Neurosurgical Review

, Volume 41, Issue 4, pp 1071–1077 | Cite as

Bone flap salvage in acute surgical site infection after craniotomy for tumor resection

  • David J. Wallace
  • Michael J. McGinity
  • John R. FloydII
Original Article


Craniotomy surgical site infections are an inherent risk and dreaded complication for the elective brain tumor patient. Sequelae can include delays in resumption in adjuvant treatments for multiple surgeries if staged cranioplasty is pursued. Here, the authors review their experience in operative debridement of surgical site infections with single-stage reimplantation of the salvaged craniotomy bone flap. A prospectively maintained database of a single surgeon’s neuro-oncology patients from 2009 to 2017 (JRF) was queried to identify 11 patients with surgical site infection after craniotomy for tumor resection. All patients underwent a protocol of aggressive operative debridement including drilling the bone edges and intraoperative flap sterilization with single-stage reimplantation, followed by tailored-antibiotic therapy. Ten of the 11 patients with frankly contaminated bone flaps from surgical site infection were able to be salvaged in a single-stage procedure. Five of these patients underwent adjuvant chemotherapy and/or radiation without secondary complication. There was one treatment failure in a delayed fashion which required additional surgery for craniectomy; however, this occurred after adjuvant treatment was administered. Surgical debridement and bone flap salvage is safe and cost-effective in managing acute surgical site infections after craniotomy for tumors. Additionally, this practice is likely beneficial in expediting the resumption of cancer therapy.


Craniotomy infection Bone flap Adjuvant therapy Pus 



The authors wish to extend their gratitude to the support staff who aid in patient care and coordination, including Veronica Toudouze, PA and Lacinda Evans, NP.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of human rights

Informed consent was obtained from all individual participants and/or surrogates included in this study. Additional informed consent was obtained from the patient whose de-identified intraoperative photographs are used in the figures.

Statement on the welfare of animals

This article does not contain any studies with animals performed by any of the authors.


  1. 1.
    Auguste KI, McDermott MW (2006) Salvage of infected craniotomy bone flaps with the wash-in, wash-out indwelling antibiotic irrigation system: technical note and case series of 12 patients. J Neurosurg 105(4):640–644. CrossRefPubMedGoogle Scholar
  2. 2.
    Baumeister S, Peek A, Friedman A, Levin LS, Marcus JR (2008) Management of postneurosurgical bone flap loss caused by infection. Plast Reconstr Surg 122(6):195e–208e. CrossRefPubMedGoogle Scholar
  3. 3.
    Bhaskar IP, Inglis TJJ, Lee GYF (2014) Clinical, radiological, and microbiological profile of patients with autogenous cranioplasty infections. World Neurosurg 82(3-4):e531–e534. CrossRefPubMedGoogle Scholar
  4. 4.
    Bruce JN, Bruce SS (2003) Preservation of bone flaps in patients with postcraniotomy infections. J Neurosurg 98(6):1203–1207. CrossRefPubMedGoogle Scholar
  5. 5.
    Chiang H, Steelman VM, Pottinger JM, Schlueter AJ, Diekema DJ, Greenlee JDW, Howard MA, Herwaldt LA (2011) Clinical significance of positive cranial bone flap cultures and associated risk of surgical site infection after craniotomies or craniectomies. J Neurosurg 114(6):1746–1754. CrossRefPubMedGoogle Scholar
  6. 6.
    Chou SN, Erickson DL (1976) Craniotomy infections. Clin Neurosurg 23(CN_suppl_1):357–362. CrossRefPubMedGoogle Scholar
  7. 7.
    Clark AJ, Butowski NA, Chang SM, Prados MD, Clarke J, Polley M-YC, Sughrue ME, McDermott MW, Parsa AT, Berger MS, Aghi MK (2011) Impact of bevacizumab chemotherapy on craniotomy wound healing. J Neurosurg 114(6):1609–1616. CrossRefPubMedGoogle Scholar
  8. 8.
    Delgado-López PD, Martín-Velasco V, Castilla-Díez JM, Galacho-Harriero AM, Rodríguez-Salazar A (2009) Preservation of bone flap after craniotomy infection. Neurocir Astur Spain 20(2):124–131. CrossRefGoogle Scholar
  9. 9.
    Denham JW, Hauer-Jensen M (2002) The radiotherapeutic injury—a complex “wound”. Radiother Oncol J Eur Soc Ther Radiol Oncol 63(2):129–145. CrossRefGoogle Scholar
  10. 10.
    Dormand E-L, Banwell PE, Goodacre TEE (2005) Radiotherapy and wound healing. Int Wound J 2(2):112–127. CrossRefPubMedGoogle Scholar
  11. 11.
    Erickson DL, Seljeskog EL, Chou SN (1974) Suction-irrigation treatment of craniotomy infections. Tech Note J Neurosurg 41(2):265–267. CrossRefGoogle Scholar
  12. 12.
    Goldmann DA, Weinstein RA, Wenzel RP, Tablan OC, Duma RJ, Gaynes RP, Schlosser J, Martone WJ (1996) Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals. A challenge to hospital leadership. JAMA 275(3):234–240. CrossRefPubMedGoogle Scholar
  13. 13.
    Gordon CR, Fisher M, Liauw J, Lina I, Puvanesarajah V, Susarla S, Coon A, Lim M, Quinones-Hinojosa A, Weingart J, Colby G, Olivi A, Huang J (2014) Multidisciplinary approach for improved outcomes in secondary cranial reconstruction: introducing the pericranial-onlay cranioplasty technique. Neurosurgery 10(Suppl 2):179–189; discussion 189-190. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Jankowitz BT, Kondziolka DS (2006) When the bone flap hits the floor. Neurosurgery 59(3):585–590; discussion 585-590. CrossRefPubMedGoogle Scholar
  15. 15.
    Josan VA, Sgouros S, Walsh AR, Dover MS, Nishikawa H, Hockley AD (2005) Cranioplasty in children. Childs Nerv Syst ChNS Off J Int Soc Pediatr Neurosurg 21(3):200–204. CrossRefGoogle Scholar
  16. 16.
    Korinek A-M, Golmard J-L, Elcheick A, Bismuth R, van Effenterre R, Coriat P, Puybasset L (2005) Risk factors for neurosurgical site infections after craniotomy: a critical reappraisal of antibiotic prophylaxis on 4,578 patients. Br J Neurosurg 19(2):155–162. CrossRefPubMedGoogle Scholar
  17. 17.
    Kshettry VR, Hardy S, Weil RJ, Angelov L, Barnett GH (2012) Immediate titanium cranioplasty after debridement and craniectomy for postcraniotomy surgical site infection. Neurosurgery 70:8–14; discussion 14-15. CrossRefPubMedGoogle Scholar
  18. 18.
    Larsson A, Engström M, Uusijärvi J, Kihlström L, Lind F, Mathiesen T (2002) Hyperbaric oxygen treatment of postoperative neurosurgical infections. Neurosurgery 50:287–295; discussion 295-296PubMedGoogle Scholar
  19. 19.
    Morton RP, Abecassis IJ, Hanson JF, Barber J, Nerva JD, Emerson SN, Ene CI, Chowdhary MM, Levitt MR, Ko AL, Dellit TH, Chesnut RM (2016) Predictors of infection after 754 cranioplasty operations and the value of intraoperative cultures for cryopreserved bone flaps. J Neurosurg 125(3):766–770. CrossRefPubMedGoogle Scholar
  20. 20.
    Morton RP, Josh Abecassis I, Hanson JF, Barber J, Nerva JD, Emerson SN, Ene CI, Chowdhary MM, Levitt MR, Ko AL, Dellit TH, Chesnut RM (2016) Predictors of infection after 754 cranioplasty operations and the value of intraoperative cultures for cryopreserved bone flaps. J Neurosurg 125(3):1–5. CrossRefGoogle Scholar
  21. 21.
    O’Keeffe AB, Lawrence T, Bojanic S (2012) Oxford craniotomy infections database: a cost analysis of craniotomy infection. Br J Neurosurg 26(2):265–269. CrossRefPubMedGoogle Scholar
  22. 22.
    Saran F, Chinot OL, Henriksson R, Mason W, Wick W, Cloughesy T, Dhar S, Pozzi E, Garcia J, Nishikawa R (2016) Bevacizumab, temozolomide, and radiotherapy for newly diagnosed glioblastoma: comprehensive safety results during and after first-line therapy. Neuro-Oncol 18(7):991–1001. CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Tibbs MK (1997) Wound healing following radiation therapy: a review. Radiother Oncol J Eur Soc Ther Radiol Oncol 42(2):99–106. CrossRefGoogle Scholar
  24. 24.
    Widdel L, Winston KR (2009) Pus and free bone flaps. J Neurosurg Pediatr 4(4):378–382. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • David J. Wallace
    • 1
  • Michael J. McGinity
    • 1
  • John R. FloydII
    • 1
  1. 1.Department on NeurosurgeryUniversity of Texas Health Science CenterSan AntonioUSA

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