- Email: [email protected]
Dhaga Technique for Tissue Plane Preservation after Decompressive Craniectomy: Comparison of New Technique with Institutional Standard
Accepted Manuscript The Dhaga Technique for Tissue plane preservation after decompressive craniectomy: Comparison of new technique with institutional standard Gohar Javed, MBBS, FCPS, Muhammad Babar Khan, MBBS, Syed Ijlal Ahmed, MBBS, Manzar Hussain, MBBS, FCPS PII:
S1878-8750(15)00477-5
DOI:
10.1016/j.wneu.2015.04.048
Reference:
WNEU 2873
To appear in:
World Neurosurgery
Received Date: 11 February 2015 Revised Date:
21 April 2015
Accepted Date: 22 April 2015
Please cite this article as: Javed G, Khan MB, Ahmed SI, Hussain M, The Dhaga Technique for Tissue plane preservation after decompressive craniectomy: Comparison of new technique with institutional standard, World Neurosurgery (2015), doi: 10.1016/j.wneu.2015.04.048. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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The Dhaga Technique for Tissue plane preservation after decompressive craniectomy: Comparison of new technique with institutional standard
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Gohar Javed MBBS, FCPS; Muhammad Babar Khan*, MBBS; Syed Ijlal Ahmed MBBS; Manzar Hussain MBBS, FCPS.
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Author affiliation: Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Stadium Road, Karachi, Pakistan. 74800
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1. Gohar Javed : [email protected] 2. Muhammad Babar Khan : [email protected] 3. Syed Ijlal Ahmed : [email protected] 4. Manzar Hussain: [email protected]
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Corresponding Author: Muhammad Babar Khan, MBBS. Section of Neurosurgery Department of Surgery Aga Khan University Hospital, Karachi, Pakistan. 74 800 Email: [email protected] Phone: 92-344-9855573
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Introduction:
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Decompressive craniectomy (DC) is a potentially lifesaving procedure indicated in the treatment of raised intracranial pressure (ICP) refractory to conservative management and is being widely used by neurosurgeons globally 2,4,5,8. Patients who survive the initial insult are offered a cranial reconstruction surgery after weeks or months to restore cerebral protection and enhance aesthetic appearance 2. At the time of cranioplasty, the temporalis muscle is firmly attached to the dural patch and intermixed with fibrotic tissue. The operating neurosurgeon thus feels considerable difficulty when dissecting the plane between the dura and the galea as well as between the dura and the temporalis muscle. This leads to increased surgical time and intraoperative blood loss. Injury to the dura can result in CSF fistula and injury to the underlying brain can lead to neurological deficits as well as the formation of hematoma. Moreover, extensive temporalis muscle damage and dural patch laceration affect the rehabilitation phase and result in localized pain, impaired chewing and aesthetic alteration 10.
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We have developed the ‘dhaga technique’ which aids in preserving the plane between the muscle and dura after DC and hence reduces the intraoperative time, blood loss and improves outcomes. Here we describe our technique and also compare the ‘dhaga technique’ with the generally accepted standard procedure.
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Methods:
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Study design and patient population: This study is a retrospective review of prospectively collected data for 133 patients from January 2010 to January 2014 who underwent DC and cranioplasty at our institution. 68 of these patients underwent cranioplasty using the techniques practiced by the other neurosurgeons of the institution and formed the control group while 65 underwent cranioplasty using the ‘dhaga technique’ practiced by the senior author of this study. The data of all these patients was collected on predesigned data collection forms. The patients were admitted either from the Emergency department (ED) or were initially seen as in-patient consults from the neurology service. The patients were discharged from our service when it was possible for them to be nursed at home or some other nursing facility. They were reviewed in outpatient clinics regularly where flap condition was assessed and the patients underwent CT scan to rule out any new pathology before being scheduled for cranioplasty. The patients were considered ready for cranioplasty when the skin flap had sunken below the bone margins of DC. All patients underwent cranioplasty using autologous bone stored in bone bank at 12-18 weeks post decompressive craniectomy. Outcome analysis was done after the six post operative months.
