce infections. Rates of VRI, SSI, VAP, CAUTI, and CLABSI can approach zero with persistence and a team-based approach.

Implementation of an infection prevention bundle is associated with reduced surgical site infections in cranial neurosurgery

OBJECTIVE

The objective of this study was to quantify surgical site infection (SSI) rates after cranial neurosurgery in a tertiary care hospital, identify risk factors for SSI, and evaluate the impact of standardized surveillance and an infection prevention bundle (IPB).

METHODS

The authors compared SSI rates during 7 months before and after the intervention. The IPB included standardized patient preparation, perioperative antibiotic/antiseptic use, barrier precautions, coaching of surgeons, and the implementation of a specialized technical operation assistant team.

RESULTS

Three hundred twenty-two unselected consecutive patients were evaluated before the IPB, and 296 were evaluated after implementation. Infection rates after 1 year decreased from 7.8% (25/322) to 3.7% (11/296, p = 0.03) with similar mortality rates (14.7% vs 13.8%, p = 0.8). The isolated bacteria included Staphylococcus aureus (42%), Cutibacterium acnes (22%), and coagulase-negative staphylococci (14%). Organ/space infections dominated with 67%, and mostly consisted of subdural empyema and meningitis/ventriculitis. Among the 36 SSIs, 13 (36%) occurred during hospitalization, and 29 (81%) within the first 3 months of follow-up. In multivariable analysis including established risk factors described in the literature, non-CNS neoplasia (odds ratio [OR] 3.82, 95% confidence interval [CI] 1.39–10.53), postoperative bleeding (OR 4.09, 1.44–11.62), operations performed by or under supervision of a senior faculty surgeon (OR 0.38, 0.17–0.84), and operations performed after the implementation of standardized surveillance and an IPB (OR 0.38, 0.17–0.85) significantly influenced the infection rate.

CONCLUSIONS

The introduction of an IPB combined with routine surveillance and personal feedback was associated with a 53% reduced infection rate. The lower infection rates of senior faculty and the strong association between postoperative bleeding and infection underline the importance of both surgical experience as well as thorough supervision and coaching of younger surgeons.

Implementation strategies to reduce surgical site infections: A systematic review

BACKGROUND

Surgical site infections (SSIs) portend high patient morbidity and mortality. Although evidence-based clinical interventions can reduce SSIs, they are not reliably delivered in practice, and data are limited on the best approach to improve adherence.

OBJECTIVE

To summarize implementation strategies aimed at improving adherence to evidence-based interventions that reduce SSIs.

DESIGN

Systematic reviewMethods:We searched PubMed, Embase, CINAHL, the Cochrane Library, the WHO Regional databases, AFROLIB, and Africa-Wide for studies published between January 1990 and December 2015. The Effective Practice and Organization Care (EPOC) criteria were used to identify an acceptable-quality study design. We used structured forms to extract data on implementation strategies and grouped them into an implementation model called the "Four Es" framework (ie, engage, educate, execute, and evaluate).

RESULTS

In total, 125 studies met our inclusion criteria, but only 8 studies met the EPOC criteria, which limited our ability to identify best practices. Most studies used multifaceted strategies to improve adherence with evidence-based interventions. Engagement strategies included multidisciplinary work and strong leadership involvement. Education strategies included various approaches to introduce evidence-based practices to clinicians and patients. Execution strategies standardized the interventions into simple tasks to facilitate uptake. Evaluation strategies assessed adherence with evidence-based interventions and patient outcomes, providing feedback of performance to providers.

CONCLUSIONS

Multifaceted implementation strategies represent the most common approach to facilitating the adoption of evidence-based practices. We believe that this summary of implementation strategies complements existing clinical guidelines and may accelerate efforts to reduce SSIs.

The implementation of an infection prevention bundle reduces surgical site infections following cranial surgery

BACKGROUND

The benefit of an infection prevention bundle made up of five basic procedures to avoid surgical site infections (SSIs) following cranial surgery was evaluated.

METHODS

Data from all patients with first time elective brain surgery from March 2014 till May 2016 were analyzed. In April 2015, an infection prevention bundle was implemented. The rate of SSIs after first time elective cranial surgery of patients operated 1 year before and 1 year after the implementation was compared.

RESULTS

Of the 321 cases operated before the implementation of the infection prevention bundle, 13 cases (4%) developed a SSI. After the implementation, only 6 patients out of 288 were re-operated due to a SSI (2%). The most frequent etiological germ cultivated was Staphylococcus aureus.

CONCLUSION

The implementation of a bundle of 5 basic infection prevention steps leads to a clinical relevant reduction of SSIs.

The incidence and treatment of seizures after cranioplasty: a systematic review and meta-analysis

OBJECT

Patients surviving initial decompressive craniectomy are needed to undergo cranioplasty, which is potentially complicated by postoperative seizures. The definite incidence of post-cranioplasty seizures and application of prophylactic antiepileptic drugs remain controversial.

METHODS

We performed systematic review to clarify these issues. Searching through PubMed, Ovid, Web of Science and Cochrane library databases, we included publications recording the incidence of seizures after cranioplasty and prophylactic treatment. We pooled the respective incidence of seizures and 95% confidence interval (CI). The overall effect was expressed with events per 1,000 person-years calculated by the mean follow-up time. Trim and fill method was used to adjust for publication bias. Subgroup analyses were conducted to examine the differences in incidences of seizures.

RESULTS

Two randomized and 14 observational studies were extracted. The pooled incidence of post-cranioplasty seizures was 0.092 (95%CI 0.063, 0.121), which decreased to 0.043 (95%CI 0.010, 0.076) after adjustment. The summarized incidences of early seizures and late seizures were 0.074 (95%CI 0.029, 0.119) and 0.053 (0.027, 0.079) respectively. In the subgroup analyses, randomized studies reported a higher incidence than observational studies, and early cranioplasty (<6 months) resulted in an increased incidence compared with late cranioplasty (>6 months). The overall effect from two randomized studies showed prophylactic antiepileptic drugs reduced nearly 80% of seizures.

CONCLUSION

The estimated incidence of post-cranioplasty seizures is 43 per 1,000 person-years after adjustment. The incidence of early seizures is obviously higher than that of late seizures. Moreover, early cranioplasty leads to more post-cranioplasty seizures than late cranioplasty does. Based on the present evidences, the application of prophylactic antiepileptic drugs effectively reduces seizures.

Reduction of Surgical Site Infections After Cranioplasty With Perioperative Bundle

BACKGROUND

Surgical site infections (SSI) are the most common complication after cranioplasty and it is associated with poor prognosis. The aim of this study was to identify the risk factors that triggered the development of SSI after cranioplasty and establish a new perioperative bundle and monitoring system to reduce SSI.

METHODS

A retrospective review of a database that included all cranioplasty patients from 2001 to 2007 was carried out to determine the prevalence of infection. A surveillance team was set up, which assessed the clinical practice and led to the development of a new perioperative bundle and supervision system. A prospective study between 2008 and 2014 was carried out to observe whether infection rates had changed and whether an active surveillance program can change clinical practice.

RESULTS

Retrospective period included 86 adult patients. The overall rate of infection was 10.5% (9 SSI in 86 patients). Age ≥60 years (OR 1.05; 95% CI: 1.00-1.10; P = 0.04), smoking (OR 9.13; 95% CI: 1.65-50.60; P = 0.01), and duration of operation ≥180 minutes (OR1.19; 95% CI: 1.06-1.34; P < 0.01) as significant predictors of postcranioplasty SSI development. Length of preoperative stay and length of hospitalization was significantly longer among infected patients compared with uninfected patients (P < 0.01, respectively). In prospective period, the general SSI rate was reduced to 1.8% (2 SSI in 113 patients). The difference was statistically significant (P = 0.01).

