Brain Surgery Information:

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CHAPTER 16: WOUND ISSUES

Wound healing is a very important aspect of surgery and postoperative recovery. It can be impaired by preexisting medical problems such as diabetes mellitus, poor nutrition, poor levels of activity, smoking, and chronic use of steroids or nonsteroidal anti-inflammatory medications such as ibuprofen and aspirin. Other things that can lead to wound problems include eyeglass frames continually rubbing over the incision or a patient scratching the incision. Conversely, a good balanced diet, regular walking, and multivitamins are likely to be of benefit. For eyeglass wearers undergoing frontotemporal craniotomy, it is recommend that a soft padded piece of gauze taped to the glasses’ frame be used as a buffer between the underlying incision and the plastic or metal frame near the ear. This padding should be worn till a few days after the sutures or staples are removed, that is, for a period of around two weeks. If soiled or damp, the padding should be changed as needed during this time.

Surgical wounds should be treated with respect. Many surgeons feel that showering is okay some time the day after surgery. The wound does not need to be covered during showering, however it is recommended that no direct shower spray be applied to the incision. It is acceptable for water to run over the incision. At the end of the shower, the incision should be gently dabbed dry, not rubbed or abraded. A patient should avoid shampooing the hair for the first 48 hours after surgery. Thereafter, a baby shampoo can be used everywhere except directly on the incision. Generally, one should not apply creams, oils or ointments to the incision. It is best to let the incision air dry. Some neurosurgeons recommend not to take a tub or spa bath or enter a swimming pool for the first 2-3 weeks after surgery, as dampness may breed infection. However, this recommendation varies between surgeons, so a patient should check with his or her surgeon first. A few days to a week after the staples or sutures have been removed, it is okay to commence normal showering, bathing and shampooing as long as the incision looks fine. It takes several weeks to a few months for the deep tissues to heal well. Any signs of wound infection, as detailed below, should be reported to the doctor at once. Sutures and staples come out somewhere between 10-12 days after surgery. If a subcuticular closure was carried out where no sutures were left on the skin surface but rather buried under the skin, then Steristrips, which are butterfly-like stickies, may have been applied to the skin surface instead. These need to come off after a shower by 7 days following surgery. Leaving these strips on longer than 7 days increases the buildup of grime and the chance of infection. Sometimes, a skin glue is used and this should dissolve within a few days of showering. Suture and staple removal can be carried out by the patient’s local nurse or doctor, or by the neurosurgeon or his or her assistant. Although there may be some gentle tugging, suture or staple removal is not painful and there is no injection. Some neurosurgeons recommend a period of 24 hours shower-free following suture or staple removal so the tiny holes can seal up.

There are a number of issues that may arise regarding the incision or the operative site. Each of these is worth considering one-by-one:

·  Wound infection: Despite the best efforts of neurosurgeons and OR personnel, and attempts to adhere to strict aseptic technique intraoperatively, approximately 1-2 in every 100 craniotomy patients get a wound infection. That is, there is a 1-2% infection rate. There is a 1% chance of wound infection at the groin puncture site for angiography or coiling. Many of these infections are superficial, and require only a brief course of oral antibiotic therapy. Others, however, are deep, and require reopening of the incision, cleansing of the infected tissue, debridement of the infected skin edges and, where applicable, possibly removal of the bone flap, which may need to be discarded. In such cases, which are rare, the bone flap may eventually be replaced months later with a synthetic bone substitute or a titanium mesh. This is known as a cranioplasty. Wound infections generally become obvious about 10-14 days after surgery. A small amount of redness and mild swelling near the incision itself is normal early after open surgery, however, this should have subsided by 5-6 days postoperatively. At 10-14 days after surgery, if the wound is getting more red, swollen or “boggy”, and tender, or if it begins to drain blood-stained fluid, these are signs that the patient needs to seek medical attention at once. Unexplained fevers associated with headache, nausea and vomiting, or neck stiffness or confusion are signs that a deep infection may be involving the brain or its coverings. Patients with suspected wound infections should be examined by their local doctor or neurosurgeon, and the appropriate action taken. The doctor can follow a patient’s healing from a wound infection clinically by bedside examination and certain blood tests and radiologically via a head CT scan. Most wound infections resolve with the appropriate management. Those few patients requiring bone flap removal generally have good outcomes after a cranioplasty is carried out to restore cosmetic and structural integrity in the operated region. During the time the bone flap is removed, no full-time helmet is required for most adults, rather, just general precautions against falls and head injuries once the patient returns home, awaiting future cranioplasty. The patient should avoid bike riding, roller blading, and contact sports during the period that the bone flap is removed, and for 2 months following cranioplasty, or as advised by the surgeon.