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Study Intervention “The Dhaga Technique”: The word ‘dhaga’ means thread in local language. The basic idea is to use threads of a material that is colored so that it can be differentiated from normal tissue at the time of cranioplasty, soft so that it can adjust itself over the uneven surface of bone and dura and not absorbable so that the threads remain intact till the time of cranioplasty. The “O” silk thread is perfect for this use.
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After doing the standard frontotemoporoparietal DC and securing hemostasis, we placed sheets of Surgicel® over the open dural flaps. Six silk threads were taken and cut to fit the craniectomy defect. They were placed over the Surgicel® in a radial fashion such that one end of the thread was under the temporalis muscle and the other end was near the edge of craniotomy (Figure 1A). The temporalis muscle was then laid down over the threads (Figure 1B). The wound was closed in 2 layers in standard fashion.
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At the time of cranioplasty, we simply identified the end of the black colored threads near the bony edge which was visible immediately after giving the skin incision (Figure 2). We then followed the threads to easily develop a plane between the dura and the galea and then between the temporalis muscle and the dura. After completing the exposure, we generally found it easy to gently pull the threads out. When this was not possible in rare cases, we left the threads in place as dissection to free the threads might cause damage to the dura and underlying brain. The technique used by the other surgeons was essentially the same procedure with the exception of use of “0” silk threads.
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Statistical Analysis:
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The variables used to compare both the techniques included complications, duration of surgery and intra operative blood loss during the cranioplasty procedure. The duration of surgery was defined as the time from skin incision to the time when the wound was closed. Blood loss was determined by subtracting the total irrigation fluid (saline) from the total draining fluid collected. Cottonoids and swabs used during the procedure were also used in the calculation of total blood loss. The data is presented as proportions for categorical variables and as mean ± standard deviation for continuous variables. Data were entered into and analyzed using IBM SPSS statistics for Windows version 20 (IBM, Armonk, NY). A Mann-Whitney test was used to compare the amount of intra operative blood loss and operating time and a Fisher’s exact test was used to check for any statistically significant difference in complications between both groups. A P value of less than 0.05 was taken to be statistically significant.
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Results: Of the initial 133 patients included in this study, complete data with follow up was available for 121 patients. Thus a total of 59 patients were included in the ‘Dhaga technique’ group and 62 in the ‘standard technique’ group. The mean age of all the patients was 32.1±15.9 years. There were 89 (73.5%) males and 32 (26.5%) female patients. The etiology of medically refractory rise in ICP included a traumatic etiology in 65.7 %, vascular including massive MCA infarction and hemorrhage in 31.1% and tumors in 3.2 % of the patients. The mean duration from craniectomy to cranioplasty was 3.7±0.6 months and the mean duration of follow up was 9.5± 2.8 months (Table 1). There were no statistically significant differences between the two cohorts with respect to age, gender, indications of surgery, side of surgery, GCS and interval between decompressive craniectomy and cranioplasty.
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Patients in the ‘dhaga technique’ group had statistically significant decreased operating time (P value= 0.037) and blood loss (P value=0.025). The overall complication rate in this study was 10.8 % with no statistically significant differences in complication rates between the two groups (Table 2).
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Discussion:
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The temporalis muscle partly atrophies and becomes firmly adherent to the underlying tissue after a few post operative weeks10. It becomes difficult to identify the cleavage plane at the time of cranioplasty and the operating neurosurgeon is forced to damage some muscle fibers or leave the temporal muscle adherent in the temporobasal dural patch area 10. Temporalis muscle damage can result in impaired chewing and suboptimal cosmetic outcome. The lack of emphasis on temporalis muscle preservation probably stems from the emergency situations in which DC is done. However, up to 40% of patients undergoing DC will have a good neurological outcome1,3,6. It is therefore very desirable to attempt to preserve temporalis muscle.
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There are only a few reports in literature on preserving the temporalis muscle during DC3. Kawaguchi et al reported placing expanded polytetrafluoroethylene (ePTFE) between the temporalis muscle and the duraplasty with a portion just beneath the skin incision for aiding visualization 7. Cranioplasty was performed 38-126 days after DC and no adhesions were found between ePTFE membrane and the surrounding tissue including the temporalis muscle. The authors did not report any complications and concluded that their technique avoided injury to the muscle, dura and underlying brain and reduced operating times and blood loss7. However, these results have not been replicated in other studies. Nakagawa et al retrospectively reviewed 83 consecutive patients who underwent DC with the same technique11. Fifty six of these patients survived and 8 (14.3%) patients developed serious infections raising questions on the utility of this technique. Lee et al placed a silicone elastomer sheet (SILASTIC® Sheeting, Medical Products Division, Dow Corning Corporation, USA) between the dura and galea as an adhesion preventing material in 24 patients and reported decreased operating time and blood loss in this group as opposed to the group of 26 patients who underwent DC without the placement of silicone sheet9. Missori et al described their technique of double dural patches to facilitate cranioplasty. They sewed a Tutoplast pericardial bovine patch (internal patch) to the dural margins and then laid a second patch on the internal patch and anchored it to the temporobasal dura. Cranioplasty was performed after a mean of 7 weeks and good results without any complications were reported in all 11 patients10. Oladunjoye et al presented their technique of multilayered on lay repair with a collagen based dural substitute (DuraGen® , Integra LifeSciences, USA) to provide water tight dural closure and a gelatin film barrier (Gelfilm®, Pfizer, USA) to prevent scarring and adhesion in 62 consecutive patients12. Their reported complications included infections in 4(6.5%) patients at the time of DC and 4(6.5%) patients at the time of cranioplasty, 8 (12.9%) patients developed extra axial fluid accumulation which resolved with conservative management, and 1 (1.6%) patient developed a subdural hematoma which was evacuated. With exception of Lee et al’s paper, these studies had small
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sample sizes or lacked a control group to definitively prove superiority of their techniques over the standard procedure. Moreover, using avascular materials for duraplasty and muscle preservation creates an avascular pocket with an increased risk of infection and abscess formation.
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In our experience with the dhaga technique, the presence of colored threads makes the dissection quick and easy. This is because the plane between the dura and muscle or galea is usually avascular and bleeding occurs when one leaves this plane and dissects towards the dura and brain or into the muscle or galea. As soon as the skin incision is given for cranioplasty, any one or more black colored silk threads are visible which can then be traced towards the temporalis and then underneath that muscle. We found a statistically significant reduction in operating time using the ‘dhaga technique’ in our patients. This is highly desirable as it not only reduces the costs associated with operating room but reduced time at cranioplasty may also be associated with a reduced risk of infections 13. Similarly, we found significant reduction in intraoperative blood loss thus avoiding need of any transfusion. Although the complications including wound dehiscence, hematomas and infections, were less common with ‘dhaga technique’, the difference was statistically not significant. Shorter operating time and less intra operative blood loss with comparable complication rate indicate the efficacy of this technique. Although the aesthetic results were not taken into account, we believe that with better preservation of the temporalis muscle, the aesthetic results are likely to be better. An advantage of the ‘dhaga technique’ over using two non autologous patches described previously is that dural vessels are in contact with the inner surface of the muscle enhancing muscle preservation and reducing the risk of infections. In addition, the cost of silk thread is much less as compared to the non autologous dural patches. Although processed biologic tissue of animal or human origin are frequently utilized and available in developed countries, there are significant issues with cost and maintaining constant supply in developing countries. The ‘dhaga technique’ is simple, cost effective and can be used globally especially in the developing countries. A possible limitation of this study is its retrospective nature. Moreover, we could not objectively compare aesthetic outcomes of the patients between the two techniques.
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Conclusion:
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The utilization of ‘dhaga technique’ can potentially improve outcomes and reduce costs by decreasing operative time and blood loss. Moreover, the temporalis muscle preservation in the dhaga technique may also enhance aesthetic outcomes and chewing which were not assessed in this study. There was no difference in complications between the two groups.
