Migration of craniotomy flap: an unusual complication.
A Goel, K Dindorkar, K Desai, D Muzumdar
Department of Neurosurgery, King Edward Memorial VII Hospital, Mumbai, India., India
Department of Neurosurgery, King Edward Memorial VII Hospital, Mumbai, India.
An unusual complication following a craniotomy is reported. The free bone flap migrated over the adjacent bone four weeks following surgery and needed operative readjustment. The probable causes for such a complication are analysed and discussed.
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Goel A, Dindorkar K, Desai K, Muzumdar D. Migration of craniotomy flap: an unusual complication. J Postgrad Med 1997;43:17-8
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Goel A, Dindorkar K, Desai K, Muzumdar D. Migration of craniotomy flap: an unusual complication. J Postgrad Med [serial online] 1997 [cited 2022 Sep 28 ];43:17-8
Available from: https://www.jpgmonline.com/text.asp?1997/43/1/17/420
Migration of a craniotomy bone flap is an unusual complication and has not been reported earlier. The various methods used to immobilise the flap testify to the fear of such a complication. In the patient reported, the effects of gravity and improper fixation of the flap probably led to its migration.
A 4 ½ year-old child presented with a two month history of fever and headaches. Apart from bilateral gross papilloedema there was no other significant neurological finding. Computerised tomographic scan showed a large posterior parieto-occipital peripheral enhancing lesion with surrounding oedema strongly suggestive of a tuberculoma. A free posterior - parietal bone flap was raised under a linear incision. The dura was opened and a large intracerebral tuberculoma was excised subtotally. The deeper component close to the occipital horn was left behind. The scalp was sutured over a lax brain. The bone flap was merely placed in the space for it without anchoring into place. The scalp was sutured in two layers. Four weeks later the child was brought back with complaint of increasing crying when recumbent supine. Examination revealed that the bone flap had migrated inferiorly and was partially over-riding the adjacent occipital bone [Figure:1]-[Figure:2]. Pressure over the flap was painful. Repositioning by manipulation failed. The flap was then surgically repositioned and anchored into place with stitches. The symptoms then resolved.
By and large the present day neurosurgeon raises free bone flaps, as against earlier practice of raising osteoplastic bone flaps. The free bone flap is retained in place by the sloping bone edges, the use of anchoring pericranial sutures or direct sutures to the free bone flap. In addition the closely conforming scalp keeps the flap gently pressed into place. Since a subgaleal haematoma may encourage migration, a low pressure suction drain is used to obviate this possibility. In the presented case the free bone flap was not anchored into place as the already existing pre-operative oedema was expected to increase and result in raised intracranial pressure. It was hoped that the riding bone flap would aid in dissipating the pressure externally. Past usage of this ploy has not resulted in migration of the flap. The flap migrated in the patient probably because of the effect of gravity and absence of anchoring stitches.
In conclusion, the migration of a bone flap is a very unusual complication inspite of the absence of the anchoring sutures. To avoid such a complication it is suggested that the bone flap should be anchored into place with sutures. A ‘tenting’ scalp suture is also likely to aid towards this goal. A ‘C’ shaped scalp incision instead of a linear one as was used in this case could have helped in avoiding the extra dissection of the scalp layers.
Goel A: ‘Tenting’ stitches for the scalp. British Journal of Neurosurgery. 1992; 6:357-358.