Scalp Reconstruction

A Review of the Literature and a Unique Case of Total Craniectomy in an Adult With Osteomyelitis of the Skull

John P. Tutela, MD; Jonathan C. Banta, BS; Travis G. Boyd, MD; Sean S. Kelishadi, MD; Saeed Chowdhry, MD; Jarrod A. Little, MD

Disclosures

ePlasty. 2014;14 

In This Article

Abstract and Introduction

Abstract

Objective: Osteomyelitis of the skull is a rare condition that can lead to systemic illness, bone loss, intracranial complications, and mortality. Osteomyelitis of the skull typically presents as the boney invasion of an overlying infection of the scalp or sinuses, and it is typically treated with antibiotics and proper wound care. Surgical debridement of the affected bone in the form of a craniectomy may be initiated to stop the progression of the infection when antibiotics fail and the underlying bone becomes grossly eroded.

Method: The authors present the case of a 54-year-old woman who required a total craniectomy after developing full-thickness osteomyelitis. A free omental flap along with dermal grafts and split-thickness skin grafts were utilized for soft tissue coverage. A semi-rigid helmet was used to provide durable protection to the brain.

Results: Omental free flap with skin graft coverage provided this patient with durable and long-term soft tissue coverage for a total craniectomy defect, as well as the ability to regain mental status.

Conclusions: Many factors must be analyzed when approaching composite defects of the scalp. Modality of treatment must be customized to the individual, and the decisions should be based on whether the defect is composed of soft tissue, bone or both, its size, etiology, and presence of a cerebral spinal fluid leak. The goals of treatment are restoration of durable soft tissue coverage, protection of vital underlying structures and control of cerebral spinal fluid leaks.

Introduction

Osteomyelitis of the skull is a rare but well-studied condition that can lead to systemic illness, bone loss, intracranial complications, and mortality. It usually presents as a chronic process that arises from an overlying infection of scalp. Osteomyelitis of the skull has also been documented as developing from pediatric tumors and specific infections such as aspergillus, cryptococcus, blastomycosis, mucormycosis, salmonella, mycobacterium, propionibacterium acnes, treponema pallidum, tuberculosis, varicella, and human immunodeficiency virus (HIV).[1,2] Furthermore, skull osteomyelitis has recently gained importance due to its association with immune-depressed states such as HIV, prolonged neutropenia in critically ill patients, drug-induced immune suppression in organ transplantation, and chemotherapy treatment for solid tumors.[1] Treating osteomyelitis of the skull has benefited from the use of antibiotics; however, the debridement of necrotic bone still remains a viable treatment should medicine fail. In such cases that warrant surgery, specific scalp reconstructive techniques, such as primary closure, skin grafts, tissue expansion, local and regional flaps, and free tissue transfer, exist to provide durable soft tissue coverage, protection of underlying structures, and control of cerebral spinal fluid leaks.[3]

The authors present the case of a 54-year-old woman who required a total craniectomy after developing full-thickness osteomyelitis of her entire cranium due to the progression of a scalp wound sustained less than 1 year prior. To the best of the authors' knowledge, this is the only case of skull osteomyelitis in the English literature that necessitated a total craniectomy. The success of this course of treatment sheds light on the extent of removal of necrotic bone that can be taken when treating widespread skull osteomyelitis in patients that fail conventional treatment with antibiotics.

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