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Figure Legend:
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Figure 1: A, Intra operative photograph at the time of DC showing the Dhaga (O’ silk thread) arranged radially over the Surgicel® and underneath the temporalis muscle. B, Final relationship of thread to temporalis just before closure.
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Figure 2: Intra operative photograph at the time of cranioplasty showing the Dhaga (O’ silk thread) overlying the dura and heading beneath the temporalis muscle. The black silk thread can easily be visualized amidst blood and fibrotic tissue and a cleavage plane is easily established by following the Dhaga making dissection easier and less traumatic.
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References
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Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM: Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 104:469-479, 2006 Coulter IC, Pesic-Smith JD, Cato-Addison WB, Khan SA, Thompson D, Jenkins AJ, et al: Routine but risky: A multi-centre analysis of the outcomes of cranioplasty in the Northeast of England. Acta Neurochir (Wien):1-8, 2014 Di Rienzo A, Iacoangeli M, Alvaro L, Colasanti R, Nocchi N, Di Somma LG, et al: Autologous vascularized dural wrapping for temporalis muscle preservation and reconstruction after decompressive craniectomy: report of twenty-five cases. Neurol Med Chir (Tokyo) 53:590-595, 2013 Gooch MR, Gin GE, Kenning TJ, German JW: Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases. Neurosurgical focus 26:E9, 2009 Guresir E, Vatter H, Schuss P, Oszvald A, Raabe A, Seifert V, et al: Rapid closure technique in decompressive craniectomy. J Neurosurg 114:954-960, 2011 Honeybul S: Complications of decompressive craniectomy for head injury. J Clin Neurosci 17:430-435, 2010 Kawaguchi T, Hosoda K, Shibata Y, J K: Expanded polytetrafluoroethylene membrane for prevention of adhesions in patients undergoing external decompression and subsequent cranioplasty. Technical note. Neurol Med Chir (Tokyo) 43:320-323, 2003 Klinger DR, Madden C, Beshay J, White J, Gambrell K, Rickert K: Autologous and Acrylic Cranioplasty: A Review of 10 Years and 258 Cases. World Neurosurg, 2013 Lee CH, Cho DS, Jin SC, Kim SH, Park DB: Usefulness of silicone elastomer sheet as another option of adhesion preventive material during craniectomies. Clin Neurol Neurosurg 109:667671, 2007 Missori P, Polli FM, Peschillo S, D'Avella E, Paolini S, Miscusi M: Double dural patch in decompressive craniectomy to preserve the temporal muscle: technical note. Surg Neurol 70:437-439; discussion 439, 2008 Nakagawa S, Hayashi T, Anegawa S, Nakashima S, Shimokawa S, Furukawa Y: Postoperative infection after duraplasty with expanded polytetrafluoroethylene sheet. Neurol Med Chir (Tokyo) 43:120-124; discussion 124, 2003 Oladunjoye AO, Schrot RJ, Zwienenberg-Lee M, Muizelaar JP, Shahlaie K: Decompressive craniectomy using gelatin film and future bone flap replacement. J Neurosurg 118:776-782, 2013 Sundseth J, Sundseth A, Berg-Johnsen J, Sorteberg W, Lindegaard KF: Cranioplasty with autologous cryopreserved bone after decompressive craniectomy. Complications and risk factors for developing surgical site infection. Acta Neurochir (Wien) 156:805-811; discussion 811, 2014
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Dhaga Standard P value Technique Technique Age 32.3±16.1 31.9±15.8 0.53 Sex Male 42 47 0.69 Female 17 15 Indication Trauma 37 44 0.32 Vascular 19 16 Tumor 3 2 0.86 Type Unilateral 54 55 Bilateral 0 1 Bifrontal 5 6 GCS Decompressive 8.5±3.3 8.4±3.5 0.34 Craniectomy 0.41 Cranioplasty 14.2±0.5 14.4±0.4 Duration (from DC to 3.8±0.4 3.6±0.5 0.65 cranioplasty) Table 1: Baseline characteristics of patients in dhaga technique group in comparison to the institutional standard group.
