Repair of cranial defects

REPAIR OF CRANIAL DEFECTS* JEWETT V. REED, M.D. INDIANAPOLIS,

W

IND.

shouId be given the benefit of a pIastic repair. The two most generaIIy accepted operations are here reviewed in the hope of

ITH our increased knowIedge of the treatment of head injuries we are saving the Iives of an increasing

FIG. 2.

FIG. I. Patient

of skull showing

bone defect.

stimuIating a more frequent use of these procedures to rehabiIitate this cIass of patients. WhiIe these operations are often tedious and time-consuming, they can be performed by the genera1 surgeon. Moreover, they do not require specia1 instruments or equipment. The resuIts folIowing the repair of a crania1 defect are most gratifying, and I have yet to see a patient who, if not entireIy reIieved of his symptoms, was not at Ieast benefited to a marked degree. The most prominent symptoms compIained of by patients with a crania1 defect are headache and dizziness which becomes worse on physica exertion and with changes in barometric pressure. Some are greatIy annoyed by the constant sensation of puIsation at the site of the defect. If the defect is over a motor area there may be attacks of Jacksonian epiIepsy. Besides

on admission to Robert Long Hospital.

number of this type of patient. Many of these individuaIs, however, after recovering from their acute condition are doomed to a Iife of chronic invalidism or suffer various degrees of physica and menta1 impairment. To prevent or to combat these disabling sequeIIae foIIowing head injuries is one of our most important problems. One type of sequeIIa that may be very disabIing is the Ioss of a part of the cranium foIIowing a compound fracture of the skuI1. Many persons are struggIing under this handicap of a cranial defect who couId be easily reIieved by a craniopIastic operation. This operation is so safe, so easy to perform, and in most cases gives such satisfactory resuIts that every aduIt patient with such a defect * Submitted

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these physica symptoms there is generaIIy a justifiabIe degree of neurosis due to the Ioss of part of the bony protection of the

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brain. The patient is in constant fear of being struck over his soft spot, and he fears Ieaving the sheIter of his home. In the most stoIid individua1, feeIing the puIsations of one’s brain just beneath the scaIp wouId be at Ieast disquieting. The neurotic symptoms may be many and varied. In some patients the neurosis may show itseIf in the form of IocaI or generaIized convuIsive attacks but it is seIdom diffIcuIt to differentiate the neurotic from the Jacksonian type of convuIsion. The patient shown in Figures I to 4 had a fronta defect, yet his chief symptom was genera1 convuIsions. These were probabIy in the nature of a defense mechanism as the attacks ceased after the cIosure of the defect. Besides the symptoms and discomforts that may be compIained of, the patient may aIso suffer embarrassment from disfigurement when the defect Iies over the fronta or temporaT areas.

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The cIosure of a crania1 defect is indicated in an aduIt who shows either physica or neurotic symptoms attributabIe

FIG. 4. X-ray

FIG. 3. Patient on dismissal.

NOVEMBER,

of skuI1 on dismissal.

to this defect, who is a fair operative risk, and who is free from acute infections or other defects that might interfere with the norma repair of tissues. The craniopIasty must not be done unti1 the injury to the scaIp has entireIy heaIed. Discharging sinuses leading to pieces of necrotic bone caI1 for a postponement of the pIastic operation unti1 a11 dead and infected bone has been removed and the sinus heaIed. Even an area of granuIation tissue must be aIIowed to hea and become entireIy covered with heaIthy epitheIium. Operations for the cIosure of skuI1 defects are not onIy usefur in cases where bone has been Iost in compound fractures, but aIso in those cases in which portions of the skuI1 have been removed on account of disease or neopIasm. Defects of the skuI1 in chiIdren do not require operative repair as young patients spontaneousIy generate new bone to cover their defects in the course of three to six months. Most of this new bone probabIy comes from the pericranium but I have seen patients who have undergone com-

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pIete regeneration of new bone who had Iost a portion of their pericranium at the time of the injury. The tendency to spontaneous