CONCLUSIONS

A perioperative bundle and monitoring system may help to reduce SSI rates after cranioplasty. This work also indicates how an active surveillance program can successfully change clinical practice.

Independent Factors Affecting Postoperative Complication Rates After Custom-Made Porous Hydroxyapatite Cranioplasty: A Single-Center Review of 109 Cases

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.

Prosthetic rehabilitation in neurosurgical cranioplasty

The defects of the skull cause mechanical vulnerability of the brain, esthetic disfigurement, and transmission of vibrations and pulsation of the brain. Subsequent cranioplasty may be required to compensate for the defect and to alleviate various signs and symptoms. When long-term outcome of biomaterial use in pediatric cases is limited, alloplastic cranioplasty in adults are supported by several large case series. This case report narrates cranioplasty using titanium alloplastic implant material.

Antibacterial prophylaxis for gram-positive and gram-negative infections in cranial surgery: A meta-analysis

BACKGROUND

Perioperative antibiotic prophylaxis against gram positive and gram negative infections is considered standard of care in the perioperative management of patients undergoing cranial surgery. The antibiotic regimen which best reduces the risk of surgical site infections (SSIs) remains controversial.

OBJECTIVES

A systematic literature review and meta-analysis were conducted to examine the effect of various prophylactic antibiotics on infection incidence among patients undergoing cranial surgeries.

METHODS

A comprehensive search was conducted on Pubmed, EMBASE and Cochrane databases through October 2014 for studies that evaluated the efficacy of antibiotic prophylaxis among patients undergoing cranial surgeries. Pooled effect estimates using both fixed- and random-effect models were calculated.

RESULTS

Eight articles were included in the meta-analysis, with a combined total of 1655 cranial procedures. Among these, 74 cases of SSIs were reported after patients received a single antibiotic or a combination of 2 or more antibiotics (pooled incidence of SSIs=6.00%; 95% CI=4.80%, 7.50%; fixed-effects model; I²=73.7%; P-heterogeneity<0.01). Incidence of SSI was 1.00% (95% CI=0.40%, 2.60%) for non-MRSA gram-positive bacterial infections; 2.70% (95% CI=0.90%, 8.00%) for gram-negative bacterial infections; 6.00% (95% CI=4.50%, 7.80%) for gram negative, and non-MRSA gram-positive bacterial infections; and 11.3% (95% CI=7.20%, 17.4%) for gram negative and MRSA gram-positive bacterial infections. Subgroup analysis revealed an effect modification by drug class (P=0.05) and infection type (P-interaction=0.01). More specifically, lincosamides (2.70%; n=1 group), glycopeptides (2.80%; n=1), third generation cephalosporins (5.30%; n=2), antibiotics combination (4.90%; n=4), and penicillin-family antibiotics (5.90%, n=1) offered better coverage against infections than first generation cephalosporins (22.0%; n=2). A meta-regression analysis on study length was not significant (P=0.13). Random-effect models were not materially different form fixed-effects. No evidence of publication bias was found.

CONCLUSION

Lincosamides, glycopeptides, third generation cephalosporins, other combinations of prophylactic antibiotics, or penicillin-family antibiotics alone offer better coverage against SSIs than first generation cephalosporin among cranial surgery patients.

Surgical Site Infection after Malignant Brain Tumor Resection: A Multicenter Study for Induction of a Basic Care Bundle

Patients with malignant brain tumors are possibly at increased risk for surgical site infections (SSIs) considering the various medical situations associated with the disease. However, the actual rate of SSI after malignant brain tumor resection has not been well established, despite the potential impact of SSI on patient outcome. To investigate the incidence of SSI following malignant brain tumor surgery, we performed a retrospective study in 3 neurosurgical units. Subsequently, aiming at the reduction of incidence of SSI, we performed a prospective study using a care bundle technique in the same units. The SSI incidence in the retrospective (n = 161) and prospective studies (n = 68) were 4.3% and 4.4%, respectively, similar to the previously reports on general craniotomies. A care bundle does not appear to enhance prevention of SSI. However, future, large studies with a new care bundle should be planned based on a zero tolerance policy.

