Bone cement versus bone flap replacement: A comparative meta-analysis of posterior fossa craniotomy complications

Background: Posterior fossa surgeries are often performed to treat infratentorial pathologies, such as tumors that increase intracranial pressure. Posterior fossa craniotomy has been shown to decrease the incidence of postoperative complications and morbidity compared to craniectomy. More recently, the use of bone cement in posterior fossa craniotomies has been implemented, but there is limited comparative postoperative data of this technique to more commonly used bone flap replacement. This study aims to address this information gap through a meta-analysis comparing the incidence of postoperative cerebrospinal fluid leakage and other complications when utilizing bone cement versus bone flap replacement in posterior fossa craniotomies. Methods: Following a literature review, search parameters for a systematic review were identified and relevant studies were sorted based on selection criteria to be included in the meta-analysis. Data analysis was performed in R studio and Microsoft Excel software. Targeted complications for analysis include cerebrospinal fluid (CSF) leakage, pseudomeningocele formation, and infection. Pooled estimates and odds ratios for dichotomous outcomes were calculated with corresponding 95% confidence intervals, and findings were translated into illustrative tables and figures. Results: Twenty-one articles were included in a systematic review, nine studies using bone cement and thirteen using bone flap (two studies reported data for both groups). With bone flap replacement, CSF leakage was 8.36% (95% confidence interval [CI] 5.89–10.86%), pseudomeningocele formation was 9.22% (95% CI 4.82–13.62%), and infection was 6.85% (95% CI 4.05–9.65%). With bone cement usage, CSF leakage was 3.47% (95% CI 2.37–4.57%), pseudomeningocele formation was 2.43% (95% CI 1.23–3.63%), and infection was 1.85% (95% CI 0.75–2.95%). The odds ratio of CSF leak, pseudomeningocele formation, and infection was 0.39 (95% CI 0.229–0.559), 0.25 (95% CI 0.137–0.353), and 0.26 (95% CI 0.149–0.363), respectively, with the use of bone cement compared to craniotomy. Conclusion: Outcomes demonstrated in this meta-analysis revealed an overall decreased incidence of postoperative complications rates of CSF leak, pseudomeningocele formation, and infection when using bone cement compared to bone flap in posterior fossa craniotomies. Our study suggests that bone cement use is safe and effective in posterior fossa surgery. Future studies should further assess the comparative outcomes of these techniques.