A Comparative Study of Watertight Dural Closure and Nonwatertight Dural Closure for Decompressive Craniectomy

Abstract

Introduction

Decompressive craniectomy (DC) remains a primary modality to effectively reduce elevated intracranial pressure (ICP), a correctly performed surgery can prevent cerebral complications and brain injuries caused due to refractory increased ICP.

Aim

This article compares the safety and efficacy of two surgical techniques—watertight (WT) dural closure and nonwatertight (NWT) dural closure for DC.

Materials and Methods

A prospective randomized comparative study was conducted from May 15, 2021 to April 15, 2022 in the neurosurgery department of a tertiary care hospital. Using the block randomization method, a total of 56 (28 patients per group: group WT including those undergoing WT dural closure and group NWT undergoing NWT dural closure) patients with indication for DC including traumatic brain injury, infarction, aneurysmal subarachnoid hemorrhage, and dural venous sinus thrombosis were included.

Results

Fifty-six randomly allocated patients were analyzed for operative characteristics and postoperative complications and for Glasgow Outcome Scale (GOS) outcomes. Compared with group WT, NWT had significantly lesser operative time. Both interventions were effective in managing the patients of traumatic brain injury. The mortality percentage was lesser in the NWT group. Despite fast surgery, the hospital stay in the NWT and WT groups were statistically similar. In the present study, GOS score was determined at 1, 2, and 3 months for determining the outcomes. GOS score improved significantly in both the groups. Statistically, the outcomes were comparable at 1 month (p = 0.105) and 3 months (p = 0.188).

Conclusion

NWT dural closure had significantly lesser operative time as compared with WT dural closure. However, amount of blood loss, hospital stay, complications, and mortality were similar among the two groups. Even the follow-up outcome response was comparable among the two groups. It can be concluded that in supratentorial craniotomies, adaptive NWT dural closure may be a good, safe, and time-saving alternative.

Keywords

GCS (Glasgow Coma Scale) - GOS (Glasgow Outcome Scale) - nonwatertight dural closure - watertight dural closure - decompressive craniectomy

Introduction

High intracranial pressure (ICP) is a critical issue encountered in neurosurgery. It is defined as an ICP raised above the level of 20 mm Hg, which is measured “within the subdural, intraventricular, or intraparenchymal compartments.”[1]

The incidence of raised ICP is significantly associated with traumatic brain injury (TBI), which can occur when a force transmitted to the head or body results in neuropathological damage and neurological dysfunction that manifests as either new-onset or worsening of at least one of the following clinical signs: any period of loss of or decreased level of consciousness, any loss of memory, any alteration in mental state (confusion or disorientation or slowed thinking, etc.), neurological deficits (weakness, loss of balance, change in vision, praxis, paresis, plegia, sensory loss, aphasia), that may or may not be transient, or intracranial lesion.[2]

In many situations, primary watertight (WT) dural closure could not be done,[3] [4] [5] [6] [7] and in others, the dura is left intentionally open as in extraintracranial bypass surgery the dura is completely excised over the cortical area of anastomosis between the superficial temporal and recipient cortical arteries without increased risk of cerebrospinal fluid (CSF) leak or wound infection.[8] [9] [10]

With the recent advancements in the management and resuscitative measures, morbidity and mortality associated with high ICP and its incidence per se, has been brought down, especially in TBI. The primary focus is to maintain the ICP and cerebral perfusion pressure, thereby preventing secondary brain injury.[1]

Decompressive craniectomy (DC) remains a primary modality to treat refractory elevated ICP that is unresponsive to medical management. TBI, middle cerebral artery (MCA) infarction, and aneurysmal subarachnoid hemorrhage (SAH) are three conditions for which DC has been predominantly used in the past.[1] DC improves brain tissue perfusion and oxygenation, as well as improving patient outcomes when performed for MCA stroke and TBI.[2] [11] [12]

DC is performed together with dura opening, and it was believed that this could maximize brain expansion after removal of part of the skull. However, opening the dura with no protection for the underlying brain tissue may increase the risk of several secondary surgical complications and CSF leakage through the scalp incision or contralateral intracranial lesion.[2] [11] [12] [13] [14]

Nowadays, DC combined with duraplasty is widely performed and is recommended. The dura suturing technique is traditionally known to require WT closure to prevent complications such as CSF leakage and infection.

