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Immediate replacement of bone flap after craniotomy for empyema in children
Charlotte Dandurand1, Cristina Schaurich2, Mandeep Tamber2
1Division of Neurosurgery, Vancouver General Hospital, University of British Columbia, Vancouver, Canada. Charlotte.dandurand@alumni.ubc.ca.
Insights
Immediate bone flap replacement after pediatric craniotomy for intracranial infection is a reasonable surgical approach. This management strategy for epidural or subdural empyema avoids further surgeries and associated costs.
Area of Science:
- Neurosurgery
- Pediatric Infectious Diseases
Background:
- Management of the bone flap after pediatric craniotomy for intracranial infection lacks clear guidelines.
- Immediate bone flap replacement is a standard practice at a Canadian center.
Purpose of the Study:
- To review outcomes of immediate bone flap replacement in pediatric patients undergoing craniotomy for intracranial infection.
- To evaluate treatment failure and reoperation rates associated with this management strategy.
Main Methods:
- Retrospective study of pediatric patients (1982-2018) with epidural or subdural empyema.
- Inclusion criteria: craniotomy for empyema evacuation and minimum 3-month follow-up.
- Primary outcome: treatment failure (reoperation for infected bone flap or repeat drainage).
Main Results:
- Four out of 24 patients (17%) experienced treatment failure, requiring repeat surgery for empyema drainage.
- Mean time to reoperation was 13 days.
- No association found between patient factors (age, sex, location, osteomyelitis) and treatment failure.
Conclusions:
- Immediate bone flap replacement is a viable option for pediatric subdural or epidural empyema.
- This approach potentially reduces morbidity and healthcare costs by avoiding later reconstructive surgeries.
Purpose:
Optimal management of the bone flap after craniotomy for intracranial infection has not been well defined in the pediatric population. This study reviewed the outcomes of a single Canadian center where immediate replacement of the bone flap was standard practice.
Methods:
This is a retrospective study of all patients who underwent craniotomies for evacuation of epidural or subdural empyema at a single center from 1982 to 2018. Patients were identified using the prospective surgical database maintained by the Division of Pediatric Neurosurgery at BC Children's Hospital. Primary outcome was treatment failure, defined as reoperation at the site of initial surgery for removal of an infected bone flap or repeat drainage of empyema under the replaced bone flap. Secondary outcome was any reoperation for recurrent infection at any site.
Results:
Twenty-four patients met the inclusion criteria with a minimum of 3-month follow-up from the index intervention. Treatment failure occurred in four patients (17%), all of whom required repeat surgery for further drainage of pus underlying the bone flap. Mean time to repeat surgery was 13 days. Any reoperation for recurrent infection at any site occurred in three patients. Seven out of 24 patients required a second surgery to evacuate empyema (29.2%). Age, sex, epidural or subdural location, osteomyelitis, and bone flap wash were not associated with the primary outcome of treatment failure.
Conclusion:
Immediate replacement of the bone flap in the surgical management of pediatric subdural or epidural empyema is reasonable. Replacing the flap at the time of first surgery avoids the morbidity and costs of a subsequent reconstructive operation.
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