FIG. 5. ScaIp flap turned back. Bone defect covered with pericranium exposed. Knife indicates point of incision in pericranium.*

repair generaIIy ceases with the sixteenth to seventeenth year of age. Of a11 the various types of craniopIastic operations devised there are onIy two that are of practica1 vaIue. In both of these operations a periostea1 bone graft is used to cover the defect. The first type devised by Frazier1r4 pIaces the graft with the bone next to the dura. This makes a very neat closure, but it has one weak point, that is the bone is adjacent to the dura which is comparatively avascuIar. In the second type, devised by BagIey2s3 the graft is reversed so that its bony portion Iies next to the under surface of the vascular scaIp. This second type does not Iend itseIf to so neat a cIosure, but for practica1 purposes it is very satisfactory. I have aIways preferred Frazier’s method, but in two cases there Iater occurred absorption in a part of the graft, foIIowed by a return of symptoms. A second operation was then performed after the method of BagIey which resulted in a soIid cIosure. * IIIustrations showing steps in operations were made from modeIs.

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RegardIess of the type of operation to be done, the first step is to dissect away any thin scar tissue that might be present over

FIG 6. P&cranium

elevated and defect prepared graft.

for

the defect. If this scar is thick and apparentIy vascuIar it may be Ieft as part of the scaIp flap, but when the scar is very thin and adherent to the dura it must be compIeteIy excised. It is often diffIcuIt to separate this epitheIized scar from the dura as pIanes of cIeavage are generaIIy obIiterated. The next step is to make incisions in the norma scaIp radiating from this denuded area in such a way as to expose the bone defect and at the same time pIan for the closure of the scaIp defect. These scaIp incisions wiI1 vary with individua1 cases. The chief point to be kept in mind is that the graft must be covered with vascuIar scaIp sutured without tension. In some cases in order to prevent this suture tension the scaIp wiI1 have to be incised simiIar to a sIiding graft Ieaving a denuded area of skuI1 in another region of the head. This denuded area can either at the same time or Iater be covered with a Thiersch or other form of skin graft. In case the scar tissue about the defect is vascuIar and not too thin to interfere with the viabiIity of the scaIp Aap a simpIe

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semi-eIIiptica1 incision may be used extending to the pericranium (Fig. 5). If the Frazier type of repair is to be done

Defects defect is then freshened and beveIed with a chiseI or gouge. The defect is now prepared to receive the graft.

FIG. 8. Suturing graft in pIace. FIG. 7.

Cutting pericrania1 bone graft.

the foIIowing steps are carried out: The scaIp is incised and reffected to expose the pericranium covering the defect. With the point of a knife an incision is made in the pericranium surrounding the defect, about g inch outside the edge of the bony defect (Fig. 5). With a smaI1 sharp periostea1 eIevator the inner edge of the periostea1 incision is separated from the edge of the bone as far as the inner surface of the skuI1. As a ruIe this can be done without tearing or opening the dura. If such an opening is accidentIy made no harm is IikeIy to occur. Some advocate opening the dura and expIoring the underIying brain but I see no reason for this unIess one suspects an underlying cyst, Ioose fragments of bone or foreign bodies. After the pericranium is compIeteIy separated from the edge of the bone defect, this redundant membrane is foIded in over the defect to heIp fii1 part of the dead space (Fig. 6). The outer edge of the cut pericranium is then eIevated just enough to aIIow the introduction of sutures. Next, the edge of the bone defect shouId be examined for rough pIaces or spicuIes extending towards the brain. These, if present, shouId be separated from the dura and removed with a rongeur. The outer edge of the bone

The periostea1 bone graft is best obtained from the parietaf region, but other areas of the skuI1 may be utiIized if the circumstances make this more practica1. If the defect is smaI1 the simpIest procedure may be to extend the origina scaIp incision and to obtain the graft adjacent to the defect. If the defect is Iarge it is generaIIy best to expose the parieta1 region of the opposite side, making a semicircuIar incision in the scaIp extending to the pericranium. To determine the size and shape of the graft a piece of thin sheet tin or Iead is used. This must be thin enough to be very pIiabIe. It is heId over the defect and pressed down so that an imprint of the edges of the defect are obtained. With scissors the meta is trimmed about ?& inch outside the imprint of the defect. This meta pattern is then firmIy heId against the exposed area of skuI1 from which the graft is to be taken, and with the point of a knife the pericranium is incised corresponding to the edge of the pattern. The pattern is then discarded. Through the circuIar incision in the pericranium a smaI1 chise1 is inserted and the skuI1 cut to the depth of about xc inch, in order to outIine the bony part of the graft on the bone. The next step is to use a sharp chise1 with a x inch cutting edge to obtain the bone

