title: Routine but risky: a multi-centre analysis of the outcomes of cranioplasty in the Northeast of England.
abstract: BACKGROUND
  Cranioplasty is undertaken as a routine secondary operation following craniectomy. At a time when decompressive craniectomy is being evaluated by several large trials, we aimed to evaluate the morbidity associated with cranioplasty and investigate its potential effect on outcome.
  
  
  METHODS
  The outcomes of 166 patients undergoing cranioplasty at two centres in the United Kingdom between June 2006 and September 2011 were retrospectively analysed. Outcome measures included mortality, morbidity and functional outcome determined by the modified Rankin score (mRS) at last follow-up. A logistic regression analysis was performed to model and predict determinants related to neurological outcome following cranioplasty.
  
  
  RESULTS
  Sixty-seven out of 166 patients (40.4 %) experienced at least one complication during a median follow-up time of 15 months (inter-quartile range 5-38 months). Thirty six patients (21.7 %) developed infection requiring antibiotics, with 27 (16.3 %) requiring removal of the cranioplasty. Nine of 25 patients (36 %) with bi-frontal defects developed an infection whereas 21 of the 153 patients (16.4 %) with a defect other than bi-frontal developed an infection (Chi square p = 0.009). Further surgery in the two groups was required in 16.4 % and 11.7, % respectively. Pseudomeningocoele (9 %), seizures (8.4 %) and poor cosmesis (7.2 %) were also commonly observed. Logistic regression analysis identified initial operation (p < 0.03), mRS at the time of cranioplasty (p < 0.0001) and complications (p < 0.04) as being predictive of neurological outcome at last follow-up. Age at the time of cranioplasty and the timing of cranioplasty were not predictive of last mRS score at follow-up.
  
  
  CONCLUSIONS
  Cranioplasty harbours significant morbidity, a risk that appears to be higher with a bifrontal defect. The complications experienced influence subsequent functional outcome. The timing of cranioplasty, early or late, after the initial operation does not impact on the ultimate outcome. These findings should be considered when making decisions relating to craniectomy and cranioplasty.
authors.affiliation: Department of Neurosurgery, James Cook University Hospital, Middlesbrough, TS4 3BW, UK, ian.coulter@doctors.org.uk.
authors.forename: Ian C
authors.initials: IC
authors.lastname: Coulter
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Pesic-Smith
authors.forename: William B
authors.initials: WB
authors.lastname: Cato-Addison
authors.forename: Shahid A
authors.initials: SA
authors.lastname: Khan
authors.forename: Daniel
authors.initials: D
authors.lastname: Thompson
authors.forename: Alistair J
authors.initials: AJ
authors.lastname: Jenkins
authors.forename: Roger D
authors.initials: RD
authors.lastname: Strachan
authors.forename: Nitin
authors.initials: N
authors.lastname: Mukerji
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D056424:Decompressive Craniectomy / Q000009:adverse effects* / Q000401:mortality / Q000706:statistics & numerical data; D004739:England / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007239:Infections / Q000188:drug therapy / Q000453:epidemiology / Q000401:mortality; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination; D011183:Postoperative Complications / Q000453:epidemiology / Q000401:mortality; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents