Nonshaved cranial neurosurgery

Technical Note

Nonshaved Cranial Neurosurgery Sanguansin Ratanalert, M.D.,* Sakchai Saehaeng, M.D.,* Boonlert Sripairojkul, M.D.,* Kriengsak Liewchanpattana, M.D.,† and Nakornchai Phuenpathom, M.D.* *Department of Surgery, Neurosurgical Unit, and †Department of Community Medicine, Faculty of Medicine, Prince of Songkhla University, Thailand

Ratanalert S, Saehaeng S, Sripairojkul B, Liewchanpattana K, Phuenpathom N. Nonshaved cranial neurosurgery. Surg Neurol 1999;51:458 – 63. BACKGROUND

Preoperative shaving for cranial neurosurgical procedures is still recommended in textbooks. There are reports demonstrating the success of nonshaved surgery. The objective of this study was to compare the surgical infection rate of cranial neurosurgical procedures with two different scalp preparations: shaved or nonshaved. METHODS

Clinical trials of nonshaved scalp preparation were performed in non-emergency cranial neurosurgical procedures at Songklanagarind Hospital from August 1994 to December 1996. Patients were entered in the nonshaved group using the following exclusion criteria: immunocompromised host, presence of infectious diseases, surgery with foreign material insertion, multiple operations within 1 month, and presence of traumatic wound around the operative site. Patients who survived less than 1 month after surgery were excluded except in cases where death resulted from intracranial infection.

dures [6,12]. Shaving permits good orientation, freedom in the placement of the incision(s), and secure bandaging [9]. But shaving may add some psychological stress for the patients and its preventive effect on postoperative surgical infection has been questioned in many reports [1,4,5,19,20,23]. Clinical trials of nonshaved neurosurgery have been performed in many institutes and success has been reported in consecutive nonshaved surgical cases [4,17,23]. The aim of this study was to compare the rates of surgical infection of shaved and nonshaved cranial neurosurgery at one institute during the same period. The results of this study will demonstrate whether the technique of nonshaved cranial neurosurgery can be implemented in Thailand where facilities and environment differ from those of Western countries.

RESULTS

During the 29-month period, 225 of 1,244 cranial neurosurgical procedures were selected for study. Ages ranged from 4 to 86 years. Brain tumors were encountered in 57%. In the nonshaved group, there were 89 procedures (80 cases), compared with 136 procedures (123 cases) in the shaved group. Surgical infection rates were 3.37% and 5.88%, respectively (p . 0.05). CONCLUSIONS

Nonshaved scalp preparation is recommended for nonemergency cranial neurosurgical procedures. © 1999 by Elsevier Science Inc. KEY WORDS

Neurosurgery, cranial, infection, hair.

having the hair has been assumed since prehistoric times to be a procedure of cleanliness and purity [3,23]. It has been adopted as a compulsory preparation for cranial neurosurgical proce-

S

Address reprint requests to: Dr. Sanguansin Ratanalert, Department of Surgery, Faculty of Medicine, Prince of Songkhla University, Hat-Yai, 90112, Thailand. Received April 21, 1998; accepted June 1, 1998. 0090-3019/99/$–see front matter PII S0090-3019(98)00132-3

Materials and Methods A clinical trial of nonshaved cranial neurosurgery was performed at Songklanagarind Hospital, a 725bed university hospital and tertiary care center with a referral population of 7 million people. All non-emergency cranial neurosurgical procedures were included. Exclusion criteria were: immunocompromised host, presence of infectious diseases, surgery with foreign material insertion (shunt, ventriculostomy, ICP monitoring device, cranioplasty), multiple operations within 1 month, and presence of traumatic wound around the operative site. Patients who survived less than 1 month after surgery were excluded except in cases where death resulted from intracranial infection. Infections were diagnosed according to the Centers for Disease Control definition of nosocomial surgical site infection [11]. Because surgical infection may develop after discharge, our patients were followed until 6 months after surgery [13]. Patients in the service of Dr. R. S. who either came © 1999 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010