Several studies have reported that nonwatertight (NWT) duraplasty may also be used as an alternate procedure after DC because NWT duraplasty can reduce the operative time while the probability of complications remains the same.[2]

The present study was conducted to compare the efficacy, surgical time, and complications between the two surgical interventions: WT duraplasty and without WT duraplasty (rapid-closure DC).

Aims and Objectives

To compare the safety and efficacy of two surgical techniques—WT dural closure and NWT dural closure for DC by comparing the incidence of postoperative complications, clinical outcome, average blood loss, and average operative time.

Materials and Methods

Study design: A prospective randomized comparative study was conducted from May 15, 2021 to April 15, 2022 at the department of neurosurgery of a tertiary care hospital in India. Using the block randomization method, a total of 56 patients were included (28 patients per group: group WT including those undergoing WT dural closure and group NWT undergoing NWT dural closure).

Study population: Patients with indication for DC including TBI, infarction, aneurysmal SAH, and dural venous sinus thrombosis were registered from the department of neurosurgery.

Inclusion criteria: Adult patients of both genders with indication for DC including TBI, infarction, aneurysmal SAH, and dural venous sinus thrombosis.

Exclusion criteria: Patients who had previously undergone any surgical treatment for other brain lesions, patients with interaxial contusions or hematomas requiring surgical evacuation with risk of CSF leak, patients planned for posterior fossa surgery, or patients suffering with polytrauma.

The study was ethically approved by the institutional ethical committee. All study participants provided their written informed consent. At every stage, privacy and confidentiality were guaranteed.

Sampling Methodology

Sample size: The values as reference were taken from the study of Vieira et al,[15] assuming standard deviation (SD) of 40 minutes, the minimum required sample size with 80% power of study and 5% level of significance was 27 patients in each study group. To reduce margin of error, total sample size taken was 56 (28 patients per group).

Sampling method: Block randomization was done with sealed envelope system where eight sealed opaque envelopes were prepared and assigned as A and B in 4 envelopes each, where A represented group WT and B represented group NWT. Once a patient consented to enter a trial, an envelope was opened, and the patient was then offered the allocated group. In this technique, patients were randomized in a series of blocks of eight. So basically, there were 7 blocks, and, in each block, 8 patients were taken and among those 8 patients, 4 patients were allocated in the WT group and 4 patients were allocated in the NWT group.

Methodology of Data Collection

The patients were fully explained about the procedure and approvals were taken with patient information sheet and the informed consent form. The demographic parameters such as age, gender, and comorbidities were noted. Detailed record was taken including vitals (pulse rate, systolic blood pressure [SBP], diastolic blood pressure [DBP]) and anisocoria, and operative parameters included operative time and blood loss. The patients' details were recorded as per study pro forma. Lax duraplasty (WT/NWT) was performed with pericranium patch as per the intervention group. Wound was closed in layers after placement of subgaleal drain. A linear incision was performed in the designated area of the right lower quadrant of the abdomen. A monopolar was used to create a pocket of adequate size within Camper's fascia. The bone flap was introduced with convex side out into the subcutaneous pocket and the wound was closed in layers.

Outcome measures assessed included operative time, blood loss, postoperative Glasgow Coma Scale (GCS) score, Glasgow Outcome Scale (GOS) score in the follow-up, hospital stay, and mortality, and the follow-ups of the patients were done at 1, 2, and 3 months for GOS score.

GCS score assessed preoperatively and postoperatively the severity of consciousness impairment. The scale rates patients based on their eye-opening, motor, and verbal responses—the three components of responsiveness. “Best eye response (E), best verbal response (V), and best motor response (M)” are the three components of the GCS. The GCS's response levels are “scored” on a scale of 1 for no response to 4 for eye-opening, 5 for verbal response, and 6 for motor response. Thus, the total GCS score ranges from 3 to 15, with 3 being the worst and 15 being the best.[16]

GOS score was assessed for the follow-up outcomes to evaluate the overall outcome following severe brain injury.

