Background:
Osteoradionecrosis (ORN) of the calvarium poses a significant management problem that currently lacks a consensus treatment approach. Current best care is provided on a case-by-case basis.
Methods:
We sought to determine a management protocol via a retrospective analysis of 37 patients at Australia’s only cancer specific public hospital. A total of 1692 patients underwent scalp radiotherapy at our specialist tertiary cancer centre between the period of Jan 2004 and December 2021, 37 of whom suffered from ORN. Statistical analysis was performed using R.
Results:
Fourteen patients were treated conservatively, nineteen treated with surgical intervention. A further three patients declined surgery and one patient was planned for surgery but deceased pre-operatively. On univariate and multivariate analysis, no statistically significant difference was found for age, gender, or ASA grade between conservative and surgical patients. Free flap reconstruction occurred in 10 cases (27%) and scalp transposition flap in 9 cases (24%). Cranioplasty and skull bone burring occurred in 10 patients and 8 patients respectively. Three grades of Calvarium ORN were determined. 18 patients had grade 1 ORN, 9 had grade 2 and 10 patients had grade 3 ORN.
Conclusions:
Our proposed treatment algorithm is such that grade 1 ORN is often successfully treated with dressings and antibiotics after surgical debridement of the necrotic tissue. Grade 2 ORN may be treated conservatively in circumstances where anaesthetic risk is too great; if suitable, resection and reconstruction is encouraged. Grade 3 lesions should be offered surgical resection with combined neurosurgical and plastic surgical involvement, i.e., craniotomy, cranioplasty and soft tissue reconstruction. Progression across grades from 1 to 3 may occur rapidly, so close follow up is recommended.