Hair and neurosurgery

The need for hair removal in paediatric brain tumour surgery?

INTRODUCTION

Preoperative hair removal is conventional practice within neurosurgery in an attempt to maintain antisepsis. However, there is a lack of evidence to suggest that it makes a difference with regards to infection. This article aims to relate preoperative hair removal to SSIs for paediatric patients.

METHODS AND MATERIALS

A retrospective analysis was conducted from a single paediatric neurosurgical database at the University Hospital of Wales. Patients were grouped according to whether they underwent preoperative hair removal or not. Findings were reviewed in light of the previously published literature.

RESULTS

One hundred eighty two paediatric intracranial tumours were operated on between November 2008 and 2019. A total of twenty-six patients (14%) developed an infection post-operatively, of which meningitis was the most common (77%). Eighty-nine operations were undertaken without preoperative hair removal, of which there were a total of fifteen infections (17%). In the hair removal group, there were a total of eleven infections out of ninety-three operations (12%). Overall, the patients without hair removal had a higher infection rate when compared to those with hair removal (17 and 12% respectively), however, this result was not statistically significant (p-value 0.3989).

CONCLUSION

We did not find evidence that hair removal in paediatric neurosurgery effects postoperative infection risk.

Preoperative hair removal to reduce surgical site infection

BACKGROUND

Hair has traditionally been removed from the surgical site before surgery; however, some studies claim that this increases surgical site infections (SSIs) and should be avoided. This is the second update of a review published in 2006 and first updated in 2011.

OBJECTIVES

To determine whether routine preoperative hair removal (compared with no removal) and the method, timing, or setting of hair removal effect SSI rates.

SEARCH METHODS

In November 2019, for this second update we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies, and scanned the reference lists of included studies plus reviews to identify additional studies. We applied no date or language restrictions.

SELECTION CRITERIA

We included randomised controlled trials or quasi-randomised trials that compared: · hair removal with no hair removal; · different methods of hair removal; and · hair removal at different times before surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the relevance of each study. Data were extracted independently by both review authors and cross-checked. We carried out 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool and assessed the certainty of evidence according to GRADE. Sensitivity analyses excluding studies at high risk of bias were conducted.

MAIN RESULTS

We included 11 new studies in this update resulting in a total of 19 randomised and 6 quasi-randomised trials (8919 participants). Clipping compared with no hair removal Low certainty evidence suggests there may be little difference in risk of SSI when no hair removal is compared with hair removal using clippers (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.65 to 1.39; three studies with 1733 participants). Shaving with a razor compared with no hair removal Moderate certainty evidence suggests the risk of SSI is probably increased in participants who have hair removal with a razor compared with no removal (RR 1.82, 95% CI 1.05 to 3.14; seven studies with 1706 participants). In terms of absolute risk this represents 17 more SSIs per 1000 in the razor group compared with the no hair removal group (95% CI 1 more to 45 more SSI in the razor group). Based on low-certainty evidence, it is unclear whether there is a difference in stitch abscesses between hair removal with a razor and no hair removal (1 trial with 80 participants; RR 1.00, 95% CI 0.21 to 4.66). Based on narrative data from one trial with 136 participants, there may be little difference in length of hospital stay between participants having hair removed with a razor compared with those having no hair removal (low-certainty evidence). Based on narrative data from one trial with 278 participants, it is uncertain whether there is a difference in cost between participants having hair removed by shaving with a razor compared with no hair removal (very low certainty evidence). Depilatory cream compared with no hair removal Low certainty evidence suggests there may be little difference in SSI risk between depilatory cream or no hair removal, although there are were wide confidence intervals around the point estimate that included benefit and harm (RR 1.02, 95% CI 0.45 to 2.31; low-certainty evidence; 1 trial with 267 participants). Based on narrative data from one trial with 267 participants, it is uncertain whether there is a difference in cost between participants having hair removed with depilatory cream compared with no hair removal (very low certainty evidence). Shaving with a razor compared with clipping Moderate-certainty evidence from 7 studies with 3723 participants suggests the risk of SSI is probably increased by shaving with a razor compared with clipping (RR 1.64, 95% CI 1.16 to 2.33). Moderate-certainty evidence suggests the risk of skin injury is probably increased in people who have hair removal with a razor rather than clipping (3 trials with 1333 participants; RR 1.74, CI 95% 1.12 to 2.71). Shaving with a razor compared with depilatory cream Moderate-certainty evidence from 9 studies with 1593 participants suggests there is probably more SSI risk when razors are used compared with depilatory cream (RR 2.28, 95% CI 1.12 to 4.65). Low-certainty evidence suggests the risk of skin injury may be increased when using a razor rather than depilatory cream for hair removal (RR 6.95, CI 95% 3.45 to 13.98; 5 trials with 937 participants). Based on narrative data from three trials with 402 participants, it is uncertain whether depilatory cream is more expensive than shaving (very low certainty evidence). Hair removal on the day of surgery compared with one-day preoperatively Low-certainty evidence suggests that there may be a small reduction in SSI risk when hair is removed on the day of surgery compared with the day before surgery although there are were wide confidence intervals around the point estimate that included benefit and harm (one trial, 977 participants; RR 0.83, 95% CI 0.54 to 1.30).

