Assessment of bone flap viability and sterility after long periods of preservation in the freezer

Cranioplasty following extended, decompressive craniectomy is a formidable challenge and its complexity increases with the size of the bone defect. Several techniques and methods are described for preservation and sterilization of craniectomy bone flap, each has its own advantage and disadvantages. In this report the authors describe a simple and cheap method for preservation of large craniectomy bone flaps. To evaluate the technique of preservation of large craniectomy bone flap in the freezer at -18°C for long periods of time, by microbiological and histological examination. This prospective study was carried out at King Khalid University Hospital, College of Medicine, King Saud University, during the period January 2001 to December 2008. Twenty-four patients had decompressive craniectomy for intractable brain oedema due to different pathology. A protocol was designed to prepare the removed bone flap for preservation in domestic freezer at -18°C. Microbiology swabs and histology specimen were taken from 14 bone flaps and sent for microbiological and histological examination to check both sterility and viability of the bone flaps after long periods of preservation. During the study period 24 decompressive craniectomy bone flaps were preserved, 15 of them were bifrontal decompressive craniectomy. Sixteen bone flaps were reapplied to their patients while 8 flaps were kept in freezer for long periods of time after expiry of donor patients. The dimensions of bone flaps ranged from 5 x 7 cm to 13 x 25 cm with a mean surface area of 228 cm[2]. Duration of preservation ranged from 60 - 1920 days, mean 313. Fourteen bone flaps were examined histologically and microbiologically, all of them showed no bacterial contamination and were viable, except one flap was not viable. Mature lamellar bone was seen in 5 specimens preserved for [60, 60, 90, 120 and 150 days], mostly viable bone was seen in 4 specimens preserved for [360, 390, 480 and 900 days], focal loss of bone was seen in 4 specimens kept for [390, 630, 720 and 780 days], and one specimen was kept in freezer 1920 days and showed no viable bone. The follow-up period after cranioplasty ranged from 5 months to 6 years, mean 11 months. One patient developed superficial wound infection which was treated with antibiotics and repeated dressings. Another patient developed partial resorption of the bone flap which was treated conservatively as spontaneous bone regrowth appeared a few months later. Preservation of bone flap in the freezer at -18°C is very simple, cheap and safe and is available in all hospitals. Bone flaps preserved using our technique remains viable and sterile for periods of up to 12 months

Spinal cord injury without radiological abnormality [SCIWORA]. A diagnosis that is missed in unconscious children

Spinal cord injury without radiographic abnormality [SCIWORA] usually occurs in the hypermobile, immature cervical spine of young children. In a comatose child, a normal spine x-ray, and CT scan exclude most cases of gross fracture and dislocation, but not SCIWORA. We present 2 children that sustained a polytrauma, which rendered each of them unconscious at the outset. In both, cervical spine x-ray excluded bony injuries, however, CT scan raised the suspicious of spinal cord injury in one, and MRI demonstrated significant cord injury in both. The first patient died from severe head and cervical spinal cord injury. The second patient recovered with mild Brown-Sequard syndrome. A high index of suspicious of SCIWORA is necessary in injured comatose children in whom movement of all limbs is not seen. Therefore, spine MRI should be considered if they are expected to remain ventilated for an unknown time

Bifrontal decompressive craniotomy for malignant brain edema

To review the outcome of bifrontal decompressive craniotomy used for the treatment of malignant brain edema due to different etiologies. The study was carried out at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia during the period from January 2000 to June 2005, and included all patients who had malignant brain edema due to different etiology and were treated with bifrontal decompressive craniotomy after failure of aggressive medical treatment. Ten patients were included in the study, 6 males and 4 females; the mean age was 24 years. Seven patients had severe head injury, 2 had aneurysmal subarachnoid hemorrhage, and one had large calcified olfactory groove meningioma. Clinically, all patients, except one, had Glasgow coma scores more than 3 before surgery, and operation was performed in all patients once clinical deterioration was observed and diagnosis confirmed by CT brain scan. The outcome of surgery was good in 70%, poor in 20%, and mortality was 10%. The mean hospital stay was 85 days. Bifrontal decompressive craniotomy offers immediate reduction of intracranial pressure to its normal levels, and improves the outcome of malignant brain edema whatever its cause, it should be performed once clinical deterioration is observed