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Dhaga Technique Standard technique P value Operating time (min) 127±27 145±30 0.037 Blood loss (ml) 163±45 185±49 0.025 Infections 4 5 0.456 Hematomas 1 2 0.531 Wound dehiscence 0 1 0.489 Table 2: Variables used to compare dhaga technique group with the institutional standard group.
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Highlights
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Decompressive craniectomy is a globally practiced lifesaving procedure indicated in the treatment of raised intracranial pressure refractory to conservative management. At cranioplasty, the temporalis muscle is firmly attached to the dural patch and intermixed with fibrotic tissue leading to considerable difficulty in dissecting the plane between the dura, galea and the temporalis muscle. We have developed the ‘dhaga technique’ which aids in preserving and delineating the plane between temporalis and dura at cranioplasty. This paper compares and analyzes the outcomes between patients who underwent cranioplasty using the ‘dhaga technique’ and those who underwent cranioplasty using the standard technique at our institution. Our analysis shows that patients in the ‘dhaga technique’ group had reduced operating times and intra-operative blood loss. We propose that the utilization of ‘dhaga technique’ can potentially improve outcomes and reduce costs by decreasing operative time and blood loss. Moreover, the temporalis muscle preservation in the dhaga technique may also enhance aesthetic outcomes and chewing.
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Abbreviations: (Arranged according to the order of appearance in text)
ICP: Intracranial pressure ED: Emergency department CT : Computed Tomography scan
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ePTFE : expanded polytetrafluoroethylene
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DC: Decompressive craniectomy
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Disclosure-Conflict of Interest
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Gohar Javed Muhammad Babar Khan Syed Ijlal Ahmed Manzar Hussain
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We hereby declare that none of the authors has any financial or otherwise conflict of interest to report.
S1878-8750(15)00477-5
DOI:
10.1016/j.wneu.2015.04.048
Reference:
WNEU 2873
To appear in:
World Neurosurgery
Received Date: 11 February 2015 Revised Date:
21 April 2015
Accepted Date: 22 April 2015
Please cite this article as: Javed G, Khan MB, Ahmed SI, Hussain M, The Dhaga Technique for Tissue plane preservation after decompressive craniectomy: Comparison of new technique with institutional standard, World Neurosurgery (2015), doi: 10.1016/j.wneu.2015.04.048. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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The Dhaga Technique for Tissue plane preservation after decompressive craniectomy: Comparison of new technique with institutional standard
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Gohar Javed MBBS, FCPS; Muhammad Babar Khan*, MBBS; Syed Ijlal Ahmed MBBS; Manzar Hussain MBBS, FCPS.
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Author affiliation: Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Stadium Road, Karachi, Pakistan. 74800
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1. Gohar Javed : [email protected] 2. Muhammad Babar Khan : [email protected] 3. Syed Ijlal Ahmed : [email protected] 4. Manzar Hussain: [email protected]
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Corresponding Author: Muhammad Babar Khan, MBBS. Section of Neurosurgery Department of Surgery Aga Khan University Hospital, Karachi, Pakistan. 74 800 Email: [email protected] Phone: 92-344-9855573
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Introduction:
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Decompressive craniectomy (DC) is a potentially lifesaving procedure indicated in the treatment of raised intracranial pressure (ICP) refractory to conservative management and is being widely used by neurosurgeons globally 2,4,5,8. Patients who survive the initial insult are offered a cranial reconstruction surgery after weeks or months to restore cerebral protection and enhance aesthetic appearance 2. At the time of cranioplasty, the temporalis muscle is firmly attached to the dural patch and intermixed with fibrotic tissue. The operating neurosurgeon thus feels considerable difficulty when dissecting the plane between the dura and the galea as well as between the dura and the temporalis muscle. This leads to increased surgical time and intraoperative blood loss. Injury to the dura can result in CSF fistula and injury to the underlying brain can lead to neurological deficits as well as the formation of hematoma. Moreover, extensive temporalis muscle damage and dural patch laceration affect the rehabilitation phase and result in localized pain, impaired chewing and aesthetic alteration 10.