Nonshaved Cranial Neurosurgery

1

Conventional Shaved Neurosurgery

Technique

Surg Neurol 459 1999;51:458 –63

for

Cranial

Preoperatively shave with razor on the ward the morning of surgery or before patient is sent to the operating theatre. Scrub with povidone-iodine soap. Paint operative site with povidone iodine solution. Mark incision line and infiltrate with xylocaine. Drape operative site with cloth towels. Suture skin with nylon. Drain, when necessary, exits via a separate wound and remains less than 48 hours.

directly to the outpatient clinic or emergency room or were referred by other departments, were selected for the nonshaved group. Patients who refused the new nonshaved technique were shifted to the shaved group. Residents and the authors were actively involved in both techniques. Data from nonshaved cranial neurosurgery were compared with that of the conventional shaved technique (Table 1) under the same inclusion and exclusion criteria. Patients in both groups underwent surgery at Songklanagarind Hospital between August 1994 and December 1996.

tive field was draped and the edges of the cloth towels were fixed with towel clamps to the hair or skin. As a prophylactic antibiotic, patients received cloxacillin intravenously at the time of induction of anesthesia and for approximately 24 hours postoperatively. As the scalp was incised, digital compression through sterile gauze pads was maintained by assistants to control bleeding and to separate most of the hair from the incision. However, hair crossing the incision was cut. Loose hair falling in the operative field was removed. During closing, particular care was taken to avoid hairs being trapped in the surgical knots or surgical wound. Scalp edges were approximated with skin staples or nylon sutures. Elastic bands were removed and blood clots in the hair were irrigated with sterile normal saline solution. Povidone iodine solution was painted on the wound. Gauze and head bandages were used to cover the wound. Surgical drains, when used, exited via a separate stab wound and remained for 24 hours.

STATISTICS The incidence of surgical infection was compared according to age, gender, disease, scalp preparation, operation type, surgical duration, history of recent cranial surgery, postoperative radiation therapy, and preoperative length of hospital stay, using the Chi-squared analysis. Linear logistic regression equation using STATA V. 4 software was used to evaluate the risk associated with each factor when adjusted for other factors. TECHNIQUE FOR NONSHAVED SURGERY On the morning of the operation, the patients were instructed to wash their hair with a regular shampoo. For urgent cases, chlorhexidine soap solution was used because it is always available on wards. After anesthesia, the hair, if sufficiently long, was parted along the proposed incision line with a hemostat clamp and secured with elastic bands (Figure 1). The entire operative region was scrubbed gently for 5 minutes with chlorhexidine soap solution followed by painting with chlorhexidine solution. Xylocaine was infiltrated along the proposed incision line for hemostasis as well as anesthesia. The scalp was dried by pressing a surgical towel against the scrubbed area. For patients with short hair, the hair was held apart at the site of incision with a sterile hemostat clamp. The opera-

Hair was parted along the proposed incision line (dashed line) with a hemostat clamp and secured with elastic bands.

1

460 Surg Neurol 1999;51:458 –63

2

Ratanalert et al

Characteristics of Patients

Age (Mean 6 SD) Sex (F:M) Disease brain tumor AVM* aneurysm CSDH** miscellaneous Surgical procedure craniotomy craniectomy burr hole suboccipital craniectomy Surgical duration (minutes) (Median 6 Q.D.) Operation (first:second) Postop. radiation Preoperative admission day (Median 6 Q.D.) Surgical infection

SHAVED

NONSHAVED

P-VALUE

46 6 19 56:80

46 6 20 41:48

.0.05 .0.05

79 (58.1%) 7 (5.2%) 20 (14.7%) 18 (13.2%) 12 (8.8%)

50 (56.2%) 6 (6.7%) 8 (9%) 13 (14.6%) 12 (13.5%)

86 (63.2%) 5 (3.7%) 31 (22.8%) 14 (10.3%) 160 6 74

46 (51.7%) 5 (5.6%) 18 (20.2%) 20 (22.5%) 240 6 115

,0.05

123:13 41 5 6 3.5

80:9 19 664

.0.05 .0.05 .0.05

8

3

.0.05

.0.05

AVM, arteriovenous malformation; CSDH, chronic subdural haematoma.

Dressings were removed on the third postoperative day and the wounds were examined daily afterward. The hair was washed with regular shampoo at least once every other day by a nurse. After discharge from hospital, the patient was advised to shampoo at home without pressure on the operative site for at least 2 months.

