Michael A. Horgan M.D., Jennifer C. Kernan, M.D., Mark S. Schwartz, M.D., Jordi X. Kellogg, M.D., Sean 0. McMenomey, M.D., and Johnny B. Delashaw, Jr., M.D. Shaveless Brain Surgery: Safe, Well Tolerated, and Cost Effective Attempts at decreasing surgical wound infection rates include the use of preoperative antibiotics,1-4comparisons of different surgical preparation solutions,56 meticulous surgical technique,7 as well as shaveless skin preparations. 1'8 Evidence supporting decreased wound infection rates after careful skin preparation without shaving7'9-"1 is rampant in the general surgical literature. It has become quite evident that shaving the skin the day prior to surgery yields greater rates of infection.912 Clipping and shaving on the day of surgery also tends to increase wound infections, although not as much.9'2.'3 Many plastic surgeons, as well as general surgeons have abandoned the practice all together.'3'14 Neurosurgeons perform operations every day, many of which involve the scalp. For a variety of understandable reasons, we have been reluctant to abandon a practice so steeped in tradition. For reasons of convenience as well as fear of infection, hair has been clipped and shaved in a ritual that dates back to the days of Cushing.' It is probably safe to say that the majority of modem neurosurgeons continue to participate in shaving the hirsute scalp. For those being operated upon, however, this is often a traumatic experience that will never be forgotten. We and others have provided evidence regarding unshaven preoperative cranial preparations that is in agreement with the general surgeons' findings.' 8.'5 Additionally, our recently published retrospective review suggested that the timing of cerebrospinal fluid (CSF) shunt operations involving shaven versus unshaven preparations are not significantly different.8 Unfortunately, multiple variables were not accounted for, given the retrospective nature of the review. Having convinced ourselves that infection rates are at least similar between groups, our aim now is to determine prospectively if there is a difference in actual timing of skin preparation and closure between unshaven and shaven scalps. Given the current economic climate in medicine, we need to remain cognizant of these variables as well. Skull Base Surgery, Volume 9, Number 4, 1999. Oregon Health Sciences University, Department of Neurosurgery, Portland, Oregon. Reprint requests: Dr. Horgan, Barrow Neurosurgical Associates, Ltd., Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 2910 North Third Ave., Phoenix, AZ 85013-4473. Copyright 1999 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1 (212) 760-0888x132. 1052-1453/1999/E1098-9072(1999)09:04:0253-0258:SBS00161X 253
SKULL BASE SURGERY/VOLUME 9, NUMBER 4 1999 METHODS In January of 1997, the senior authors ceased shaving the scalp for most intracranial procedures. A reproducible ritual of shaveless preparation was instituted based upon a description by Winston with a revision by Piatt.1,8 Operations involving scalp incisions for tumor or vascular anomalies were reviewed and superficial and deep infections were noted. Follow-up was defined as the date at which time the patient was last seen by the senior author or colleague. Later in the year, 20 consecutive patients with standard incisions including but not limited to pterional, 3/4 coronal, coronal and retromastoid, were assigned to either shave (group A) or shaveless (group B) preparations in a randomized fashion. The length of hair and incision length were noted. The timing of scalp preparation and two-layer skin closure was recorded for both groups as were infectious complications. Differences between group means were assessed using the Student's t-test. Length of hair and incision length were controlled for. Infections were defined as superficial or deep and deemed to be the consequence of a preventable or potentially preventable error of neuro surgical technique or judgement. TECHNIQUE Following undiluted 4% chlorhexidine (Hibiclens; Baxter Health Care, Dearfield, IL) shampoo the morning of operation, the patient's scalp, hair, and operative site is vigorously washed with an iodophor detergent scrub solution (E-Z scrub) by the operating surgeon (Fig. 1). The hair is then parted along the anticipated surgical incision with a sterile comb (Fig. 2). Betadine paint is then generously applied with a sponge, preserving the part (Fig. 3). The incision site is marked with a skin scribe (Fig. 4). After placement of sterile disposable drapes, an iodineimpregnanted, self-adhesive sheet is laid down. Staples are then placed along both edges of the proposed scalp incision, helping to prevent uninvited hair from entering the surgical site (Fig. 5). All wounds are closed with interrupted vicryl in the deeper layers followed by fast absorbing 4-0 vicryl for skin approximation (Fig 6). The wound in then lined with bacitracin ointment every 8 hr for 2 consecutive days. A head wrap is never applied. Figure 1. Following undiluted 4% chlorhexidine (Hibiclens) shampoo the morning of operation, the patient's scalp, hair, and operative site is vigorously washed with an iodophor detergent scrub solution (E-Z scrub) by the operat- 254 ing surgeon.