AUTHORS' CONCLUSIONS

Compared with no hair removal, there may be little difference in risk of SSI when clippers or depilatory cream are used (low-certainty evidence). However, there are probably fewer SSIs when hair is not removed compared with shaving with a razor (moderate-certainty evidence). If hair has to be removed, moderate-certainty evidence suggests using clippers or depilatory cream probably results in fewer SSIs and other complications compared with shaving using a razor. There may be a small reduction in SSIs when hair is removed on the day of, rather than the day before, surgery.

Ventriculoperitoneal Shunt without Hair Shaving Using Absorbable Suture Materials

OBJECTIVE

Infection is one of most devastating complications in ventriculoperitoneal (VP) shunt surgery. Preoperative hair removal has traditionally been performed to reduce infectious complications. We performed VP shunt surgeries and evaluated the prevalence of infection in patients who were shaved and those who were unshaven.

METHODS

A retrospective analysis was conducted of 82 patients with hydrocephalus of various pathologies who underwent VP shunt surgery, with or without having the head shaved, between March 2010 and March 2017. For patients in the non-shaved group (n=36), absorbable suture materials were used for wound closure, and Nylon sutures or staples were used in the shaved group (n=46). We evaluated the infection outcomes of patients in the two groups.

RESULTS

There was no difference in the average age of patients in the two groups. In the non-shaved group, there were no infections, while two patients in the shaved group required revision because of shunt infection.

CONCLUSION

Non-shaved shunt surgery may be safe and effective, with no increase of infection rate. We recommend that shunt procedures could be performed without shaving the hair, which may increase patients' satisfaction without increasing infection risk.

Hair-sparing technique using absorbable intradermal barbed suture versus traditional closure methods in supratentorial craniotomies for tumor

BACKGROUND

Hair-sparing techniques in cranial neurosurgery have gained traction in recent years and previous studies have shown no difference in infection rates, yet limited data exists evaluating the specific closure techniques utilized during hair-sparing craniotomies. Therefore, it was the intention of this study to evaluate the rate of surgical site infections (SSIs) and perioperative complications associated with using an absorbable intradermal barbed suture for skin closure in hair-sparing supratentorial craniotomies for tumor in order to prove non-inferiority to traditional methods.

METHODS

A retrospective review of supratentorial craniotomies for tumor by a single surgeon from 2011 to 2017 was performed. All perioperative adverse events and wound complications, defined as a postoperative infection, wound dehiscence, or CSF leak, were compared between three different groups: (1) hair shaving craniotomies + transdermal polypropylene suture/staples for scalp closure, (2) hair-sparing craniotomies + transdermal polypropylene suture/staples for scalp closure, and (3) hair-sparing craniotomies + absorbable intradermal barbed suture for scalp closure.

RESULTS

Two hundred sixty-three patients underwent hair shaving + transdermal polypropylene suture/staples, 83 underwent hair sparing + transdermal polypropylene suture/staples, and 100 underwent hair sparing + absorbable intradermal barbed suture. Overall, 2.9% of patients experienced a perioperative complication and 4.3% developed a wound complication. In multivariable analysis, the use of a barbed suture for scalp closure and hair-sparing techniques was not predictive of any complication or 30-day readmission. Furthermore, the absorbable intradermal barbed suture cohort had the lowest overall rate of wound complications (4%).

CONCLUSIONS

Hair-sparing techniques using absorbable intradermal barbed suture for scalp closure are safe and do not result in higher rates of infection, readmission, or reoperation when compared with traditional methods.

Intradermal Scalp Closure Using Barbed Suture in Cranial Tumor Surgeries: A Technical Note

BACKGROUND AND IMPORTANCE

Traditional scalp closure technique following elective craniotomy involves placement of staples or a continuous running suture. Despite low complication rates, these techniques are often considered to be disfiguring by patients, contribute to the psychosocial trauma of brain surgery, and are associated with discomfort during postoperative staple or suture removal. Some authors have described scalp closure using intradermal absorbable suture, but this technique likely does not reach the tensile strength of closure using traditional methods, and requires knots at the apices of the incision, which can act as a nidus for infection.

CLINICAL PRESENTATION

We employed a barbed intradermal closure method in supratentorial elective craniotomies for tumor resection. Complication rates were recorded, and cosmetic outcomes were informally assessed. Intradermal closure with barbed sutures was utilized in 76 patients. At the 2-wk postoperative clinic visit, cosmetic outcomes were excellent in all cases. There was 1 superficial wound infection that presented 6 wk after a pterional craniotomy for low-grade glioma. This resolved with superficial wound revision and oral antibiotic therapy.

CONCLUSION

We present a novel scalp closure technique for craniotomies using intradermal barbed Monocryl suture. We have had excellent cosmetic outcomes, and the infection rate of 1.3% compares favorably to published rates. Further studies are required to quantify the improvement in patient satisfaction compared to conventional closure methods.

Infections in deep brain stimulation: Shaving versus not shaving

Background:

To report our experience of infections in deep brain stimulation (DBS) surgeries comparing shaving versus no shaving of cranial hair. Nonshaving is strongly preferred by patients due to aesthetic and psychological factors.

