In decompressive craniectomy procedures it does not matter which way you do the duraplasty, or, does it? A study on an experimental model

The pathophysiology of malignant intracranial hypertension is a deleterious cycle of increased intracranial pressure, decreased tissue perfusion, declining intracellular energy production, increasing cellular edema, and subsequent increasing intracranial pressure. Decompressive craniectomy offers an effective treatment for intracranial hypertension that is refractory to standard medical treatment. There is no standardized technique suggested for durotomy and expansile duraplasty till date. We conducted this study on a model designed from locally available materials to objectively quantify the volume expansion achieved by the various durotomy and expansion duraplasty techniques. Amongst the more popularly used techniques for durotomy and duraplasty, the apparent volume expansion achieved appears to be maximum with a horse shoe shaped incision (43 ml) as opposed to a cruciate (30 ml) or a multipinnate (36 ml) incision. However, after correcting for the volume of the outpouchings, horse shoe shaped incision looses much of it's sheen (10 cm) lagging far behind the other two duraplasty techniques. Our study has proven the generally held view that there is not much to choose from between the cruciate and multipinnate durotomy techniques in performing expansile duraplasty. A horse shoe shaped durotomy on the other hand appears to be far less fruitful.