SHAVELESS BRAIN SURGERY-HORGAN ETAL Figure 2. The hair is then parted along the anticipated surgical incision with a sterile comb. Figure 3. Betadine paint is then generously applied with a sponge, preserving the part. 255
, 111 11 _ r a. } ~~~~~~~~~~~~~~~~~~~. liiif....... 11 SKULL BASE SURGERY/VOLUME 9, NUMBER 4 1999 Figure 4. The incision site is marked with a skin scribe. a... -... Stpesae hn lce logbohede o hepopsd clpiciin helping toxpreen uninviteed har...nern 256~~~~ th.ez' sit. surgca...sp..fie.p-,
SHAVELESS BRAIN SURGERY-HORGAN ET AL RESU LTS Prior to randomization, 45 patients were operated on with shaveless technique beginning in May of 1997. These patients were chosen randomly based on surgeon preference. Operations for CSF shunt revisions were not included among these patients based on an as yet unsubstantiated view that infection risk would be higher in a field with hair and a foreign body. No infections were identified in this preliminary group of patients after a mean follow-up of over 6 months. The scope of the second portion of the study encompassed 20 consecutive operations by the senior surgeon over a 6-week period in late 1997. Patients undergoing major surgery for tumor or vascular anomaly were included. Every other patient beginning with the first was chosen for a shaveless preparation regardless of sex, hair type, hair length, or type of operation. The study population was made up of 11 females and 9 males that were followed for a mean of 6 months. Hair length was broken down into three groupings with a median of 2-4 cm in all patients. The mean incision length of all patients was 18 ±7 cm (Table 1). The mean incision length in both groups was statistically similar at 18 ±7 cm in the shaved and 19 ±7 cm in the unshaved. Both groups had a median time of scalp preparation of 9 min (P = 0.78). The unshaven skin closure took slightly longer with a median of 27 min compared with 24 min for the shaved group, but this was not statistically significant (P = 0.69) (Table 2). It was not necessary to compare timing of preparation or closure on a per centimeter scale, as both groups were well matched in this regard. There were no cases of infection in either group. An informal query regarding satisfaction with shaveless surgery among that group was answered with a resounding "yes."9 DISCUSSION AND CONCLUSIONS Leclair and colleagues5 stated in 1968 that "the pathogenesis of infection is shaped by the microbial ecology of the scalp." The microbial landscape of the scalp is made up of transient and resident populations of bacteria, with residents making up to 50% and residing more deeply in sebaceous glands and under the overlying stratum comeum.5 These are mostly diptheroids and Gram-positive rods that are rarely pathogenic, which is fortunate because they are exceedingly difficult if not impossible to eradicate with even the most destructive of agents.5 Staphylococcus nonaureus make up 90% of the transient population that reside predominantly on the Figure 6. All wounds are closed with interrupted vicryl in the deeper layers followed by fast absorbing 4-0 vicryl for skin approximation. The wound in then lined with bacitracin ointment every 8 hr for 2 consecutive days. A head wrap is never applied. 257
SKULL BASE SURGERY/VOLUME 9, NUMBER 4 1999 Table 1. Patient Characteristics Gender 11 male 9 female Median hair length 2-4 cm Median incision length 18 ± 7 cm hair and skin surface. These are the common culprits in postoperative wound infections. The goal of the preoperative prep is not to sterilize, but rather to disinfect or reduce the population of transients as much as possible.' Hair or no hair, little cover is provided for these transients when the scalp is scrubbed and prepped prior to surgery. 