gms | German Medical Science

Objective: Wound healing disorders and surgical site infection count up to the most frequently encountered complications after decompressive hemicraniectomy (DHC). Subgaleal CSF accumulations cause additional tension of the scalp flap and thereby increase risk for wound dehiscence, CSF fistula and infection. Lumbar CSF drainage might relieve subgaleal CSF accumulation and is often used when a CSF fistula through the surgical wound appears. The aim of this study was to investigate if an early lumbar drainage might reduce the rate of postoperative wound revisions after DHC.

Methods: The authors retrospectively analyzed 73 consecutive patients who underwent a DHC from 01/2019 to 05/2021. Before 01/2020, patients did not routinely receive a lumbar drain, whereas after 01/2020, we changed our clinical practice and applied an early postoperative lumbar drain after DHC. In the drainage group, patients received a lumbar drain within three days after DHC for a total 4 (2-5) days if the first postoperative CT scan confirmed open basal cisterns. The other group received conventional treatment. Primary endpoint was severe impairment of wound healing requiring surgical revision. Secondary endpoints were the rate of sugbaleal CSF accumulations and hygromas on postoperative CT scans as well as the rate of paradoxical herniation occurring in the drainage group.

Results: 34 patients with and 39 patients without lumbar drainage within the first three postoperative days were included. Predominant underlying pathology was malignant hemispheric stroke (58.8% vs 66.7%) followed by traumatic brain injury (20.6% vs. 23.1%). The rate of surgical wound revisions was significantly lower in the early drainage group (5 (14.7%) vs 14 (35.9%); p = 0.04). One patient was subject to paradoxical herniation, however, symptoms rapidly resolved after lumbar drainage was discontinued and he survived with only moderate deficits. Further, two patients in the drainage group required revision with evacuation of progressive subdural hygromas. In the drainage group, the rate of radiological herniation signs was not increased. Median ICU stay was similar with 12 days (IQR 9-23) in the drainage group compared to 13 days (IQR 11-23) in the control group (p = 0.21).

Conclusion: In patients after DHC and open basal cisterns in the postoperative CT scan, early lumbar drainage appears to be safe and might reduce the high rate of surgical wound revisions after DHC, while the risk for provoking paradoxical herniation is low early after surgery.