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We have developed the ‘dhaga technique’ which aids in preserving the plane between the muscle and dura after DC and hence reduces the intraoperative time, blood loss and improves outcomes. Here we describe our technique and also compare the ‘dhaga technique’ with the generally accepted standard procedure.
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Methods:
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Study design and patient population: This study is a retrospective review of prospectively collected data for 133 patients from January 2010 to January 2014 who underwent DC and cranioplasty at our institution. 68 of these patients underwent cranioplasty using the techniques practiced by the other neurosurgeons of the institution and formed the control group while 65 underwent cranioplasty using the ‘dhaga technique’ practiced by the senior author of this study. The data of all these patients was collected on predesigned data collection forms. The patients were admitted either from the Emergency department (ED) or were initially seen as in-patient consults from the neurology service. The patients were discharged from our service when it was possible for them to be nursed at home or some other nursing facility. They were reviewed in outpatient clinics regularly where flap condition was assessed and the patients underwent CT scan to rule out any new pathology before being scheduled for cranioplasty. The patients were considered ready for cranioplasty when the skin flap had sunken below the bone margins of DC. All patients underwent cranioplasty using autologous bone stored in bone bank at 12-18 weeks post decompressive craniectomy. Outcome analysis was done after the six post operative months.
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Study Intervention “The Dhaga Technique”: The word ‘dhaga’ means thread in local language. The basic idea is to use threads of a material that is colored so that it can be differentiated from normal tissue at the time of cranioplasty, soft so that it can adjust itself over the uneven surface of bone and dura and not absorbable so that the threads remain intact till the time of cranioplasty. The “O” silk thread is perfect for this use.
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After doing the standard frontotemoporoparietal DC and securing hemostasis, we placed sheets of Surgicel® over the open dural flaps. Six silk threads were taken and cut to fit the craniectomy defect. They were placed over the Surgicel® in a radial fashion such that one end of the thread was under the temporalis muscle and the other end was near the edge of craniotomy (Figure 1A). The temporalis muscle was then laid down over the threads (Figure 1B). The wound was closed in 2 layers in standard fashion.
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At the time of cranioplasty, we simply identified the end of the black colored threads near the bony edge which was visible immediately after giving the skin incision (Figure 2). We then followed the threads to easily develop a plane between the dura and the galea and then between the temporalis muscle and the dura. After completing the exposure, we generally found it easy to gently pull the threads out. When this was not possible in rare cases, we left the threads in place as dissection to free the threads might cause damage to the dura and underlying brain. The technique used by the other surgeons was essentially the same procedure with the exception of use of “0” silk threads.
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Statistical Analysis:
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The variables used to compare both the techniques included complications, duration of surgery and intra operative blood loss during the cranioplasty procedure. The duration of surgery was defined as the time from skin incision to the time when the wound was closed. Blood loss was determined by subtracting the total irrigation fluid (saline) from the total draining fluid collected. Cottonoids and swabs used during the procedure were also used in the calculation of total blood loss. The data is presented as proportions for categorical variables and as mean ± standard deviation for continuous variables. Data were entered into and analyzed using IBM SPSS statistics for Windows version 20 (IBM, Armonk, NY). A Mann-Whitney test was used to compare the amount of intra operative blood loss and operating time and a Fisher’s exact test was used to check for any statistically significant difference in complications between both groups. A P value of less than 0.05 was taken to be statistically significant.
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Results: Of the initial 133 patients included in this study, complete data with follow up was available for 121 patients. Thus a total of 59 patients were included in the ‘Dhaga technique’ group and 62 in the ‘standard technique’ group. The mean age of all the patients was 32.1±15.9 years. There were 89 (73.5%) males and 32 (26.5%) female patients. The etiology of medically refractory rise in ICP included a traumatic etiology in 65.7 %, vascular including massive MCA infarction and hemorrhage in 31.1% and tumors in 3.2 % of the patients. The mean duration from craniectomy to cranioplasty was 3.7±0.6 months and the mean duration of follow up was 9.5± 2.8 months (Table 1). There were no statistically significant differences between the two cohorts with respect to age, gender, indications of surgery, side of surgery, GCS and interval between decompressive craniectomy and cranioplasty.