Routine neuroimaging (computed tomography head) was done from 5th to 10th postoperative day. Patients were assessed for incidence of complications, namely, CSF leak (CSF drainage through surgical wound), subgaleal fluid collections and ipsilateral/contralateral subdural hygroma (CSF drainage to the subcutaneous/epidural space, but not through surgical wound), wound infection (limited to the subcutaneous/epidural space), or brain abscess (infection involving the brain parenchyma) and were compared between the two groups.

Data Compilation Presentation and Analysis

The information collected was tabulated and analyzed using standard statistical software (SPSS) version 25. Data was compiled on Microsoft Excel version 2010 and was presented in tabular form. The presentation of the categorical variables was done in the form of number and percentage (%). On the other hand, the quantitative data were presented as means ± SD and as median with 25th and 75th percentiles (interquartile range). The data normality was checked by using the Kolmogorov–Smirnov test. The cases in which the data was not normal, nonparametric tests were used. To compare the quantitative variables, the Mann–Whitney test (variables which were quantitative and not normally distributed) and independent t-test (variables which were quantitative and normally distributed) were used. To compare qualitative variables the chi-square test and Fisher's exact test (cell had an expected value of less than 5) were used. For statistical significance, a p-value of less than 0.05 was considered statistically significant.

Results

Sixty-eight patients were assessed for eligibility out of which five were excluded due to not meeting the inclusion criteria and seven declined to participate in the study. Of the remaining 56 patients, 28 were assigned to each group. A total of 28 patients each were analyzed for operative characteristics and postoperative complications, while GOS outcomes was done in 25 patients in group A and 27 patients in group B ([Fig. 1]).

Fig. 1 Flowchart of the study.

Fifty-six patients within the range of 16 to 84 years were included. Thirty-six patients were male. In the WT group, hypertension was present in 5 patients and diabetes mellitus was present in 4 cases, while in the NWT group, both diabetes mellitus and hypertension were present in 5 patients each. Compared with group WT, NWT had significantly lesser operative time (200.36 ± 39.09 vs. 263.21 ± 33 minutes, p < 0.0001), showing that the morbidity associated with the operation was controlled faster in the NWT group ([Table 1]). The mean preoperative GCS was 7.25 ± 2.15 in the WT group, while in the NWT group it was 7.36 ± 1.97. Twenty-eight patients were randomized to each group ([Table 2]).

Table 1 Patients characteristics

Variables	WT group (n = 28)	NWT group (n = 28)	p-Value
Age (mean ± SD)	44.5 ± 16.28	45.79 ± 20.33	0.795
Gender
Female (%)	9 (32.14%)	11 (39.29%)	0.577
Male (%)	19(67.86%)	17 (60.71%)
Associated comorbidities
No comorbidities	22(78.57%)	20 (71.43%)	0.537
Diabetes mellitus	4 (14.29%)	5 (17.86%)	1
Hypertension	5 (17.86%)	5 (17.86%)	1
Type of index diseases
Traumatic brain injury	12 (42.8%)	14 (50%)	0.7
Cerebral infarction	9 (32.1%)	8 (28.5%)	0.8
Aneurysmal SAH	3 (10.7%)	3 (10.7%)	0.1
Dural vein thrombosis	4 (14%)	3 (10.7%)	0.7
Vitals
Pulse rate (mean ± SD)	95.32 ± 12.82	97.11 ± 13.06	0.608
SBP (mean ± SD)	124.29 ± 10.3	125 ± 11.09	0.804
DBP (mean ± SD)	76.32 ± 11.74	75.86 ± 12.01	0.884
Anisocoria (pupil size)
Absent	20 (71.43%)	26 (92.86%)	0.078
Present	8 (28.57%)	2 (7.14%)
Operative parameters
Operative time (min) (mean ± SD)	263.21 ± 33	200.36 ± 39.09	<.0001
Blood loss (mL) (mean ± SD)	462.5 ± 126.6	410.71 ± 103.06	0.109
Postoperative complications
No	17 (60.71%)	15 (53.57%)	0.589
Yes	11 (39.29%)	13 (46.43%)
Hospital stay (d) (mean ± SD)	13.79 ± 5.37	16.21 ± 5.83	0.12
Mortality rate
No	25 (89.29%)	27 (96.43%)	0.611
Yes	3 (10.71%)	1 (3.57%)

Abbreviations: DBP, diastolic blood pressure; NWT, nonwatertight; SAH, subarachnoid hemorrhage; SBP, systolic blood pressure; SD, standard deviation; WT, watertight.

