POSTOPERATIVE WOUND CARE
Postoperative wound care after a craniotomy or craniectomy has few specific rules to assessing wound healing and managing complications.
Uncomplicated wound care consists of simple management by dressing, drainage and stitch removal. We prefer not to change unnecessarily the undamaged or uncontaminated dressing unless a procedure such as drainage or stitch removal has to be done or a complication is suspected. Drainages from the epidural and subgaleal residual spaces of the wound are kept in place no more than 48 hours postoperatively; indeed, continuing discharge for a longer time is an urgent indication to the surgeon that he must decide either to keep the drainage a little longer or proceed to surgical revision and perfect haemostasis.
Within the normal range of tissue healing, skin suturing material can be removed 5 to 8 days after surgery. Even with apparently healed wound incision the presence of separating tension of the edges may require leaving the stitches up to the eighth day. Posterior fossa wounds are kept with stitches in longer due to the higher tension applied by neck muscles.
However we do not recommend keeping them more than 12 days, except under very special circumstances.
Wound complications require specific care depending on the complication. The most important of them is bleeding in the operative wound. Bleeding can occur in any of the residual cavities after surgery. The intracranial blood cloth acts as a space occupying lesion with acute brain compression. It is detected by clinical monitoring criteria and imaging studies and requires the utmost attention of the surgeon. If a cloth is producing deterioration in the neurological condition, increase in the intracranial pressure or is significant in size, it must be removed urgently by wound revision. The dura and all overlaying levels are once again closed with the same care as previously. Cloths located outside the bone flap and exerting tension on the flap and sutures must also be removed.
Wound infection affects different layers to a different extent. It can lead to the formation of an abscess, osteomyelitis or a fistulous path if it is limited extradurally, or to the more severe meningitis or subdural empyema. As the dura is the most important barrier to infection, intra-dural infection requires an immediate decision on the plan of treatment, which may contain surgical procedures in emergency. General measures focus on massive cover with systemic antibiotic treatment. Antibiotic treatment is nonspecific at the beginning, but after results of culturing specimens from the infected area - pus, necrotic tissue, and antibiograms are obtained it may be changed to treat the isolated microorganismс specifically. Empyemas and abscesses are evacuated urgently, the cavities washed with antibiotic solutions suitable for intracranial (intrathecal) application, and then drained. Epidural and subdural collections are also evacuated and drained, and any bone affected by osteomyelitis removed. All suturing material and foreign bodies should be also removed from the wound. A fistula persisting more than 2-3 weeks, despite local and systemic treatment indicates some underlying cause - infected necrotic parts, suturing or plastic materials, or sequestrated osteomyelitic bone. The infected nidus can then only be identified and removed through a thorough surgical revision.
CSF leak can be observed at different stages of wound healing. The most common cause is the gapping dura, usually associated with a certain degree of increase in CSF pressure. Dural closure, even with a graft, is the best preventive measure against a leak. A persisting CSF fistula after the complete healing of the wound much reduces its chances of spontaneous closure, and it must be closed surgically. The surgical revision of the wound is undertaken to identify the dural defect and perform its most thorough and watertight closure. Before decision for surgery is taken, closure of the fistula by stitching and lumbar drainage can be attempted. A decision on surgical closure should not be delayed more than 2-3 weeks because of the risk of meningitis. However, if the fistula is already associated with meningitis, closure should be postponed until the complete resolution of the intrathecal inflammation (and CSF hypersecretion) is achieved.
Subgaleal fluid collections can be observed during wound healing, but there is an established policy always to avoid unnecessary punctures and evacuations due to the risk of subsequent abscesses formation or meningitis (if the collection is CSF). Follow-up has demonstrated reabsorption in a high percentage of such cases without any specific measures.
Necrosis and poor healing are treated cautiously, sparing as much vital tissue as possible from the wound. Necrotic parts are excised to facilitate resuture or granulation formation.
Resuturing is undertaken only after complete control of secondary infection. Some graftings and flap rotations have improved the results of secondary treatment of complicated wounds.
Postoperative radiotherapy is delayed until a complete control of wound complications is established.