Risk factors for surgical site infections and assessment of vancomycin powder as a preventive measure in patients undergoing first-time cranioplasty

OBJECTIVE Craniectomy is often performed to decrease intracranial pressure following trauma and vascular injuries. The subsequent cranioplasty procedures may be complicated by surgical site infections (SSIs) due to prior trauma, foreign implants, and multiple surgeries through a common incision. Several studies have found that intrawound vancomycin powder (VP) is associated with decreased risk of SSIs after spine operations. However, no previously published study has evaluated the effectiveness of VP in cranioplasty procedures. The purpose of this study was to determine whether intrawound VP is associated with decreased risk of SSIs, to evaluate VP's safety, and to identify risk factors for SSIs after cranioplasty among patients undergoing first-time cranioplasty. METHODS The authors conducted a retrospective cohort study of adult patients undergoing first-time cranioplasty for indications other than infections from January 1, 2008, to July 31, 2014, at an academic health center. Data on demographics, possible risk factors for SSIs, and treatment with VP were collected from the patients' electronic health records. RESULTS During the study period, 258 patients underwent first-time cranioplasties, and 15 (5.8%) of these patients acquired SSIs. Ninety-two patients (35.7%) received intrawound VP (VP group) and 166 (64.3%) did not (no-VP group). Patients in the VP group and the no-VP group were similar with respect to age, sex, smoking history, body mass index, and SSI rates (VP group 6.5%, no-VP group 5.4%, p = 0.72). Patients in the VP group were less likely than those in the no-VP group to have undergone craniectomy for tumors and were more likely to have an American Society of Anesthesiologists physical status score > 2. Intrawound VP was not associated with other postoperative complications. Risk factors for SSI from the bivariable analyses were diabetes (odds ratio [OR] 3.65, 95% CI 1.07-12.44), multiple craniotomy procedures before the cranioplasty (OR 4.39, 95% CI 1.47-13.18), prior same-side craniotomy (OR 4.73, 95% CI 1.57-14.24), and prosthetic implants (OR 4.51, 95% CI 1.40-14.59). The multivariable analysis identified prior same-side craniotomy (OR 3.37, 95% CI 1.06-10.79) and prosthetic implants (OR 3.93, 95% CI 1.15-13.40) as significant risk factors for SSIs. After adjusting for potential confounders, patients with SSIs were more likely than those without SSIs to be readmitted (OR 7.28, 95% CI 2.07-25.60). CONCLUSIONS In this study, intrawound VP was not associated with a decreased risk of SSIs or with an increased risk of complications. Prior same-side craniotomy and prosthetic implants were risk factors for SSI after first-time cranioplasty.

Cranioplasty

Cranioplasty following craniectomy for trauma is a common, safe neurosurgical procedure that restores the natural cosmesis and protective barrier of the skull and may be instrumental in normalizing cerebrospinal fluid dynamics after decompressive surgery. Understanding the factors influencing patient selection and timing of cranioplasty, the available materials and methods of skull reconstruction, and the technical nuances is critical for a successful outcome. Neurosurgeons must be prepared to manage the complications specific to this operation. This article reviews the indications, preoperative assessment and timing, most commonly used materials, operative technique, postoperative care, and complication management for cranioplasty.

Prophylactic Levetiracetam for Seizure Control After Cranioplasty: A Multicenter Prospective Controlled Study

OBJECTIVE

To study efficacy and safety of prophylactic levetiracetam (LEV) administration in adults undergoing cranioplasty.

METHODS

We prospectively enrolled and randomly divided 200 adults undergoing cranioplasty into 2 groups: LEV (prophylactic LEV for 24 weeks) and control (no prophylactic antiepileptic drugs). Demographic and clinical characteristics; occurrence of postoperative seizure; changes in IQ, memory quotient, and activities of daily living scores; and postoperative side effects during hospital stay were analyzed at 2-, 24-, and 48-week follow-up visits.