Table 2 Comparison of preoperative and postoperative Glasgow Coma Scale between the WT group and the NWT group

Pre- and postoperative Glasgow Coma Scale	WT group (n = 28)	NWT group (n = 28)	p-Value
Preoperative
Moderate (9–12)	5 (17.86%)	9 (32.14%)	0.217[c]
Severe (3–8)	23 (82.14%)	19 (67.86%)
Mean ± SD	7.25 ± 2.15	7.36 ± 1.97
Median	7 (6–8)	7.5 (6–9)	0.648[b]
Range	4–12	4–11
Postoperative
Mean ± SD	6.46 ± 1.67	7.43 ± 3.07	0.473[a]
Median	6.5 (5–7)	6 (6–8)
Range	3–10	4–15

Abbreviations: NWT, nonwatertight; SD, standard deviation; WT, watertight.

^a Mann–Whitney test.

^b Fisher's exact test.

^c Chi-square test.

Postoperative complications were present in 11 out of 28 patients (39.29%) in the WT group whereas 13 out of 28 patients (46.43%) in the NWT group. Complications included subgaleal fluid collection in four cases and two cases, CSF leak in two cases and four cases, meningitis in two cases and one case, wound infection/surgical site infection in one patient and in three cases, and abscess in one patient and three cases of the WT and NWT groups, respectively. Two cases were complicated with fever in the WT group only.

Compared with group WT, NWT had significantly lesser operative time (200.36 ± 39.09 vs. 263.21 ± 33 minutes, p < 0.0001), showing that the morbidity associated with operation was controlled faster in the NWT group ([Table 1]). Using GCS, both interventions were effective in managing patients of TBI. In the WT group, 3 (10.71%) patients died and in the NWT group, 1 (3.57%) patient died. Though the mortality percentage was lesser in the NWT group, statistically it was comparable (p = 0.611). Despite fast surgery, the hospital stay in the NWT and WT groups were statistically similar (16.21 ± 5.83 vs. 13.79 ± 5.37 days, p = 0.12) ([Table 1]).

GOS score was determined at 1, 2, and 3 months for determining the outcomes. GOS score improved significantly in both the groups. In the WT group, GOS from a score of 2 (42.86%) and 3 (46.43%%) at 1 month improved to score of 2 (25%), 3 (57.14%), and 4 (7.14%) at 2 months and to a score of 3 (32.14%) and 4 (57.14%), while in the NWT group, GOS from a score of 2 (71.43%) and 3 (25%%) at 1 month improved to score of 2 (0%), 3 (78.57%), and 4 (17.86%) at 2 months and to a score of 3 (14.29%) and 4 (82.14%). Statistically, the outcomes were comparable at 1 month (p = 0.105) and 3 months (p = 0.188) ([Table 3]).

Table 3 Comparison of GOS between the WT group and the NWT group

GOS	WT group (n = 28)	NWT group (n = 28)	p-Value
At 1st month
1 (Dead)	3 (10.71%)	1 (3.57%)	0.105[a]
2 (Vegetative)	12 (42.86%)	20 (71.43%)
3 (Severe disability)	13 (46.43%)	7 (25%)
At 2nd month
1 (Dead)	3 (10.71%)	1 (3.57%)	0.01[a]
2 (Vegetative)	7 (25%)	0 (0%)
3 (Severe disability)	16 (57.14%)	22 (78.57%)
4 (Moderate disability)	2 (7.14%)	5 (17.86%)
At 3rd month
1 (Dead)	3 (10.71%)	1 (3.57%)	0.188[a]
3 (Severe disability)	9 (32.14%)	4 (14.29%)
4 (Moderate disability)	16 (57.14%)	23 (82.14%)

Abbreviations: GOS, Glasgow Outcome Scale; NWT, nonwatertight; WT, watertight.

