Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA.
Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, MD, USA.
Neurosurg Rev. 2024 Feb 14;47(1):79. doi: 10.1007/s10143-024-02307-1.
Decompressive hemicraniectomy (DHC) is a critical procedure used to alleviate elevated intracranial pressure (ICP) in emergent situations. It is typically performed to create space for the swelling brain and to prevent dangerous and potentially fatal increases in ICP. DHC is indicated for pathologies ranging from MCA stroke to traumatic subarachnoid hemorrhage-essentially any cause of refractory brain swelling and elevated ICPs. Scalp incisions for opening and closing the soft tissues during DHC are crucial to achieve optimal outcomes by promoting proper wound healing and minimizing surgical site infections (SSIs). Though the reverse question mark (RQM) scalp incision has gained significant traction within neurosurgical practice, alternatives-including the retroauricular (RA) and Kempe incisions-have been proposed. As choice of technique can impact postoperative outcomes and complications, we sought to compare outcomes associated with different scalp incision techniques used during DHC. We queried three databases according to PRISMA guidelines in order to identify studies comparing outcomes between the RQM versus "alternative" scalp incision techniques for DHC. Our primary outcome of interest in the present study was postoperative wound infection rates according to scalp incision type. Secondary outcomes included estimated blood loss (EBL) and operative duration. We identified seven studies eligible for inclusion in the formal meta-analysis. The traditional RQM technique shortened operative times by 36.56 min, on average. Additionally, mean EBL was significantly lower when the RQM scalp incision was used. Postoperatively, there was no significant association between DHC incision type and mean intensive care unit (ICU) length of stay (LOS), nor was there a significant difference in predisposition to developing wound complications or infections between the RQM and retroauricular/Kempe incision cohorts. Superficial temporal artery (STA) preservation and reoperation rates were collected but could not be analyzed due to insufficient number of studies reporting these outcomes. Our meta-analysis suggests that there is no significant difference between scalp incision techniques as they relate to surgical site infection and wound complications. At present, it appears that outcomes following DHC can be improved by ensuring that the bone flap is large enough to enable sufficient cerebral expansion and decompression of the temporal lobe, the latter of which is of particular importance. Although previous studies have suggested that there are several advantages to performing alternative scalp incision techniques during DHC, the present study (which is to our knowledge the first to meta-analyze the literature on outcomes in DHC by scalp incision type) does not support these findings. As such, further investigations in the form of prospective trials with high statistical power are merited.
去骨瓣减压术（DHC）是一种用于紧急情况下降低颅内压（ICP）的关键手术。它通常用于为肿胀的大脑腾出空间，并防止 ICP 升高带来危险和潜在的致命后果。DHC 适用于从 MCA 中风到创伤性蛛网膜下腔出血等各种病理情况，基本上任何导致难治性脑肿胀和 ICP 升高的原因都适用。DHC 期间打开和关闭软组织的头皮切口对于实现最佳结果至关重要，它可以促进适当的伤口愈合并最大限度地减少手术部位感染（SSI）。尽管反向问号（RQM）头皮切口在神经外科实践中得到了广泛应用，但也提出了替代方法，包括耳后（RA）和 Kempe 切口。由于技术选择会影响术后结果和并发症，我们试图比较 DHC 期间使用不同头皮切口技术相关的结果。我们根据 PRISMA 指南查询了三个数据库，以确定比较 RQM 与“替代”头皮切口技术用于 DHC 的结果的研究。本研究的主要研究结果是根据头皮切口类型的术后伤口感染率。次要结果包括估计失血量（EBL）和手术时间。我们确定了七项符合正式荟萃分析标准的研究。传统的 RQM 技术可将手术时间平均缩短 36.56 分钟。此外，使用 RQM 头皮切口时 EBL 明显更低。术后，DHC 切口类型与 ICU 住院时间（LOS）之间没有显著关联，RQM 头皮切口组与耳后/Kempe 切口组之间发生伤口并发症或感染的倾向性也没有显著差异。收集了但由于报告这些结果的研究数量不足而无法进行分析的有浅颞动脉（STA）保留和再次手术率。我们的荟萃分析表明，在与手术部位感染和伤口并发症相关的情况下，头皮切口技术之间没有显著差异。目前，通过确保骨瓣足够大以实现大脑的充分扩张和颞叶减压，可以改善 DHC 后的结果，后者尤为重要。尽管之前的研究表明，在 DHC 期间进行替代头皮切口技术有几个优点，但本研究（据我们所知，是首次对 DHC 按头皮切口类型进行文献结果进行荟萃分析）不支持这些发现。因此，值得进行形式为具有高统计学效力的前瞻性试验的进一步调查。
