Potential techniques to facilitate dissection in patients undergoing cranioplasty following decompressive craniectomy.

Decompressive craniectomy is a common neurosurgical procedure for cases of increased intracranial pressure. In patients undergoing cranioplasty, dissection planes are usually difficult to identify due to adhesions. We highlight the possible ways to make dissection easier in cranioplasty. A systematic search was performed on PubMed, Web of Science, Scopus, and Embase from inception until January 2025 to include studies that reported the possible techniques to mitigate the risk for adhesions following decompressive craniectomy and during cranioplasty. Operative metrics including the surgical time, estimated blood loss, the presence of gross adhesions, integrity of temporalis muscle, and the underlying dura as well as the primary pathology and the post-operative complications were extracted. Overall, 22 studies involving a total of 570 patients were included. Stroke was the primary pathology in 253 (54.6%) patients. The time between craniectomies and cranioplasties ranged from 10 days to several years. Different techniques were employed to reduce the risk for adhesion formation. A total of 99 out of 479 (20.5%) experienced postoperative complications following cranioplasty procedures. Epidural or subdural fluid collections were the most common complication, affecting 40 patients (8.6%), followed closely by wound infections in 39 patients (8.1%). Dural tears were reported in 10 patients (2%), while cortical injuries occurred in 6 patients (1.2%). Several materials have been used for duraplasty following decompressive craniectomy, with the aim of reducing adhesions and facilitating subsequent cranioplasty. Additionally, waterjet dissection has been proposed as a potential technique for safer tissue separation, but its safety profile and efficacy require further investigation. The evidence from these studies remains inconclusive and requires further investigation in large scale randomized controlled trials.