Results In the 29-month period, there were 1,244 cranial neurosurgical procedures at Songklanagarind Hospital, and 203 patients with 225 cranial procedures were suitable for analysis. Ages ranged from 4 to 86 years. Male gender was predominent and brain tumors were the major disease in our study. Preoperative length of hospital stay ranged from 1–36 days with a median of 5 6 4 days. Lack of hospital facilities and human resources were the major factors responsible for these delays. Two patients were shifted from the nonshaved to the shaved group, one because she preferred to be shaved; the other was shaved on the ward in the early period of this study. There were 136 procedures (123 cases) in the shaved group compared with 89 procedures (80 cases) in the nonshaved group. Duration of nonshaved surgery was longer than in the shaved group (p , 0.05). These findings are summarized in Table 2. Surgical site infections, which occurred within 30 days after surgery, were observed in seven cases and caused one death from Gram-

negative bacilli meningitis. After discharge, additional infections were detected in four cases. All late infections were superficial surgical site infections; Staphylococcus aureus was the most common isolate pathogenic bacteria. Gram-negative bacteria were isolates in four specimens from in-hospital surgical site infections. The details of the 11 patients with infections are outlined in Table 3. The infection rate for shaved surgery was 5.88% compared with 3.37% for nonshaved (p . 0.05). Logistic regression analysis did not identify risk factors for surgical site infection (Table 4).

Discussion The effect of surgical site infections on morbidity, mortality, and economic loss is enormous. A national study on nosocomial infections in Thailand showed a prevalence rate of 11.7% [7]. (This was high in comparison with the international study by the World Health Organization [15].) Surgical site infections ranked second with a prevalence rate of 2.3%. The high temperature and high humidity in our country may play a contributory role in infections [7]. Regarding surgical preparation, guidelines for the prevention of surgical wound infections by the Hospital Infection Control group of Thailand suggest methods other than shaving [21]. However, most neurosurgeons prefer shaving the whole scalp. Some shave 1.5–2 cm beyond the margin of the

M M M 12 62 50 9 10 11

Characteristics of Group With or Without Surgical Infection

INFECTION

NO SURGICAL INFECTION

38 6 17.5 4:7

46 6 19 93:121

9 1 — — 1

120 12 28 31 23

6 1 1 3

126 9 48 31

250 6 75 3:8 9:2 4 562

183 6 85 86:128 194:20 56 564

SURGICAL *S1, Superficial incisional surgical site infection; #, time between surgery and the presence of infection; S2, meningitis; **GBM, Glioblastoma multiforme; 1, Preoperative hospital stay.

Salmonella gr.D S. aureus. No growth S1 S1 S1 360 150 300 9 5 2

shaved shaved shaved

Craniotomy Craniotomy Suboccipital craniectomy

90 100 180

S1 600 21 8

F

Frontoethmoidal meningoencephalocele AVM GBM** Vestibular schwannoma

9

nonshaved

Craniotomy

45

4

39 28 72 30 30 37 37

M M M F F F M

Pituitary adenoma Medulloblastoma Metastatic tumor Anaplastic astrocytoma Vestibular schwannoma Astrocytoma Grade III Meningioma

10 5 9 2 5 8 5

shaved shaved shaved shaved shaved nonshaved nonshaved

Craniotomy Suboccipital craniectomy Burr hole Craniotomy Suboccipital craniectomy Craniotomy Craniotomy

230 300 95 110 295 220 250

3 4 4 11 14 14 14

S2 S2 S1 S1 S2 S2 S1

Citrobacter spp. No growth S. aureas. S. aureas. Proteus mirabilis Corynebacterium spp. Acinetobacter spp & S. epidermidis S. aureas.

Surg Neurol 461 1999;51:458 –63

1 2 3 4 5 6 7

SEX

DIAGNOSIS

PREOP (DAY) PREPARATION CASE NO. AGE

3

Clinical Data of Patients Who had Surgical Site Infections

PROCEDURE

SURGICAL DURATION TIME INFECTION (MIN) (DAYS) TYPE

ORGANISM

Nonshaved Cranial Neurosurgery

Age (Mean 6 SD) Female:Male Disease brain tumor AVM* aneurysm CSDH** miscellaneous Surgical craniotomy craniectomy burr hole suboccipital craniectomy Surgical duration (minute) (Median 6 Q.D.) Nonshaved:shaved Operation (first:second) postop. radiation Preoperative admission day (Median 6 Q.D.)

