Autologous bone reconstruction as sandwich technique in pediatric posterior fossa surgery: finding a noble eightfold path for developing countries
Keywords:Stony Brook scar evaluation scale, Delayed dragging headache, Satisfaction score, Neo bone
Background: Sub-occipital craniotomy in pediatric population is difficult owing to uneven surface of growing calvaria and thin dura. Our novel technique using autologous bone chips and gelfoam bridges the two standard techniques. In this study, we intend to compare the surgical outcome in pediatric posterior fossa tumours.
Methods: We included patients, operated via midline sub-occipital approach, from January 2013 to October 2018 and grouped them, on basis of whether or not sandwich reconstruction was done. We compared pseudomeningocele, post-operative headache, CSF leakage and postoperative hydrocephalus requiring CSF diversion. The aesthetic outcome was assessed using Stony Brook scar evaluation scale (SBSES).
Results: 124 patients, divided into group A (n=53), group B (n=58) and group C (n=13) based on technique of surgical closure. The sandwich closure is significantly better in terms of both aesthesis and post-operative pain (p<0.05). There was a trend showing that sandwich closure decreases risk for pseudomeningocoele, wound infection, CSF leak and post-operative hydrocephalus. Median SBSES Score in group B was 4 compared to 2 in group A and patients were significantly more satisfied.
Conclusions: The uniform bone coverage with sandwich closure provides nearly similar reconstruction to craniotomy. All risks of using drill over pediatric calvaria are eliminated and advantages are carried. The bony barrier prevents adhesion and decreases both immediate and delayed headache. The technique is not only technically easier and aesthetically better, but also has better long term satisfactory results with possibility of neo-bone formation.
Kurpad SN, Cohen AR. Posterior fossa craniotomy: an alternative to craniectomy. Pediatr Neurosurg. 1999;31(1):54-7.
Hadanny A, Rozovski U, Nossek E, Shapira Y, Strauss I, Kanner AA, et al. Craniectomy Versus Craniotomy for Posterior Fossa Metastases: Complication Profile. World Neurosurg. 2016;89:193-8.
Gonzalez AC, Costa TF, Andrade ZA, Medrado AR. Wound healing - A literature review. An Bras Dermatol. 2016;91(5):614-20.
Yasargil MG, Fox JL. The microsurgical approach to acoustic neuromas. Surg Neurol. 1974;2:393-98.
Missori P, Rastelli E, Polli FM, Tarantino R, Rocchi G, Delfini R. Reconstruction of suboccipital craniectomy with autologous bone chips. Acta Neurochir (Wien). 2002;144:917-20.
Chowdhury FH, Goel A, Haque R, Islam S, Sarkar MH, Kawsar KA. Bony reconstruction by reposition of bony chips in suboccipital craniectomy. Neurol India. 2010;58(4):634-6.
Waqas M, Ujjan B, Hadi YB, Najmuddin F, Laghari AA, Khalid S, et al. Cranioplasty after Craniectomy in a Pediatric Population: Single-Center Experience from a Developing Country. Pediatr Neurosurg. 2017;52(2):77-9.
Grant GA, Jolley M, Ellenbogen RG, Roberts TS, Gruss JR, Loeser JD. Failure of autologous bone-assisted cranioplasty following decompressive craniectomy in children and adolescents. J Neurosurg. 2004;100:163-8.
Legnani FG, Saladino A, Casali C, Vetrano IG, Varisco M, Mattei L, et al. Craniotomy vs. craniectomy for posterior fossa tumors: a prospective study to evaluate complications after surgery. Acta Neurochir (Wien). 2013;155(12):2281-6.
Singer AJ, Arora B, Dagum A, Valentine S, Hollander JE. Development and validation of a novel scar evaluation scale. Plast Reconstr Surg. 2007;120(7):1892-7.
Gnanalingham KK, Lafuente J, Thompson D, Harkness W, Hayward R. Surgical procedures for posterior fossa tumors in children: does craniotomy lead to fewer complications than craniectomy? J Neurosurg. 2002;97:821–6.
Sheikh BY. Simple and safe method of cranial reconstruction after posterior fossa craniectomy. Surg Neurol. 2006;65:63-6.
Matsumoto K, Kohmura E, Kato A, Hayakawa T. Restoration of small bone defects at craniotomy using autologous bone dust and fibrin glue. Surg Neurol. 1998;50(4):344-6.