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portion of the graft. This chise1 is heId in a very obhque position and starting at one edge of the circuIar cut in the bone the

FIG. 9. Preparing

graft

in hinge

method.

chise1 is sIowIy and carefuIIy driven under the disc of pericranium, chipping ffakes of bone from the skuI1. These chips wiI1 vary in size and thickness. It is best to confine the bone chipping to the outer tabIe for if the chise1 penetrates the diploe it tends to go too deep and cuts chips too thick to be There is aIways a properIy mouIded. tendency for the chise1 to go too deep and as soon as this is noted it shouId be withdrawn, the handIe Iowered, and chipping on a higher IeveI resumed. If this chipping is properIy done the chips of bone wiI1 remain attached to the under surface of the pericranium (Fig. 7). As the cutting of the bone proceeds the graft tends to cur1 upward. After it is entireIy cut the graft can be mouIded between the thumb and fingers to give it its norma contour. The next step is to pIace the graft over the defect, the bone side next to the dura. The edge of the periosteum of the graft is then sutured to the edge of the pericranium about the defect by fine siIk, interrupted sutures (Fig. 8). The scaIp wound is then cIosed by two rows of interrupted sutures, deep and superficial. Fine bIack siIk is very satisfactory. No drainage is required. If there is persistent breeding from the skuI1 where the graft

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was removed, bone wax. The second

this

FIG.

hinge

IO. Suturing

289

can be controIIed

method

graft

by

of cIosure

is by

in place

defect.

over

means of a hinged graft. In this method the graft is cut from the area adjacent to the defect, the pericranium being Ieft uncut aIong the border where the edge of the graft and the defect meet (Fig. 9). The periostea1 bone graft is cut as in the first method Ieaving a hinge of periosteum on one side. The graft is then foIded over the defect, the bone chips being on the outer side. The pericranium of the graft is then sutured to the pericranium about the defect with interrupted siIk sutures (Fig. IO). The scaIp is then cIosed in the usua1 manner. In order to make a neat cIosure with the hinge graft it is necessary that one side of the defect be in the form of a straight edge, otherwise it wiI1 be impossibIe to obtain a perfect pericrania1 hinge. The first time I attempted this method was in a patient with a circuIar defect; who, after a craniopIasty by the first method, showed a partia1 absorption of bone in the graft with a return of symptoms. A second operation was made by the hinge graft and when compIeted Iooked far from neat; nevertheIess, the final resuIt was a firm closure with a disappearance of symptoms. Confronted again with a simiIar case of

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absorption of the graft I would dispense with the hinge, cut the graft completely free from the skull as in the first method,

FIG. I I. Case B. C. Anterior-posterior first admission.

view of defect on

Defects was an’-absorption of one side onIy of the graft. The edge of this secondary defect was almost straight which made it very easy to cut a long narrow strip of graft and turn it over the softened area. There is a marked similarity in the history, complaints, and postoperative course of patients suffering from cranial defects. The latter case, however, showed some unusual features that warrants its report in detail: CASE I. B. C., white, maIe, aged twentyone, was admitted to the Methodist HospitaI, Indianapohs, on May 30, 1928, compIaining of Ieft-sided epiIeptic fits and right-sided crania1 defect. The past history showed that five years before the boy was in a stone quarry accident when a Iarge stone crushed the right side of the skuI1. The treatment at that time was the remova of fragments of skuI1 through the scaIp wound foIIowed by cIosure of the scaIp. Aside from some weakness in the left hand and a certain amount of fear on account of the Iarge skull defect he considered himseIf recovered. Three years Iater he began to have twitchings in the Ieft hand which graduaIIy

FIG. I 2. Case B. C. Lateral view of defect on admission.