AVM, Arteriovenous malformation; CSDH, Chronic subdural haematoma.

incision [18]. Shaving on the morning of surgery or a few minutes before surgery in the operating theatre were studied in our hospital and showed the same results in terms of scalp bacterial colonization and surgical site infection [22]. Since then, it has been our practice to shave patients on the ward a few hours before the operation. Though pathogenic bacteria can reside on hair, hair can be cleaned with mechanical and chemical cleansing procedures [3,23]. Preparation by shaving the operative site on the day before surgery has been found to increase the infection rate [19]. Abrasions made during the preparation may act as culture sites for bacteria and could be the cause of surgical infections [5,21]. Cruse and Foord reported on 62,939 prospectively studied surgical wounds and concluded that shaving the operative site increased the infection rate of clean wounds [5]. Winston reported his series of 638 consecutive cases supporting the notion that the scalp can be prepared safely for neurosurgical procedures without removing the hair [23]. Braun and Richter found no surgical site infection in their 57 cases of nonshaved cranial surgery [4]. Clinical trials at our hospital also confirmed the safety of nonshaved neurosurgery. Though the duration of nonshaved surgery was longer than that of shaved surgery, the infection rate was not statistically different between groups.

462 Surg Neurol 1999;51:458 –63

Our rate of total surgical site infection (4.89%) was higher than the attainable standard (1% or less) [10]. Several factors can account for this rate. First, our length of preoperative hospital stay was considerably longer than in western countries [16,2]. Patients may be susceptible to infection by virulent bacteria that colonize on the patient’s skin [5,21]. Second, as mentioned earlier, our climate is hot and humid. The study of Alexander et al, from Cincinnati, Ohio also found the highest infection rate in the summer [1]. The striking data were the higher rate of infection in shaved patients who had a shorter surgeries than nonshaved patients. We cannot deny the possibility of random contamination during surgery but particular concern for antiseptic techniques in nonshaved surgery may play a major role in this finding. The difference in antiseptic solutions may affect skin bacteria because chlorhexidine has excellent residual antimicrobial activity and is superior to iodophor for scalp preparation [14]. The hair itself may exert some protective effect by mechanically attracting bacteria before they enter the wound [23]. The ideal antimicrobial agent for neurosurgical prophylaxis has not been established [8]. We chose cloxacillin because of its low cost. The other reason is that the incidence of methicillin-resistant S. aureus infection or colonization in our hospital in 1996 was 0.02% (446/22,472 admitted patients), which was lower than other reports [13]. All of the Staphylococcus infections in this study were methicillinsensitive organisms. Though the selection method of our study was not actually randomized, there was no difference in the general profiles of patients between shaved or nonshaved groups except the surgical duration. Duration of nonshaved surgery was longer than shaved surgery and may be attributed to the difference in difficulty of intracranial lesion management. However, we accepted that nonshaved surgery required extra time for hair management during incision and wound closure. The length of time for preoperative shaving was replaced by the time spent on hair management before incision. Not shaving the scalp also decreased the work load for nurses. Depending on the length of incision, scalp closure may take 10 –30 minutes longer than with shaving [4]. This may be considered the price for a high quality postoperative course. Patients may return earlier to their professional and private lives without any psychological stress or changing of their image. In cases when postoperative radiation is needed, hair may cause some difficulty in preparing the patient’s head for spot radiation. Focal hair is usually lost during or after radiation but it is easy

Ratanalert et al

to cover by using the intact hair outside the radiated area.