^a Fisher's exact test.

Discussion

This study was conducted with an objective to compare the two interventions of DC with WT dural closure and NWT dural closure for treatment of patients of TBI with respect to the outcomes and operative characteristics.

In the present study, compared with group WT, NWT had comparable mean age (45.79 ± 20.33 vs. 44.5 ± 16.28, p = 0.795), gender distribution (60.71% vs. 67.86% males, p = 0.577), comorbidities (diabetes: 17.86% vs. 14.29%; hypertension: 17.86% vs. 17.86%, p = 1), vitals (pulse rate: 97.11 ± 13.06 vs. 95.32 ± 12.82, p = 0.608; SBP: 125 ± 11.09 vs. 124.29 ± 10.3, p = 0.804; DBP: 75.86 ± 12.01 vs. 76.32 ± 11.74, p = 0.884), and anisocoria (7.14% vs. 28.57%, p = 0.078). In comparison, Vieira et al[15] conducted a study including 57 patients, who underwent unilateral DC where the patients were categorized into: those with WT duraplasty (WT, n = 29) and without WT duraplasty (NWT, n = 27). The results showed that the mean age of the patients was 33.4 years, with no significant difference in age between the NWT and WT groups (p > 0.05). Compared with WT, NWT also had similar anisocoria (44.5% vs. 25%, p = 0.130).

In the present study, compared with group WT, NWT had significantly lesser operative time (200.36 ± 39.09 vs. 263.21 ± 33 minutes, p < 0.0001), showing that the morbidity associated with the operation was controlled faster in the NWT group. Similar to the present study results, NWT dural closure is reported to take lesser operative time than WT closure technique in previous studies also. Vieira et al[15] reported that compared with WT, NWT had significant lesser time of surgery (101 vs. 132 minutes, p = 0.001). Similar to this, Barth et al[16] reported that in the NWT dural closure group, surgeries were faster as closure time was significantly lesser in the NWT group than the primary and secondary WT groups (5.3 vs. 13.1 vs. 14.6 minutes, p < 0.05). It must be stressed here that NWT holds superiority to WT in this aspect since such a time reduction may decrease morbidity associated with longer surgeries, which are often associated with greater blood loss and this may ultimately lead to better neurosurgical outcomes.[15]

Concurrent with this notion of lesser morbidity with respect to lesser time of surgery, in the present study compared with group WT, NWT had lesser blood loss (410.71 ± 103.06 vs. 462.5 ± 126.66 mL) but statistically it was not significantly different (p = 0.109). To the best of our knowledge, none of the similar previous studies evaluated the amount of blood loss between WT and NWT dural closure.

It was observed that preoperatively, both groups had comparable GCS, with a mean value of 7.25 ± 2.15 in the WT group and 7.36 ± 1.97 in the NWT group (p = 0.648). Postoperatively also, both groups showed comparable GCS (WT group vs. NWT group: 6.46 ± 1.67 vs. 7.43 ± 3.07, p = 0.473). This showed that both interventions were effective in managing patients of TBI. This was supported by the findings of Vieira et al,[15] who reported that compared with WT, NWT had similar postoperative GCS scores (GCS score 3–8: 48.1% vs. 50%; GCS score 3–8: 51.9% vs. 42.9%; 14–15: 0% vs. 7.1%; p = 0.524).

