In children, the repair of skull defects arising from decompressive craniectomy presents a unique set of challenges. Single-center studies have identified different risk factors for the common complications of cranioplasty resorption and infection. The goal of the present study was to determine the risk factors for bone resorption and infection after pediatric cranioplasty.
The authors conducted a multicenter retrospective case study that included all patients who underwent cranioplasty to correct a skull defect arising from a decompressive craniectomy at 13 centers between 2000 and 2011 and were less than 19 years old at the time of cranioplasty. Prior systematic review of the literature along with expert opinion guided the selection of variables to be collected. These included: indication for craniectomy; history of abusive head trauma; method of bone storage; method of bone fixation; use of drains; size of bone graft; presence of other implants, including ventriculoperitoneal (VP) shunt; presence of fluid collections; age at craniectomy; and time between craniectomy and cranioplasty.
A total of 359 patients met the inclusion criteria. The patients’ mean age was 8.4 years, and 51.5% were female. Thirty-eight cases (10.5%) were complicated by infection. In multivariate analysis, presence of a cranial implant (primarily VP shunt) (OR 2.41, 95% CI 1.17–4.98), presence of gastrostomy (OR 2.44, 95% CI 1.03–5.79), and ventilator dependence (OR 8.45, 95% CI 1.10–65.08) were significant risk factors for cranioplasty infection. No other variable was associated with infection.
Of the 240 patients who underwent a cranioplasty with bone graft, 21.7% showed bone resorption significant enough to warrant repeat surgical intervention. The most important predictor of cranioplasty bone resorption was age at the time of cranioplasty. For every month of increased age the risk of bone flap resorption decreased by 1% (OR 0.99, 95% CI 0.98–0.99, p < 0.001). Other risk factors for resorption in multivariate models were the use of external ventricular drains and lumbar shunts.
This is the largest study of pediatric cranioplasty outcomes performed to date. Analysis included variables found to be significant in previous retrospective reports. Presence of a cranial implant such as VP shunt is the most significant risk factor for cranioplasty infection, whereas younger age at cranioplasty is the dominant risk factor for bone resorption.
Correspondence Brandon G. Rocque: University of Alabama at Birmingham, Birmingham, AL. email@example.com.ACCOMPANYING EDITORIAL DOI: 10.3171/2018.4.PEDS18184.INCLUDE WHEN CITING Published online June 8, 2018; DOI: 10.3171/2018.3.PEDS17234.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
BowersCARiva-CambrinJHertzlerDAIIWalkerML: Risk factors and rates of bone flap resorption in pediatric patients after decompressive craniectomy for traumatic brain injury. J Neurosurg Pediatr11:526–5322013
BowersCA, Riva-CambrinJ, HertzlerDAII, WalkerML: Risk factors and rates of bone flap resorption in pediatric patients after decompressive craniectomy for traumatic brain injury. 11:526–532, 201310.3171/2013.1.PEDS1248323473303)| false
FrassanitoP, MassimiL, CaldarelliM, TamburriniG, Di RoccoC: Complications of delayed cranial repair after decompressive craniectomy in children less than 1 year old. 154:927–933, 201210.1007/s00701-011-1253-522198327)| false
GrantGAJolleyMEllenbogenRGRobertsTSGrussJRLoeserJD: Failure of autologous bone-assisted cranioplasty following decompressive craniectomy in children and adolescents. J Neurosurg100 (2 Suppl Pediatrics):163–1682004
GrantGA, JolleyM, EllenbogenRG, RobertsTS, GrussJR, LoeserJD: Failure of autologous bone-assisted cranioplasty following decompressive craniectomy in children and adolescents. 100 (2 Suppl Pediatrics):163–168, 200414758944)| false
InamasuJKuramaeTNakatsukasaM: Does difference in the storage method of bone flaps after decompressive craniectomy affect the incidence of surgical site infection after cranioplasty? Comparison between subcutaneous pocket and cryopreservation. J Trauma68:183–1872010
InamasuJ, KuramaeT, NakatsukasaM: Does difference in the storage method of bone flaps after decompressive craniectomy affect the incidence of surgical site infection after cranioplasty? Comparison between subcutaneous pocket and cryopreservation. 68:183–187, 20102006577310.1097/TA.0b013e3181c45384)| false
PosnickJC, GoldsteinJA, ArmstrongD, RutkaJT: Reconstruction of skull defects in children and adolescents by the use of fixed cranial bone grafts: long-term results. 32:785–791, 1993849285310.1227/00006123-199305000-00011)| false
YadlaS, CampbellPG, ChitaleR, MaltenfortMG, JabbourP, SharanAD: Effect of early surgery, material, and method of flap preservation on cranioplasty infections: a systematic review. 68:1124–1130, 20112124283010.1227/NEU.0b013e31820a5470)| false