Conclusion In an era of quality management for our patients, nonshaved cranial neurosurgery should be considered for selected patients. This technique may be used safely at hospitals in both well developed and developing countries. REFERENCES 1. Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. The influence of hair removal methods on wound infections. Arch Surg 1983;118:347–52. 2. Barber GR, Miransky J, Brown AE, Coit DG, Lewis FM, Thaler HT, Kiehn TE, Armstrong D. Direct observations of surgical wound infections at a comprehensive cancer center. Arch Surg 1995;130:1042–7. 3. Beck WC. Hair and asepsis and antisepsis. Surg Gynecol Obst 1986;163:479. (editorial). 4. Braun V, Richter HP. Shaving the hair—is it always necessary for cranial neurosurgical procedures? Acta Neurochir (Wien) 1995;135:84 – 6. 5. Cruse PJE, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980;60:27– 40. 6. Cushing H. Surgery of the head. In: Keen WW, ed. Surgery: its principles and practice. Philadelphia: WB Saunders, 1908:261. 7. Danchaivijitr S, Chokloikaew S. A national prevalence study on nosocomial infections 1988. J Med Assoc Thai 1989;72(Suppl.2):1– 6. 8. Gaskill SJ. Prophylactic antibiotics. In: Wilkins RH, Renchachary SS, eds. Neurosurgery, 2nd ed. New York: McGraw-Hill, 1996:547–52. 9. Goldhahn WE. Neurosurgical operations. Berlin: Springer-Verlag, 1984:118. 10. Haines SJ. Comment on investigations of the bacteriological factors in clean neurosurgical wounds. Neurosurgery 1994;34:417:421–2. 11. Horan T, Gaynes RP, Martone WJ, Jarvis WR, Emori G. CDC definitions of nosocomial surgical site infection. 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606 – 8. 12. Horsley V. Brain-surgery. Br. Med J 1886;2:670 –5. 13. Jerningan JA, Clemence MA, Stott GA, Titus MG, Alexander CH, Palumbo CM, Farr BM. Control of methicillin-resistant Staphylococcus aureus at a university hospital: one decade later. Infect Control Hosp Epidemiol 1995;16:686 –96. 14. Leclair JM, Winston KR, Sullivan BF, O’Connell JM, Harrington SM. Goldmann DA. Effect of preoperative shampoos with chlorhexidine or iodophor on emergence of resident scalp flora in neurosurgary. Infect Control Hosp Epidemiol 1988;9:8 –12. 15. Mayon-White Rt, Ducel G, Kereselidze T, Tikhomirov E. An international survey of the prevalence of hospital-acquired infection. J Hosp Infect 1988;S43– 8. 16. Medina-Cuadros M, Sillero-Arenas M, MantinezGallego G, Delgado-Redriguez M. Surgical wound in-

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fections diagnosed after discharge from hospital: epidemiologic differences with in-hospital infections. AJIC 1996;24:421– 8. Piatt JH, Steinbok P. Hair and neurosurgery. 1994;34: 770 (Letter) Rhoton AL Jr. General and Micro-Operative Technigues. In. Youmans JR. ed. Neurological surgery, 4th ed. Philadelphia: W.B. Saunders, 1996:724 – 66. Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg 1971;251– 4. Stern WE. Preoperative evaluation: complications,

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their prevention and treatment. In. Youman JR. Neurological surgery, 2nd ed. Philadelphia: W.B. Saunders, 1982:1051–116. 21. The Hospital Infection Control Group of Thailand. Guidelines for the prevention of surgical wound infection. J Med Assoc Thai 1989;72[Suppl 2]:76 –7. 22. Watanakitkrilert D, Singcharngchai P, Ratanalert S. The different time of preoperative scalp shaving: effect on bacterial colonization. J Songklanagarind Nursing 1991;11:20 – 8 [Thai] 23. Winston KR. Hair and neurosurgery. Neurosurgery 1992;31:320 –9.

Shepherd-Boy, who watched a flock of sheep near a village, brought out the villagers three or four times by crying out, “Wolf! Wolf!” and when his neighbors came to help him, he laughed at them for their pains. The Wolf, however, did truly come at last. The Shepherd-Boy, now really alarmed, shouted in an agony of terror, “Pray, do come and help me; the Wolf is killing the sheep.” But no one paid any heed to his cries, nor rendered any assistance. The Wolf, having no cause of fear, at his leisure destroyed the whole flock.

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“There is no believing a liar, even when he speaks the truth.” —Æsop’s Fables