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Patients in the ‘dhaga technique’ group had statistically significant decreased operating time (P value= 0.037) and blood loss (P value=0.025). The overall complication rate in this study was 10.8 % with no statistically significant differences in complication rates between the two groups (Table 2).
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Discussion:
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The temporalis muscle partly atrophies and becomes firmly adherent to the underlying tissue after a few post operative weeks10. It becomes difficult to identify the cleavage plane at the time of cranioplasty and the operating neurosurgeon is forced to damage some muscle fibers or leave the temporal muscle adherent in the temporobasal dural patch area 10. Temporalis muscle damage can result in impaired chewing and suboptimal cosmetic outcome. The lack of emphasis on temporalis muscle preservation probably stems from the emergency situations in which DC is done. However, up to 40% of patients undergoing DC will have a good neurological outcome1,3,6. It is therefore very desirable to attempt to preserve temporalis muscle.
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There are only a few reports in literature on preserving the temporalis muscle during DC3. Kawaguchi et al reported placing expanded polytetrafluoroethylene (ePTFE) between the temporalis muscle and the duraplasty with a portion just beneath the skin incision for aiding visualization 7. Cranioplasty was performed 38-126 days after DC and no adhesions were found between ePTFE membrane and the surrounding tissue including the temporalis muscle. The authors did not report any complications and concluded that their technique avoided injury to the muscle, dura and underlying brain and reduced operating times and blood loss7. However, these results have not been replicated in other studies. Nakagawa et al retrospectively reviewed 83 consecutive patients who underwent DC with the same technique11. Fifty six of these patients survived and 8 (14.3%) patients developed serious infections raising questions on the utility of this technique. Lee et al placed a silicone elastomer sheet (SILASTIC® Sheeting, Medical Products Division, Dow Corning Corporation, USA) between the dura and galea as an adhesion preventing material in 24 patients and reported decreased operating time and blood loss in this group as opposed to the group of 26 patients who underwent DC without the placement of silicone sheet9. Missori et al described their technique of double dural patches to facilitate cranioplasty. They sewed a Tutoplast pericardial bovine patch (internal patch) to the dural margins and then laid a second patch on the internal patch and anchored it to the temporobasal dura. Cranioplasty was performed after a mean of 7 weeks and good results without any complications were reported in all 11 patients10. Oladunjoye et al presented their technique of multilayered on lay repair with a collagen based dural substitute (DuraGen® , Integra LifeSciences, USA) to provide water tight dural closure and a gelatin film barrier (Gelfilm®, Pfizer, USA) to prevent scarring and adhesion in 62 consecutive patients12. Their reported complications included infections in 4(6.5%) patients at the time of DC and 4(6.5%) patients at the time of cranioplasty, 8 (12.9%) patients developed extra axial fluid accumulation which resolved with conservative management, and 1 (1.6%) patient developed a subdural hematoma which was evacuated. With exception of Lee et al’s paper, these studies had small
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sample sizes or lacked a control group to definitively prove superiority of their techniques over the standard procedure. Moreover, using avascular materials for duraplasty and muscle preservation creates an avascular pocket with an increased risk of infection and abscess formation.
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In our experience with the dhaga technique, the presence of colored threads makes the dissection quick and easy. This is because the plane between the dura and muscle or galea is usually avascular and bleeding occurs when one leaves this plane and dissects towards the dura and brain or into the muscle or galea. As soon as the skin incision is given for cranioplasty, any one or more black colored silk threads are visible which can then be traced towards the temporalis and then underneath that muscle. We found a statistically significant reduction in operating time using the ‘dhaga technique’ in our patients. This is highly desirable as it not only reduces the costs associated with operating room but reduced time at cranioplasty may also be associated with a reduced risk of infections 13. Similarly, we found significant reduction in intraoperative blood loss thus avoiding need of any transfusion. Although the complications including wound dehiscence, hematomas and infections, were less common with ‘dhaga technique’, the difference was statistically not significant. Shorter operating time and less intra operative blood loss with comparable complication rate indicate the efficacy of this technique. Although the aesthetic results were not taken into account, we believe that with better preservation of the temporalis muscle, the aesthetic results are likely to be better. An advantage of the ‘dhaga technique’ over using two non autologous patches described previously is that dural vessels are in contact with the inner surface of the muscle enhancing muscle preservation and reducing the risk of infections. In addition, the cost of silk thread is much less as compared to the non autologous dural patches. Although processed biologic tissue of animal or human origin are frequently utilized and available in developed countries, there are significant issues with cost and maintaining constant supply in developing countries. The ‘dhaga technique’ is simple, cost effective and can be used globally especially in the developing countries. A possible limitation of this study is its retrospective nature. Moreover, we could not objectively compare aesthetic outcomes of the patients between the two techniques.