·  CSF leak: Leakage of clear tear-like fluid from an incision or other site following brain surgery is uncommon, but something that needs to be reported to the doctor should it occur. Other sites that CSF may leak from, depending on the site of surgery, include the ear, an event known as otorrhea, or the nose, an event known as rhinorrhea. CSF rhinorrhea may manifest as a continuous salty taste down the back of the throat, or tear-like fluid dripping like a tap from the nose. CSF leaks from incisions can be treated by oversewing the wound in the Office or ER under local anesthetic, with recheck in an outpatient setting. Alternatively, placement of a lumbar drain for a few days and a pressure head wrap with observation in a hospital in-patient setting may be recommended. It is very rare for a patient to require surgery specifically for a postoperative CSF leak, in this case exploration and revision of the wound, if there is no hydrocephalus causing the leak. Here, hydrocephalus causes an increase in pressure within the brain, and forces CSF out a path of least resistance, such as a fresh incision or a previous EVD site. If there is delayed hydrocephalus, which is uncommon but can occur in, say, ruptured aneurysm or brain tumor patients, shunt placement is usually recommended.

·  Swelling: It is normal to experience some swelling in the incision area following surgery. Sometimes the swelling is dramatic, and can even cause the eye on the same side of the surgery to be swollen shut for a few or several days. There may be bruising of the affected eye depending on the type of craniotomy, and this may persist for several weeks before subsiding. This is particularly common in OZ craniotomies. For swelling in the wound area, icepacks and walking around can be helpful. Except for patients undergoing OZ craniotomies in whom eye swelling is expected to last in the order of weeks, if swelling around the face and incision has not begun to subside by 3-5 days after neurosurgery, the patient should contact his or her doctor. Sometimes CSF or dissolving blood clot fluid can collect under the scalp, and usually this resolves by reabsorbing on its own after a few to several days. However, if the collection under the scalp enlarges, it may be a sign that the patient has some degree of hydrocephalus, especially in the case of a ruptured aneurysm or incompletely removed tumor. A CT scan of the head should be obtained. This may also rule out infection of the underlying deep scalp and skull bone as a cause of delayed swelling in a wound.

·  Cosmetic issues: The vast majority of craniotomy wounds heal very well, and are generally invisible as most lie behind the hairline. However, some craniotomies can be “complicated” by cosmetic issues. For example, there may be some loss of muscle bulk, referred to as atrophy, in the temporalis muscle. This is a chewing muscle at the side of the head in the “temple” or temporal region, just in front of and above the ear. The temporalis muscle is taken down, and at the end of the procedure reattached, during a frontotemporal or “pterional” craniotomy. Note that in a mini-OZ craniotomy, carried out by some neurosurgeons for certain lesions, there is only a minimal cut in the muscle, thereby making temporalis muscle atrophy less likely to occur. Another cosmetic issue may be that the bone flap may settle such that a ridge is seen or felt, or a titanium miniplate or screw head is felt. When weighing up survival from a significant brain disorder versus these cosmetic issues, patients and physicians alike tend to agree that these cosmetic nuisances are part and parcel of surgery.

·  Pain, numbness and dysesthesia: There will be pain after surgery, because tissues were incised in order to carry out the operation. For most patients, the pain is well controlled with IV medications early after surgery, converted to oral pain medications soon thereafter. By 2-4 days, the pain is substantially better for most patients, and almost resolved by 7-10 days. Pain medications are then weaned. The pain threshold for each patient varies, but by far the majority are pain free somewhere within 2 weeks. Persistent pain is uncommon and should be reported to the doctor. Many patients report some form of isolated numbness or a strange feeling referred to as “dysesthesia” around some part of the incision. This is likely due to cutting of small sensory nerves in the incision site. This tends to resolve in weeks to months, however at times it may persist. There is generally no treatment sought or offered for this, as again, weighing this against the serious nature of many brain conditions puts things in perspective for patients and doctors alike. Additionally, some patients report discomfort with chewing, or incomplete mouth opening. This is more commonly reported following a frontotemporal or full-OZ craniotomy in which the temporalis muscle is incised early in the operation. This generally resolves as the incision heals, but it may take several days to several weeks. PT for the jaw is recommended for those rare patients with significant or persistent symptoms. Finally, some patients undergoing a craniotomy report symptoms such as “fluid in the ear” or “ear fullness” or a “crackling sound”. These ear symptoms typically settle within days to weeks. If fluid is dripping from the ear, a patient should report this to his or her doctor.