Methods:

This study is a prospective follow-up of the infection rate in 43 nonshaven DBS cases between April 2014 and December 2015 compared to our former infection rate with shaving in our center. Minimum follow-up was 6 months. All patients, except 7 epilepsy patients, received implantation of the electrodes together with the extension cables and internal pulse generator in one session.

Results:

In 43 nonshaven patients, a total of 81 electrodes were implanted or revised with a mean follow-up of 16 months. One patient (2.32%) developed an infection of the implanted DBS-hardware and was treated with antibiotics.

Conclusion:

In our experience nonshaving of cranial hair in DBS surgery does not lead to more infections when compared to shaving. We have changed our protocol to nonshaving based on these findings.

Surgical Site Infections: An Update

Surgical site infections (SSIs) lead to adverse patient outcomes, including prolonged hospitalization and death. Wound contamination occurs with each incision, but proven strategies exist to decrease the risk of SSI. In particular, improved adherence to evidence-based preventative measures related to appropriate antimicrobial prophylaxis can decrease the rate of SSI. Aggressive surgical debridement and effective antimicrobial therapy are needed to optimize the treatment of SSI.

A Bundle Protocol to Reduce the Incidence of Periprosthetic Joint Infections After Total Joint Arthroplasty: A Single-Center Experience

BACKGROUND

Periprosthetic joint infection (PJI) represents a devastating complication of total hip arthroplasty (THA) or total knee arthroplasty (TKA). Modifiable patient risk factors as well as various intraoperative and postoperative variables have been associated with risk of PJI. In 2011, our institution formulated a "bundle" to optimize patient outcomes after THA and TKA. The purpose of this report is to describe the "bundle" protocol we implemented for primary THA and TKA patients and to analyze its impact on rates of PJI and readmission.

METHODS

Our bundle protocol for primary THA and TKA patients is conceptually organized about 3 chronological periods of patient care: preoperative, intraoperative, and postoperative. The institutional total joint database and electronic medical record were reviewed to identify all primary THAs and TKAs performed in the 2 years before and following implementation of the bundle. Rates of PJI and readmission were then calculated.

RESULTS

Thirteen of 908 (1.43%) TKAs performed before the bundle became infected compared to only 1 of 890 (0.11%) TKAs performed after bundle implementation (P = .0016). Ten of 641 (1.56%) THAs performed before the bundle became infected, which was not statistically different from the 4 of 675 (0.59%) THAs performed after the bundle that became infected (P = .09).

CONCLUSION

The bundle protocol we describe significantly reduced PJIs at our institution, which we attribute to patient selection, optimization of modifiable risk factors, and our perioperative protocol. We believe the bundle concept represents a systematic way to improve patient outcomes and increase value in total joint arthroplasty.

2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis

The Infectious Diseases Society of America (IDSA) Standards and Practice Guidelines Committee collaborated with partner organizations to convene a panel of 10 experts on healthcare-associated ventriculitis and meningitis. The panel represented pediatric and adult specialists in the field of infectious diseases and represented other organizations whose members care for patients with healthcare-associated ventriculitis and meningitis (American Academy of Neurology, American Association of Neurological Surgeons, and Neurocritical Care Society). The panel reviewed articles based on literature reviews, review articles and book chapters, evaluated the evidence and drafted recommendations. Questions were reviewed and approved by panel members. Subcategories were included for some questions based on specific populations of patients who may develop healthcare-associated ventriculitis and meningitis after the following procedures or situations: cerebrospinal fluid shunts, cerebrospinal fluid drains, implantation of intrathecal infusion pumps, implantation of deep brain stimulation hardware, and general neurosurgery and head trauma. Recommendations were followed by the strength of the recommendation and the quality of the evidence supporting the recommendation. Many recommendations, however, were based on expert opinion because rigorous clinical data are not available. These guidelines represent a practical and useful approach to assist practicing clinicians in the management of these challenging infections.

Fundamental Basis of Scalp Layering Techniques to Protect Against Wound Infection: A Comparative Study Between Conventional and In-to-Out Dissection of the Superficial Temporal Artery

BACKGROUND

Superficial temporal artery (STA) to middle cerebral artery (MCA) bypass is associated with several surgical problems. Despite the vascular patency and hemodynamic changes after the anastomosis, wound problems can be a major surgical complication.

METHODS

In a review of 41 surgical cases of STA-MCA bypass for moyamoya disease or cerebral occlusive vascular disease, we compared the conventional (out-to-in) dissection method for STA (n = 23) with the in-to-out (ITO) dissection method (n = 18) and evaluated the surgical results with respect to wound problems.

RESULTS

The incidence of skin maceration was significantly higher in the conventional dissection group than the ITO dissection group (34.8% vs. 5.5%; P < 0.01). Skin necrosis also showed a higher incidence in the conventional dissection group (39.1%) than the ITO group (22.2%).

CONCLUSIONS

These data suggest that the simple layering technique of the ITO dissection method can protect against contamination from bacteria and reduce postoperative surgical wound problems. Sealing of the galea aponeurotica (first protective barrier), including fibrous septa and loose areolar tissues, including the periosteal layer (second protective barrier), is an important factor to decrease the rate of scalp wound infection.