RESULTS

Significant differences were found between groups in both early-stage seizures in the initial 2 weeks and late-stage seizures in the 3-24 weeks after cranioplasty (P < 0.05). Postoperative seizures occurred in 17.0% in the control group and 4.1% in the LEV group 48 weeks after cranioplasty, which was found to be significant (P = 0.0020). Patients with abnormal preoperative or postoperative electroencephalography (EEG) with spikes or sharp waves presented with an increased number of postoperative seizures compared with patients with normal EEG readings at 48 weeks. Significant differences were found between patients with postoperative seizures and patients without postoperative seizures in regard to changes in IQ, memory quotient, activities of daily living, and patient satisfaction scores (P < 0.01). No significant difference was found in side effects between the 2 groups.

CONCLUSIONS

Postoperative seizure is a common complication of cranioplasty, especially in patients with preoperative or postoperative abnormal EEG with spikes or sharp waves. Prophylactic LEV administration significantly reduced postcranioplasty seizures during LEV usage and had few side effects.

Implementation of a care bundle and evaluation of risk factors for surgical site infection in cranial neurosurgery

OBJECTIVES

Surgical site infection [SSI] increases mortality, morbidity and length of hospital stay. Peri-operative 'care bundles' have reduced SSI in some fields of surgery. The aim of this study was to determine the impact of bundle compliance on SSI in patients undergoing a craniotomy.

PATIENTS AND METHOD

Cohort study of patients [N=1253] undergoing a craniotomy over 17 months at a single centre. SSI was defined as arising within 30days of operation or 1year where an implant(s) remains. 'Bundle compliance' required administration of antibiotics <60min of induction, maintenance of intraoperative blood sugar (BM) <11mmol and temperature at >36°C. SSI incidence was compared between bundle compliant and non-compliant groups. Case mix adjustment was performed using binary logistic regression.

RESULTS

Over the study period, 1253 procedures were carried out and 66 patients (5.3%) developed a SSI. The majority (38, 57.6%) of these cultured Staphyloccoccus species. Only the use of an implant was found to be an independent risk factor for SSI [AOR 2.5, p<0.005, 95%CI 1.4, 4.3]. The use of the bundle did not reduce the occurrence of SSI.

CONCLUSIONS

An evidence-based bundle did not reduce SSI in this neurosurgical series. The use of an implant was an independent risk factor of its occurrence.

Analysis of Factors Contributing to Infections After Cranioplasty: A Single-Institution Retrospective Chart Review

OBJECTIVE

Cranioplasty is one of the most common neurosurgical procedures, yet has one of the greatest rates of infection among cranial operations. Although studies have reported on cranioplasty complications, it is unclear what factors contribute to the high rate of infection. This study aims to determine which patient characteristics and operative factors lead to postcranioplasty infections.

METHODS

This was a retrospective chart review of 186 patients. Factors analyzed included sex, reason for cranioplasty, type of infection, medical comorbidities, and surgical factors.

RESULTS

The overall infection rate was 24%. Skin flora was the most common pathogen. Wound dehiscence and presence of a postoperative fluid collection were associated significantly with a greater rate of infection (P < 0.001), whereas the use of autologous bone flap and a state of immunosuppression trended toward statistical significance (P = 0.075 and P = 0.089, respectively). Male sex, history of previous infection, history of craniectomy for trauma, cranioplasty size, and time to cranioplasty were not found to be significant factors related to cranioplasty infection.

CONCLUSIONS

Although wound dehiscence and postoperative fluid collections were associated significantly with infection in this study, the number in each sample size was small, and further studies with a larger number of patients in each subgroup is necessary to validate our findings.

Risk factors for surgical site infections after neurosurgery: A focus on the postoperative period

BACKGROUND

Surgical site infection (SSI) after neurosurgery has potentially devastating consequences.

METHODS

A prospective cohort study was conducted over a period of 24 months in a university center. All adult patients undergoing neurosurgical procedures, with exception of open skull fractures, were included. Multivariate logistic regression analysis was used to identify independent risk factors.