1,8 Convincing evidence is provided in the general surgical literature in the form of collective reviews of over 15,000 wounds revealing that preoperative shaving increases the risk of infection between three and five times that of unshaven preparations.9"16"17 One author went as far as to conclude that preoperative shaving is "deleterious and should be abandoned."9 Winston,' in 1992, provided the first convincing evidence in the neurosurgical literature regarding the potentially damaging effects of shaving. He prospectively reviewed 638 cases of unshaven prepped wounds and found an overall wound infection rate of 1.1%. This broke down further to a rate of 2.8% in cases of CSF diversion and 0.39% in other cranial cases. These numbers are certainly within acceptable norms. His conclusion was that "... the removal of hair by shaving does not lower the risk of surgical wound infection and may increase the risk."' Horgan and Piatt8 later came to similar conclusions after reviewing over 300 cases of CSF diversion procedures, 141 of which were unshaved. They concluded that shaving may be a risk factor in the prevention of infection. Why does shaving potentially increase the rate of infection? It is thought that microabrasions created during the shave become populated with transient organisms that later divide and colonize the wound.""1 It has long been known that wounds that are shaved the night prior to surgery have a greater propensity to become in- Table 2. Results Shaved Unshaved (Group A) (Group B) Number patients 10 10 5 male 4 male 5 female 6 female Incision Length 18 ± 7 cm 19 ± 7 cm (p <.05) Median prep time 9 min 9 min (p = 0.78) Median closure time 24 min 27 min 258 (P= 0.69) fected912 and most neurosurgeons have abandoned this practice. Based on the evidence sited above, it is reasonable to conclude that even a shave directly prior to surgery might put the wound at a slightly greater risk. Increasingly, the general surgeons and even the craniofacial plastic surgeons have ceased shaving.14 So why are neurosurgeons so reluctant to throw away the razor? As we stated in our last report, the reason is most likely a mixture of myth and ritual. We have shown that the bacteria hair harbors can easily be removed. We have demonstrated a reproducible technique that can be used to plan, execute, and close a wound with only a modicum of extra effort. Does that extra effort take an undue amount of time? We do not think so. The advantages of a shaveless preparation are obvious. The convincing evidence that shaving does not decrease rates of surgical wound infections coupled with the obvious satisfaction from our patients and their release from the stigma associated with "brain surgery" makes the effort worthwhile. REFERENCES 1. Winston K. Hair and neurosurgery. Neurosurg 1992;31 :320-329 2. Savitz M, Katz S. Prevention of primary wound infection in neurosurgical patients: A 10-year study. Neurosurgery 1986; 18:685-688 3. Haines S, Walters B. Antibiotic prophylaxis for cerebrospinal fluid shunts: A metanalysis. Neurosurgery 1994;34:87-92 4. Classen D, et al. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med 1992;326:281-286 5. Leclair J, et al. Effect of preoperative shampoos with chlorhexidine or iodophor on emergence of resident scalp flora in neurosurgery. Infect Control Hosp Epidemiol 1988;9:8-12 6. Garibaldi R. Prevention of intraoperative wound contamination with chlorhexidine showere and scrub. J Hosp Infect 1988; 11(Suppl B):5-9 7. Ko W, et al. Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. Ann Thorac Surg 1992;53:301-305 8. Horgan M, Piatt J. Shaving of the scalp may increase the rate of infection in CSF shunt surgery. Pediatr Neurosurg 1997; 26:180-184 9. Alexander J, et al. The influence of hair-removal methods on wound infections. Arch Surg 1983;118:347-352. 10. Balthazar E, Colt J, Nichols R. Preoperative hair removal: A random prospective study of shaving versus clipping. South Med J 1982;75:799-800 11. Olson M, MacCallum J, McQuarrie D. Preoperative hair removal with clippers does not increase infection rate in clean surgical wounds. Surg Gynecol Obstet 1986;162:181-182 12. Mehta G, Prakash B, Karmoker S. Computer assisted analysis of wound infection in neurosurgery. J Hosp Infect 1988; 11: 244-252 13. McIntyre F, McCloy R. Shaving patients before operation: A dangerous myth? Ann R Coll Surg Engl 1994;76:3-4 14. Habal M. To shave or not to shave. J Craniofac Surg 1992;3: 185-186 15. Howell J, Morgan J. Scalp laceration repair without prior hair removal. Am J Emerg Med 1988;6:7-10 16. Seropian R, Reynolds B. Wound infections after preoperative depilatory versus razor preparation. Am J Surg 1971;121: 251-254 17. Cruse P, Foord R. A five-year prospective study of 23,649 surgical wounds. Arch Surg 1973;107:206-210