Cochlear Implantation: Minimal Hair Removal Technique

This prospective study was undertaken to evaluate the safety and patient acceptance of minimal hair removal during cochlear implantation. Forty-six consecutive patients (17 adults, 29 children; age range 13 months to 84 years) received cochlear implantation with a minimal hair removal technique. A questionnaire was used to evaluate acceptance and value of this technique among the first 15 patients and parents. Postoperative examinations were completed 1 and 4 weeks after implantation. Patients were monitored for complications, which included 3 cases of transient seroma, 2 cases of transient dysequilibrium, 2 individual electrode failures, and 1 facial nerve stimulation. Importantly, no wound infections were documented. Use of a small shave technique did not increase surgical risk. This technique has proved to be cosmetically and psychologically more desirable for the patients and their families than complete hair removal in the operative field.

Evaluation of Commonly Used Products for Disinfecting Clipper Blades in Veterinary Practices: A Pilot Study

Nosocomial infections are a concern of growing interest in veterinary medicine. Clipper blades have been confirmed as fomites for numerous potential pathogens and, as such, may be associated with wound and surgical site infections. The goal of this study was to evaluate the disinfectant capabilities of several commonly used clipper blade cleaning products. Seventy sterile clipper blades were inoculated with strains of Pseudomonas aeruginosa , Escherichia coli , and Staphylococcus aureus . Blades were then subjected to one of seven treatment groups for disinfecting. Quantitative cultures of remaining bacteria were performed. All blades in the control group showed large amounts of bacterial recovery. Culture results showed no recovery in blades soaked in alcohol or chlorhexidine or those sprayed with an ethanol/o-phenylphenol product, while moderate recovery was seen with all other treatments. These results show that persistent contamination of clipper blades can occur with the use of several commonly used disinfectant products. Further research is necessary to evaluate fungicidal capabilities as well as the effect of disinfection on clipper blade maintenance.

Nonshaved cranial surgery in black Africans: technical report and a medium-term prospective outcome study

Nonshaved neurosurgery, cranial or spinal, is well reported among Caucasians but hardly among native Africans. The ungroomed scalp hairs of black Africans have unique anthropological characteristics needing special attention for shaveless cranial surgery. A technical report of the execution of this surgical procedure among an indigenous patient population in a sub-Sahara African country is presented, as well as an outcome analysis in a prospective cohort over a 7-year period. A total of 303 patients (211 males, 70 %) fulfilled the criteria for this study. The surgical procedure was primary in 278 (92 %) and redo in 8 %. It was emergency surgery in 153 (51 %). They were trauma craniotomies or decompressive craniectomies in 95 cases (31 %), craniotomies for tumour resections in 86 (28 %), and the surgical dissections for other conditions in 122 (41 %). The duration of surgery ranged from 30 min to 8.5 h, mean 2.5 (SD, 1.6), median 2. In-hospital clinical outcome was good (normal status or moderate deficit on dichotomized Glasgow outcome scale (GOS)) in 273 (90.1 %) cases while surgical site infections occurred in only 10 cases (3.3 %). The type of surgery, redo or primary, did not have any significant association with the in-hospital outcome (p = 0.5), nor with the presence of surgical site infection (SSI) (p = 0.7). The length of follow-up ranged from 2 to 63 months (mean, 7) with no untoward complications reported so far. Medium-term outcome of nonshaved neurosurgery in this indigenous black Africans remains favourable with no attendant significant adverse after-effects.

Is It Necessary to Shave the Pubic and Genital Regions of Patients Undergoing Endoscopic Urological Surgery?

To determine whether postoperative urinary infections were related to shaving before undergoing endoscopic urological surgery, 90 patients were randomly assigned to shaving or not shaving. Urinary cultures revealed infection in 10 patients. Half of them had been shaved, suggesting that this practice does not affect the incidence of urinary infections.

What's the evidence? Systematic literature review of risk factors and preventive strategies for surgical site infection following pediatric spine surgery

BACKGROUND

Despite relatively high rates of surgical site infections (SSIs) after pediatric spine surgery, practice guidelines are absent. We performed a systematic review of the literature, determining the level of evidence for risk factors for SSIs and prevention practices to reduce SSIs following pediatric spine surgery.

METHODS

The search utilized the root search words "spine," "scoliosis," and "infection" resulting in 9594 abstracts. Following removal of duplicate abstracts, those that assessed only SSI rates, SSI treatment, nonoperative spine infections, or adult populations, 57 relevant studies were rated for level of evidence and graded using previously validated scales.

RESULTS

Very few studies lead to grade A (good evidence) or grade B (fair evidence) recommendations. Ceramic bone substitute did not increase the risk of SSIs when compared with autograft (grade A). Comorbid medical conditions, particularly cerebral palsy or myelodysplasia; urinary or bowel incontinence; nonadherence to antibiotic prophylaxis protocols; and increased implant prominence increase the risk of SSIs (grade B). SSIs caused by gram-negative bacilli were more frequent in neuromuscular populations and first-generation stainless steel implants increased the risk of delayed infection compared to newer generation titanium implants (grade B). Evaluations of other risk factors for SSIs yielded conflicting or poor-quality evidence (grade C); these included malnutrition or obesity; number of levels fused or fusion extended to the sacrum/pelvis; blood loss; and use of allograft. Insufficient evidence (0 to 1 published studies) was available to recommend numerous practices shown to reduce SSI risk in other populations such as chlorhexidine skin wash the night before surgery, preoperative nasal swabs for Staphylococcus aureus, chlorhexidine skin disinfection, perioperative prophylaxis with intravenous vancomycin, vancomycin, or gentamicin powder in the surgical site or graft.

CONCLUSIONS

Few studies have evaluated risk factors and preventive strategies for SSIs following pediatric spine surgery. This systematic review documents the relative lack of evidence supporting SSI prevention practices and highlights priorities for research.

LEVEL OF EVIDENCE

Level III therapeutic study.

Post-operative central nervous system infections after cranial surgery in China: incidence, causative agents, and risk factors in 1,470 patients

A post-operative central nervous system infection (PCNSI) is a dangerous complication after cranial surgery. Although a large number of neurosurgical procedures are performed in hospitals in China, PCNSI-related data from this country are rarely reported. To address this issue, we examined the incidence of PCNSI after cranial surgery, the potential risk factors, and the offending etiologic agents in a large Chinese population. The medical records and post-operative courses for patients >16 years of age who underwent elective or emergency cranial surgeries between May 2010 and May 2012 and who survived for >7 days were reviewed retrospectively. Pre-operative data, surgery-related records, and post-operative variables were evaluated as risk factors for PCNSI after cranial surgery. Among 1,470 surgeries, 1,340 were craniotomies and 130 involved the cerebrospinal fluid (CSF). There were 109 patients with PCNSIs, resulting in a total infection rate of 7.4 %. The dominant Gram-positive organism isolated (Staphylococcus aureus) was the most common pathogen isolated. Based on multivariate analysis, the risk of PCNSI was increased by a CSF leak [odds ratio (OR), 3.545; 95 % confidence interval (CI), 2.053-6.122; p < 0.001], CSF drainage of any kind (OR, 2.858; 95 % CI, 1.577-5.181; p = 0.001), subsequent short-term surgery (OR, 2.224; 95 % CI, 1.229-4.024; p = 0.008), and surgery duration (OR, 1.331; 95 % CI, 1.230-1.440; p < 0.001). PCNSI remains a critical problem for neurosurgeons in China. CSF leakage, CSF drainage of any kind, subsequent short-term surgery, and surgery duration were major risk factors, indicating that surgery-focused management might be the most effective way to minimize the risk for PCNSI after cranial surgery.

Is there a relationship between preoperative shaving (hair removal) and surgical site infection?

The preoperative preparation of patients for surgery has traditionally included the routine hair removal at the operating site as a part of cleanliness. This literature review will investigate the relationship between preoperative hair removal and surgical site infection. It aims to identify the best method of hair removal to reduce the infection if hair removal is necessary, and to apply the evidence findings into nursing practice.

The incidence of infection for adults undergoing supra-tentorial craniotomy for tumours without hair removal

AIMS & OBJECTIVES

The aim of the study was to look at the infection rate in adults undergoing craniotomies without hair removal and compare the results with the usual practice of pre-operative shaving/clipping.

MATERIALS & METHODS

One-hundred consecutive adult patients who had elective supra-tentorial craniotomy for tumour were studied prospectively. A uniform policy of performing surgery without hair removal was adopted. Patients were followed up prospectively to look for surgical site infection. The rate of infection was determined and the results were compared with the published data on similar procedures where hair removal was carried out before surgery.

RESULTS

A total of three patients developed surgical-site infection. One infection occurred in the glioma and two in the meningioma subgroup. The rate of infection is comparable to the published figures where pre-operative hair removal was performed routinely.

CONCLUSIONS

Cranial surgery with hair left in place does not pre-dispose to an increased infection risk for adults undergoing tumour surgery.

Infection following operations on the central nervous system: deconstructing the myth of the sterile field

Neurosurgical patients are at a high risk for infectious sequelae following operations. For neurosurgery in particular, the risk of surgical site infection has a unique implication given the proximity of the CSF and the CNS. Patient factors contribute to some degree; for example, cancer and trauma are often associated with impaired nutritional status, known risk factors for infection. Additionally, care-based factors for infection must also be considered, such as the length of surgery, the administration of steroids, and tissue devascularization (such as a craniotomy bone flap). When postoperative infection does occur, attention is commonly focused on potential lapses in surgical “sterility.” Evidence suggests that the surgical field is not free of microorganisms. The authors propose a paradigm shift in the nomenclature of the surgical field from “sterile” to “clean.” Continued efforts aimed at optimizing immune capacity and host defenses to combat potential infection are warranted.

Skin closure in vascular neurosurgery: A prospective study on absorbable intradermal suture versus nonabsorbable suture

Background:

The craniotomy performed with minimal hair removal and closure with intradermal suture alone is an option in neurosurgical procedures, which can help faster psychological recovery of the patient, as it allows a better cosmetic result. This study is aimed at evaluating if such method is safe and effective, compared with continuous skin sutures with 2-0 nylon.

Methods:

We analyzed the sutures in 117 patients undergoing craniotomies for cerebral aneurysm clipping. In the case group (n = 49), closure of the scalp was performed only with intradermal absorbable sutures using wire Monocryl^® 2-0. In the control group (n = 68), closure was performed with continuous suture using 2-0 nylon.