RESULTS

We included 949 patients. Among them, 43 were diagnosed with SSI (4.5%). A significant reduction in postneurosurgical SSI from 5.8% in 2009 to 3.0% in 2010 (P = .04) was observed. During that period, an active surveillance with regular feedback was established. The most common microorganisms isolated from SSI were Staphylococcus aureus (23%), Enterobacteriaceae (21%), and Propionibacterium acnes (12%). We identified the following independent risk factors for SSI postcranial surgery: intensive care unit (ICU) length of stay ≥7 days (odds ratio [OR] = 6.1; 95% confidence interval [CI], 1.7-21.7), duration of drainage ≥3 days (OR = 3.3; 95% CI, 1.1-11), and cerebrospinal fluid leakage (OR = 5.6; 95% CI, 1.1-30). For SSIs postspinal surgery, we identified the following: ICU length of stay ≥7 days (OR = 7.2; 95% CI, 1.6-32.1), coinfection (OR = 9.9; 95% CI, 2.2-43.4), and duration of drainage ≥3 days (OR = 5.7; 95% CI, 1.5-22).

CONCLUSION

Active surveillance with regular feedback proved effective in reducing SSI rates. The postoperative period is associated with overlooked risk factors for neurosurgical SSI. Infection control measures targeting this period are therefore promising.

Prophylactic Effect of Vancomycin on Infection after Cranioplasty in Methicillin-Resistant Staphylococcus Aureus Carriers with Traumatic Brain Injury

Objective

Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase negative staphylococci (MRCNS) are major causes of neurosurgical infection. Nasal colonization of MRSA is the most important risk factor and MRSA screening can be a screening method to identify MRSA and MRCNS colonization. We retrospectively evaluated prophylactic effect of vancomycin on MRSA or MRCNS surgical site infection (SSI) after cranioplasty following decompressive craniectomy (DC) after traumatic brain injury (TBI) in MRSA carriers.

Methods

The study included 21 patients who were positive in MRSA screening before cranioplasty. These patients underwent DC after TBI and subsequent cranioplasty with autologous bone. The patients were separated into SSI group and no SSI group according to the development of SSI due to MRSA or MRCNS after cranioplasty. Mean follow-up period after cranioplasty was 23.5±22.8 months (range, 3 to 73 months). The rate of MRSA or MRCNS SSI and factors including the prophylactic preoperative antibiotics were compared between groups.

Results

The rate of MRSA or MRCNS SSI was 23.8% (5/21 patients). Mean time from cranioplasty to confirm the SSI was 19.6±10.9 days (6 to 63 days). The rate of MRSA or MRCNS SSI was significantly different from the use of preoperative prophylactic antibiotics (p=0.047). MRSA or MRCNS SSI developed in 1 of 13 patients (7.6%) who received vancomycin and in 4 of 8 patients (50%) who received 3rd generation cephalosporin.

Conclusion

Preoperative MRSA screening and administration of vancomycin as a preoperative prophylactic antibiotic should be considered in MRSA carriers who are scheduled to cranioplasty to reduce MRSA or MRCNS SSI.

Perioperative use of antibiotics in otologic procedures

PURPOSE OF REVIEW

Surgical site infections (SSIs) have garnered tremendous attention in recent years. Surgeons tend to administer antimicrobial agents liberally, partly over fears of being sued or not paid to care for the SSI. As a result, microbial resistance to conventional agents continues to increase.

RECENT FINDINGS

Few new studies have been published in the otologic literature. The use of perioperative 'bundles' has been shown to be effective in reducing SSIs in procedures such as craniotomy. A single dose of antistaphylococcal and antipseudomonal prophylaxis appears to be highly efficacious prior to contaminated tympanomastoid surgery. Overuse of antimicrobial therapy can paradoxically increase SSIs.

SUMMARY

Otologic surgeons should adhere to established best practices when prescribing antimicrobial therapy perioperatively. Clinical trials of perioperative bundles are needed for otologic procedures.