FIG. 13. Case B. C. Second admission showing partial absorption of graft.

and then suture the graft over the defect with the bone side out. In the case cited here the hinge graft

extended to the entire arm. This was soon foIIowed by a simiIar twitching in the Ieft Ieg and foot. The Ieft hand then became spastic and paraIyzed and he began to have typical Ieft-sided Jacksonian epiIepsy. These attacks

was of distinct advantage. In this case of the repair of a very large crania1 defect there

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gradualIy increased in frequency, and during the past three months before admission were occurring at intervals of fifteen to thirty minutes. He rareIy Iost consciousness during these attacks. The remaining personal history was unimportant, and the famiIy history was negative except that the mother was confined to bed with an active puImonary tubercuIosis. Examination showed a weII-nourished young man of apparentIy good inteIIigence. Over the right parieta1 area was the Iargest skuI1 defect that I had ever seen in a Iiving person (Figs. I I and 12). When the head was raised there was a very marked depression, and when the head was Iowered there was a marked buIging showing that the brain underwent considerabIe movement on changes in posture. Most of the scaIp over the defect was repIaced by very thin scar tissue. The patient suffered attacks of Jacksonian epiIepsy invoIving a11 of the Ieft side from the feet to the neck muscIes. These attacks occurred at intervaIs of about every fifteen minutes. AI1 drugs faiIed to modify these attacks to any noticeabIe degree. The Ieft Ieg was spastic but not paraIyzed. The Ieft hand was paraIyzed and heId in the typica “cIaw hand” position. Further examination was essentiaIIy negative. Operation: On June 6, a craniopIasty was performed after the method of Frazier. The graft was obtained from the opposite parietal region. With dificuIty the graft was cut in one piece. The operation consumed four hours and the cIosure was satisfactory. Subsequent History: The patient had one miId convuIsive attack the day foIIowing the operation. Th is was his Iast and onIy epiIeptic attack for two, and one-half years. The wounds heaIed per primam. He was discharged JuIy 6. He waIked out with a sIight Iimp due to the spastic Ieft Ieg. No improvement was noted in the left arm or hand. The crania1 defect was perfectIy solid to the touch. About one year later he reported that he was married and making his Iiving doing genera1 work on a farm. Second Admission: On December 13, 1930 he was admitted to the Robert Long HospitaI, IndianapoIis, compIaining of a sIight return of the Jacksonian attacks, and a softened area at the upper edge of the oId defect (Fig.

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13). Examination showed that there had been some absorption of the edge of the upper part of the graft about 35 inch wide through which puIsation couId be feIt. The remainder of the graft seemed perfectIy soIid. Operation consisted in exposing the softened area onI? and covering this with a hinged graft which seemed idea1 in this case. Wound healed per primam and a11 suggestion of epileptic attacks ceased. The patient was discharged four weeks after his admission apparently in good condition. WhiIe in the hospital he showed an eIevation of temperature of about one degree daily. Tuberculosis was suspected as he ‘had been exposed to this infection while Iiving with his mother who had recentIy died, but examination failed to demonstrate this condition. * Third Admission: February 15, 1931. Four weeks after his Iast dismissa he was re-admitted to the Robert Long HospitaI complaining of diarrhea and abdomina1 cramps. No history of epileptic attacks. Examination showed the crania1 defect firmIy closed. Genera1 examination showed a marked degree of diffuse acute puImonary tubercuIosis together with acute tubercuIous enteritis. He was discharged from the hospita1 March 9, 1931, unimproved. He died about six weeks Iater.

COMMENT: This case shows some interesting features. It is unusua1 to see such an extensive crania1 defect, and it shows that there is probabIy no defect too Iarge to attempt a cIosure. If a first attempt is not successfu1, repeated attempts wiI1 finaIIy produce a soIid skuI1. In the past twenty-five years I have made many attempts to reIieve patients with Jacksonian epiIepsy using a11 methods described. With the exception of sIight or temporary improvement a11 of these cases resuIted in faiIure. In the foregoing case, the stopping of the attacks foIIowing the stabiIizing of the brain within the skuI1 by cIosing the defect makes me fee1 that the cause of the attacks may be due more to the motions of the brain from this instability than to the adhesions between the brain and dura. [For References see p.293.1