Results:

The case group was composed of 49 patients in whom just intradermal suture was performed. One (2.2%) patient developed wound infection and was given proper medical treatment. No cases of dehiscence or cerebrospinal fluid leaks were observed. The control group was composed of 68 patients in whom the skin was closed with 2-0 nylon continuous suture. Three (5.3%) patients developed wound infection and were given proper medical treatment. There were no cases of wound dehiscence. The overall infection rate in the control group was 4%. There was no statistically significant difference in the number of wound infections between the two groups (P = 0.73).

Conclusion:

The closure with intradermal suture alone in craniotomies is as safe as the traditional skin closure with nylon sutures, besides eliminating the need for suture removal and providing a cosmetic advantage.

Revision surgeries are associated with significant increased risk of subsequent cerebrospinal fluid shunt infection

BACKGROUND

The object of this study was to determine whether cerebrospinal fluid (CSF) shunt revision(s) are associated with increased risk of CSF shunt infection, after adjusting for baseline factors that contribute to infection risk.

METHODS

This was a retrospective cohort study of 579 children aged 0-18 years who underwent initial CSF shunt placement between January 01, 1997 and October 12, 2006 at a tertiary care children's hospital. The outcome of interest was CSF shunt infection. Data for all subsequent CSF shunt revisions leading up to and including the initial CSF shunt infection, when applicable, were obtained. The likelihood of infection was determined using a Cox proportional hazard model accounting for patient characteristics and CSF shunt revisions, and is reported using hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

There were 123 children who developed infection. Baseline factors independently associated with hazard of infection included age 0 to <6 months at CSF shunt placement (HR 2.4, 95% CI: 1.02-6.7) and myelomeningocele (HR 0.4, 95% CI: 0.2-0.8). Controlling for baseline factors, the risk of infection after shunt revision was significantly greater than at the time of initial placement (HR 3.0, 95% CI: 1.9-4.7), and this risk increased as numbers of revisions increased (≥2 revisions HR 6.5, 95% CI: 3.6-11.4).

CONCLUSIONS

Although younger age is associated with increased hazard of infection, subsequent CSF shunt revision significantly increases infection risk.

Association of intraventricular hemorrhage secondary to prematurity with cerebrospinal fluid shunt surgery in the first year following initial shunt placement

OBJECT

The neurosurgical literature has conflicting findings regarding the association between indications for CSF shunt placement and subsequent shunt surgery. The object of this study was to identify baseline factors at the time of initial CSF shunt placement that are independently associated with subsequent surgery.

METHODS

This was a retrospective cohort study of children ages 0-18 years who underwent initial CSF shunt placement between January 1, 1997, and October 12, 2006, at a tertiary care children's hospital. The outcome of interest was CSF shunt surgery (either for revision or infection) within 12 months after initial placement. Associations between subsequent CSF shunt surgery and indication for the initial shunt, adjusting for patient age and surgeon factors at the time of initial placement, were estimated using multivariate logistic regression. Medical and surgical decisions, which varied according to surgeon, were examined separately in a univariate analysis.

RESULTS

Of the 554 children in the study cohort, 233 (42%) underwent subsequent CSF shunt surgery, either for revision (167 patients [30%]) or infection (66 patients [12%]). In multivariate logistic regression modeling, significant risk factors for subsequent CSF shunt surgery included (compared with aqueductal stenosis) intraventricular hemorrhage (IVH) secondary to prematurity (adjusted odds ratio [AOR] 2.2, 95% CI 1.1-4.5) and other unusual indications (AOR 3.7, 95% CI 1.0-13.6). The patient's age at initial CSF shunt placement was not significantly associated with increased odds of subsequent surgery after adjusting for other associated factors.

CONCLUSIONS

The occurrence of IVH is associated with increased odds of subsequent CSF shunt surgery within 12 months after shunt placement. Families of and care providers for children with IVH should be attuned to their increased risk of shunt failure.

The role of perioperative care in reducing rates of methicillin resistant Staphylococcus aureus

Methicillin resistant Staphylococcus aureus (MRSA) is defined as any strain of Staphylococcus aureus resistant to beta-lactam antibiotics, including the penicillins and cephalosporins. Over the past ten years the UK has seen a dramatic increase in MRSA prevalence in healthcare facilities and the community, with an estimated 30-50% of healthy adults thought to be colonised with MRSA. Surgical patients are among those at highest risk. With potential sequelae including septicaemia, septic shock, septic arthritis, osteomyelitis, meningitis, pneumonia or endocarditis, it is vital that all care facilities have up to date evidence-based guidelines to tackle this problem. The purpose of this review is to highlight the current evidence supporting some of the key perioperative measures which may be implemented in preventing MRSA.

Preoperative hair removal to reduce surgical site infection

BACKGROUND

Although preparation of people for surgery has traditionally included removal of hair from the incision site, some studies claim that preoperative hair removal is harmful, causes surgical site infections (SSIs), and should be avoided.

OBJECTIVES

To determine if routine pre-operative hair removal (compared with no removal) and the timing or method of hair removal influence rates of SSI..