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Conclusion:
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The utilization of ‘dhaga technique’ can potentially improve outcomes and reduce costs by decreasing operative time and blood loss. Moreover, the temporalis muscle preservation in the dhaga technique may also enhance aesthetic outcomes and chewing which were not assessed in this study. There was no difference in complications between the two groups.
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Figure Legend:
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Figure 1: A, Intra operative photograph at the time of DC showing the Dhaga (O’ silk thread) arranged radially over the Surgicel® and underneath the temporalis muscle. B, Final relationship of thread to temporalis just before closure.
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Figure 2: Intra operative photograph at the time of cranioplasty showing the Dhaga (O’ silk thread) overlying the dura and heading beneath the temporalis muscle. The black silk thread can easily be visualized amidst blood and fibrotic tissue and a cleavage plane is easily established by following the Dhaga making dissection easier and less traumatic.
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References
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Dhaga Standard P value Technique Technique Age 32.3±16.1 31.9±15.8 0.53 Sex Male 42 47 0.69 Female 17 15 Indication Trauma 37 44 0.32 Vascular 19 16 Tumor 3 2 0.86 Type Unilateral 54 55 Bilateral 0 1 Bifrontal 5 6 GCS Decompressive 8.5±3.3 8.4±3.5 0.34 Craniectomy 0.41 Cranioplasty 14.2±0.5 14.4±0.4 Duration (from DC to 3.8±0.4 3.6±0.5 0.65 cranioplasty) Table 1: Baseline characteristics of patients in dhaga technique group in comparison to the institutional standard group.
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Dhaga Technique Standard technique P value Operating time (min) 127±27 145±30 0.037 Blood loss (ml) 163±45 185±49 0.025 Infections 4 5 0.456 Hematomas 1 2 0.531 Wound dehiscence 0 1 0.489 Table 2: Variables used to compare dhaga technique group with the institutional standard group.
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Highlights
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Decompressive craniectomy is a globally practiced lifesaving procedure indicated in the treatment of raised intracranial pressure refractory to conservative management. At cranioplasty, the temporalis muscle is firmly attached to the dural patch and intermixed with fibrotic tissue leading to considerable difficulty in dissecting the plane between the dura, galea and the temporalis muscle. We have developed the ‘dhaga technique’ which aids in preserving and delineating the plane between temporalis and dura at cranioplasty. This paper compares and analyzes the outcomes between patients who underwent cranioplasty using the ‘dhaga technique’ and those who underwent cranioplasty using the standard technique at our institution. Our analysis shows that patients in the ‘dhaga technique’ group had reduced operating times and intra-operative blood loss. We propose that the utilization of ‘dhaga technique’ can potentially improve outcomes and reduce costs by decreasing operative time and blood loss. Moreover, the temporalis muscle preservation in the dhaga technique may also enhance aesthetic outcomes and chewing.
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Abbreviations: (Arranged according to the order of appearance in text)
ICP: Intracranial pressure ED: Emergency department CT : Computed Tomography scan
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ePTFE : expanded polytetrafluoroethylene
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DC: Decompressive craniectomy
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Disclosure-Conflict of Interest
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Gohar Javed Muhammad Babar Khan Syed Ijlal Ahmed Manzar Hussain
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We hereby declare that none of the authors has any financial or otherwise conflict of interest to report.