In the present study, complications were present in 39.29% (n = 11) patients in the WT group and in 46.43% (n = 11) patients in the NWT group ([Fig. 2]); but statistically, it was found that complication rate was comparable among the two groups (p = 0.589). The common complications were subgaleal fluid collection and CSF leak in group WT and CSF leak and wound infections in the NWT group. In corroboration with the present study, Vieira et al[15] reported that compared with WT, NWT had comparable complications (14.8% vs. 17.9%, p = 1). CSF leak developed in two patients in each group, wound infection in one patient in each group, and subgaleal fluid collection developed in two patients in the control group and one patient in the test group. It was concluded that no increased risk of CSF leaks exists once the arachnoid is intact. Additionally, attempts to achieve WT closure may cause small defects on suture lines, creating a “one-way valve” effect that may increase CSF leakage development. Cho et al[17] analyzed the occurrence of CSF leakage after NWT closure. Comparable rate of CSF leakage between NWT closure and WT closure was seen in supratentorial approach. In infratentorial approach, higher rate of CSF leakage was seen in NWT closure than that in WT closure.

Fig. 2 Comparison of various postoperative complications between the watertight (WT) group and the nonwatertight (NWT) group.

Similar to the present study, Abouelmaaty and Molla[18] found that compared with the WT group, the NWT group had similar subcutaneous CSF collection (8% vs. 4%), delayed wound healing (8% vs. 4%), meningitis (4% vs. 0%), and CSF leak (4% vs. 4%) (p > 0.05). Thus, NWT dural closure was suggested to be safe option to WT dural closure in patients who undergo supratentorial craniotomies; however, it was not considered to be superior to WT. Wang et al[19] in their study explained the higher rate of infection was by the fact that in patients who undergo NWT dural closure, circulation of CSF occurs between the epidural and subdural space and contacts the skull, galea, muscle, and scalp. The probability of infection is raised due to this process.

In the present study, in the WT group 3 (10.71%) patients died and in the NWT group 1 (3.57%) patient died. Though the mortality percentage was lesser in the NWT group, statistically it was comparable (p = 0.611). This was in line with the findings by Vieira et al,[15] who reported that compared with WT, NWT had comparable mortality rate (37% vs. 25%, p = 0.334).

Despite fast surgery, the hospital stay in the NWT and WT groups was statistically similar (16.21 ± 5.83 vs. 13.79 ± 5.37 days, p = 0.12), which might be because of comparable rate of postoperative complications and management. Moreover, the hospital stay also gets affected by the mortality of the serious patients. None of the similar previous studies evaluated hospital stay between WT and NWT dural closure.

In the present study, GOS score was determined at 1, 2, and 3 months for determining the outcomes. GOS score improved significantly in both the groups. In the WT group, GOS from a score of 2 (42.86%) and 3 (46.43%%) at 1 month improved to score of 2 (25%), 3 (57.14%), and 4 (7.14%) at 2 months and to a score of 3 (32.14%) and 4 (57.14%); while in the NWT group, GOS from a score of 2 (71.43%) and 3 (25%%) at 1 month improved to score of 2 (0%), 3 (78.57%), and 4 (17.86%) at 2 months and to a score of 3 (14.29%) and 4 (82.14%). Statistically, the outcomes were comparable at 1 month (p = 0.105) and 3 months (p = 0.188). The findings were in line with the study of Vieira et al,[15] who reported that compared with WT, NWT had comparable GOS scores (GOS score 1: 37% vs. 25%; 2: 18.5% vs. 10.7%; 3: 25.9% vs. 25%; 4: 1% vs. 14.3%; 5: 7.4% vs. 25%; p = 0.428). This shows that overall, both interventions fair equally well with respect to the outcomes of the patients with the only difference being in the operative time.

Limitations

The present study did not compare the cost-effectiveness of WT and NWT dural closure in TBI patients. The patient care guidelines for elective cranial surgery differ from one institution to the next. As a result, the study results that were determined through the analysis might not be applicable to other institutions.

Conclusion

This study indicates that the NWT group had significantly lesser operative time as compared with the WT group. However, amount of blood loss, hospital stay, complications, and mortality were similar among the two groups. Even the follow-up outcome response was comparable among the two groups. It can be concluded that although not significantly superior to WT dural closure in supratentorial craniotomies, adaptive NWT dural closure may be a good, safe, and time-saving alternative to it.

Conflict of Interest

None declared.

Acknowledgment

The authors acknowledge all the patients, who were actively involved in this study.

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Publication History

Article published online:
05 December 2025