SEARCH METHODS

For this second update we searched the Cochrane Wounds Group Specialised Register (searched 12 August 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (1950 to August Week 1 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations August 11, 2010); Ovid EMBASE (1980 to 2011 Week 31) and EBSCO CINAHL (1982 to 11August 2011). No date or language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi randomised trials (QRCTs) that compared:1) hair removal with no hair removal; 2) different methods of hair removal; 3) hair removal at different times before surgery; and, 4) hair removal in different settings (e.g. ward, anaesthetic room).

DATA COLLECTION AND ANALYSIS

Three authors independently assessed relevance and quality of each trial. Data were extracted independently by two authors and cross-checked.

MAIN RESULTS

We included 14 trials (17 comparisons) in the review; three trials involved multiple comparisons. Six trials, two of which had three comparison arms, (972 participants) compared hair removal (shaving, clipping, or depilatory cream) with no hair removal and found no statistically significant difference in SSI rates however the comparison is underpowered. Three trials (1343 participants) that compared shaving with clipping showed significantly more SSIs associated with shaving (RR 2.09, 95% CI 1.15 to 3.80). Seven trials (1213 participants) found no significant difference in SSI rates when hair removal by shaving was compared with depilatory cream (RR 1.53, 95% CI 0.73 to 3.21), however this comparison is also underpowered. One trial compared two groups that shaved or clipped hair on the day of surgery compared with the day before surgery; there was no statistically significant difference in the number of SSIs between groups however this comparison was also underpowered.We identified no trials that compared clipping with depilatory cream; or investigated application of depilatory cream at different pre-operative time points, or hair removal in different settings (e.g. ward, anaesthetic room).

AUTHORS' CONCLUSIONS

Whilst this review found no statistically significant effect on SSI rates of hair removal insufficient numbers of people have been involved in this research to allow confidence in a conclusion. When it is necessary to remove hair, the existing evidence suggests that clippers are associated with fewer SSIs than razors. There was no significant difference in SSI rates between depilatory creams and shaving, or between shaving or clipping the day before surgery or on the day of surgery however studies were small and more research is needed.

Shaveless brain surgery: safe, well tolerated, and cost effective

Neurosurgeons perform operations every day, many of which involve the scalp. There is evidence supporting similar or decreased wound infection rates in the unshaven scalp. Patients with standard scalp incisions were assigned to either shave or shaveless preparations (n = 20). The timing of preparation and skin closure was recorded for both groups as were infectious complications. All of the patients have been followed for an average of 10 months. There were no cases of infection. The timing of scalp preparation and closure was not significantly different between the two groups (P < .05). We have previously suggested that shaving the scalp is not a critical step in the prevention of infection. We confirm that the timing of this technique is not prolonged over that of standard preparations.

Functional outcome in the neurosurgical patient and its impact on quality of life

Outcomes research has become an integral part of most clinical studies today. Extent of resection, increased median survival, and "time to progression" are no longer the only important end points in need of assessment. Identifying the long-term adverse effects of treatment has become increasingly important as patients try to resume previous activities and an independent lifestyle. The measurement of functional states and health-related quality of life issues are at the forefront of medicine and have become necessary measures of functional outcome following the treatment of a variety of medical and surgical disorders. In this article, we review the most recent studies on the functional outcome of patients undergoing neurological surgeries and its impact on quality of life.

Surgical site infection prevention: how we do it

BACKGROUND

Efforts to prevent surgical site infection (SSI) employ methods that are valid scientifically, but each institution and each surgeon also incorporates methods believed to be useful although this has not been proved by clinical trials.

METHODS

The surgical literature was reviewed, as were practices at the University of Virginia that the authors believe are of value for the prevention of SSI.

RESULTS

Preventive antibiotics are established measures. A case can be made for increasing the dose in patients with a large body mass, and antibiotics probably should be re-administered during procedures lasting longer than 3 h. Chlorhexidine showers for the patient are not proven; however, they are inexpensive and of potential benefit. Hair removal is always done with clippers and in the operating room at the time of the procedure. No scientific case can be made specifically for using antiseptic at the surgical site before the incision. Keeping the blood glucose concentration and the core body temperature near normal probably are important, but how close to normal is unclear. Transfusion enhances SSI, but leukocyte reduction of transfused blood may be of benefit. Some evidence supports the value of antibacterial suture in preventing SSI.

CONCLUSIONS

Many proven and potentially valid methods are employed to prevent SSI. Coordinated and standardized protocols with good data collection can assist the multi-disciplinary efforts to reduce SSI within the unique practices of a given institution.

Reuse of ventricular drain sites for cerebrospinal fluid shunting in patients with no prior infection

OBJECT

The safety of reusing ventricular drain sites for shunting CSF in patients with no history of infection involving either the ventricular drain or the CSF was the focus of this investigation.

METHODS

Prospectively accrued clinical data on all patients who, in an 8-year span ending in June 2008, underwent external ventricular drain placement and subsequently required CSF shunts were retrospectively evaluated for evidence of shunt infection and other complications.

RESULTS

The infection rate for 50 consecutive operations in 50 patients who met the inclusion criteria was 2.0%.

CONCLUSIONS

Data from this study support the position that the reuse of ventriculostomy tracts when implanting first-time CSF shunts is, with regard to the risk of infection, a safe practice and avoids all risks associated with making a new ventricular entry.

Pus and free bone flaps

OBJECT

The goal of this investigation is to describe the results of a vigorous attempt to preserve contaminated free bone flaps and avoid the problems associated with the traditional and common practice of discarding the flap, administering a course of antibiotics, and after several months, performing a cranioplasty.

METHODS

Patients with clearly contaminated, free cranial bone flaps, including so-called high risk cases, were treated by meticulous debridement of the surgical bed, scrubbing, soaking, and then replacing the bone flap in its normal position, and administering a course of intravenous antibiotics.

RESULTS

Fourteen patients with contaminated avascular cranial bone flaps were treated using this technique. All bone flaps were able to be preserved. Conclusions Patients with bacteriologically contaminated, free bone flaps can be treated successfully without discarding the flaps. Success is dependent upon aggressive surgical debridement and persistence.

Repercussões na auto-estima provocadas pela tricotomia em craniotomia

O objetivo do estudo foi avaliar a repercussão da tricotomia na autoestima do paciente no pós-operatório de craniotomia. Estudo quantitativo do tipo prospectivo. Os dados mostram que a maioria dos pacientes referiu não ter sua autoestima alterada em função da tricotomia; predomina a manutenção da autoestima entre os pacientes que receberam orientação sobre a tricotomia; a maioria fez uso de acessórios como estratégia para ocultar a área raspada, e acredita que a tricotomia não prejudica a qualidade de vida nem interfere nas relações sociais. Conclui-se que os sentimentos relacionados à diminuição da autoestima são a perda da atração, a insegurança e a vergonha; há a necessidade de uso de acessórios para melhorar a auto-imagem, e os profissionais da saúde devem trabalhar com os aspectos psicossociais dos pacientes no pré e pós-operatórios.

Cerebrospinal fluid shunt operations without cranial bandaging. Clinical article

OBJECT

Cranial bandages are commonly applied over scalp incisions immediately after cerebrospinal fluid (CSF) shunt surgery, putatively to prevent complications, particularly infection. These bandages require resources, consume the time of healthcare workers, and incur non-negligible expenses. It is therefore both reasonable and important to examine the efficacy of cranial bandaging.

METHODS

The combined experience of 3 neurosurgeons over 6.75 years with using no cranial bandaging after operations for implantation or revision of CSF shunts is the basis of this report. These data were prospectively accrued and retrospectively analyzed.

RESULTS

The infection rate was 4.2% (95% CI 3.1-5.6%) for 1064 operations performed without postoperative cranial bandaging after either shunt insertion or revision surgery through clean or clean-contaminated wounds. The age distribution extended from premature infants through adults 77 years of age.

CONCLUSIONS

The results of this investigation support the position that bandaging scalp wounds after CSF shunt implantation or revision surgery adds no benefit beyond the easier, simpler, faster, and cheaper practice of using antibiotic ointment as a dressing without bandaging.

Absorbable Intradermal Closure of Elective Craniotomy Wounds

Objective:

More and more commonly, craniotomies are being performed with minimal hair shaving to improve cosmesis and facilitate return to a normal life. In such patients, traditional sutures or metal staples are used for scalp closure. This practice requires suture removal, often perceived as a cause of discomfort by the patient. We investigate the safety and efficacy of intradermal sutures in a large, consecutive series of patients undergoing elective craniotomy.

Methods:

Wound healing complications were investigated in a consecutive series of 208 patients who underwent elective craniotomy during a 2-year period. In all patients, minimal shaving, performed by shaving a small strip of hair along the planned wound, was used. Scalp closure was achieved with only absorbable intradermal running sutures. All wounds were covered with sterile adhesive strips, which were kept in place for 24 hours postoperatively. Patients were followed for a mean follow-up period of 10.6 months (range, 1–23 mo).

Results:

All patients except two had satisfactory wound healing. One patient (0.48%) developed cerebrospinal fluid leakage, which responded to bed rest and lumbar drainage. Another patient (0.48%) had a superficial skin infection, which was successfully treated with topical wound care and oral antibiotics.

Conclusion:

The closure method described is safe and effective. The absence of visible sutures in the postoperative course reinforces the cosmetic advantage of no shaving and decreases discomfort associated with the removal of sutures or staples.

Does shaving the incision site increase the infection rate after spinal surgery?

STUDY DESIGN

A prospective randomized clinical study.

OBJECTIVE

To determine whether shaving the incision site before spinal surgery causes postsurgical infection.

SUMMARY OF BACKGROUND DATA

Spine surgeons usually shave the skin of the incision site immediately before surgery is performed. However, evidence from some surgical series suggests that presurgical shaving may increase the postsurgical infection rate. To our knowledge, no previously published studies have addressed this issue.

METHODS

A total of 789 patients scheduled to undergo spinal surgery were randomly allocated into 2 groups: those in whom the site of operation was shaved immediately before surgery (shaved group; 371 patients) and the patients in whom presurgical shaving was not performed (unshaved group; 418 patients). The mean duration of anesthesia and the infection rates in both groups were recorded and compared.

RESULTS

The duration of anesthesia did not differ in the 2 groups (P > 0.05). A postoperative infection developed in 4 patients in the shaved group and in 1 patient in the nonshaved group (P < 0.01).

CONCLUSIONS

The shaving of the incision site immediately before spinal surgery may increase the rate of postoperative infection.