AUTHOR(S): Winston, Ken R., M.D. Department of Surgery (Neurosurgery) of the University of Colorado Medical School and The University of Colorado Health Sciences Center, Denver, Colorado Neurosurgery 31; 320-329, 1992 ABSTRACT: THE VALUE OF removing hair in preparation for neurosurgery is addressed in detail. One neurosurgeon's series, accrued over 40 consecutive months, of 638 prospectively examined, consecutive cases is the basis of this report. The overall surgical wound infection rate was 1.1 %. The infection rate for the 313 cranial cases was 0.3% and 2.8% for the 218 procedures involving cerebrospinal fluid diversion (shunts). These data are discussed in the context of extensive nonneurosurgical and microbiological literature. It is concluded that the removal of hair by shaving does not lower the risk of surgical wound infection and may increase the risk. A technique for preparing skin and hair for neurosurgery and for the management of hair during neurosurgical procedures is discussed. KEY WORDS: Antisepsis; Cerebrospinal fluid shunt infection rates; Hair; Neurosurgical wound infection rates; Shaving; Skin preparation for surgery; Surgical wound infection rates Why are patients shaved in preparation for neurosurgical procedures? Although most patients are not strongly averse to being shaved for spinal or abdominal incisions, almost all perceive having their scalp shaved as a wretchedness to be endured in order to be eligible for the benefits of neurosurgery; all assume that the practice has a solid scientific basis. When asked, neurosurgeons typically respond that shaving is "necessary to prevent infection." But is this true? Both surgery and shaving in preparation for surgery are innasible, and the two ideas are historically inseparable. Hair has been associated with scruffiness and uncleanliness and its removal, particularly by shaving, has been associated from prehistoric times in the minds of the practitioners and the public with cleanliness and purity. The two earliest records of shaving (face, scalp, entire body?) are Joseph's shaving in preparation for meeting Pharaoh and the Israelites' requirement that a captured woman who was to be taken as a wife be shaved (7). These ancient accounts of shaving were probably, at the time of their recording, established rituals signifying a cleansing or purification. Shaving acquired a lifesaving tradition as a consequence of Alexander the Great who, in the fourth century B.C., required his soldiers to shave to deny the Persians a
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convenient handle while they tried to incise (nonsurgically) Macedonian throats (19). The English word barber is thought to have derived from a Sanskrit word meaning unintelligible or stammerer (48) . Individuals willing to deal with human hair, probably foreigners who garbled the local language, were the obvious choice for handling such other unsavory jobs as attending wounds and extracting teeth. It is reasonable to believe that these early barbers, possessing better shaving skills than surgical techniques, combined their skills--or perhaps never viewed them as separate--when dealing with wounds. Shaving gained a theological buttress and became even more closely tied to bodily wounds and blood in 1092 as a consequence of a decree forbidding monks from wearing beards; this decree gave rise to a profession serving the purpose of shaving and therapeutically bleeding monks (58). In 1461, Edward IV incorporated the Company of Barber-surgeons and later Henry VIII changed the name to Company of Barbers and Surgeons, with the former restricted to hairdressing and dentistry and the latter being more involved with blood letting and the management of wounds. In 1886, Gustav Neuber wrote that the skin in the operative area should be shaved to allow careful washing of the area. In 1895, Carl Beck (5) stated, "The field of operation must invariably be shaved if there is the slightest evidence of the presence of hairs." According to Victor Horsley (31), "The day before the operation, the patient's head is shaved ... "and Harvey Cushing (20) wrote," The scalp, which may have been shampooed, is shaved just before the operation ... ." Concerning the prevention of surgical wound infections, the guidelines of the Centers for Disease Control (27) list no indication for removing hair and state "Unless hair near the operative site is so thick that it will interfere with the surgical procedure, it should not be removed." On the subject of shaving, the guidelines state "If hair removal is necessary, it should be done either by clipping or using a depilatory rather than shaving." PATIENTS AND METHODS Patients Prospectively kept records on all patients who were operated on by one neurosurgeon between July 1, 1988, and November 1, 1991, are the basis for this report. The operations were performed in seven hospitals (designated A-G in Table 1) in Denver, Colorado. Surgical residents were actively involved in the preoperative, operative, and postoperative care of all patients except those of hospitals F and G (Table 1). The attending neurosurgeon was present and scrubbed for each case. Dirty or infected cases were excluded, i.e., patients presenting with suppurative wounds, but clean-contaminated and contaminated cases were included (see below). The following operative procedures were excluded: tracheotomy, insertion of intracranial pressure monitor, and percutaneous ventriculostomy, unless these were part of a larger operative undertaking. Also the 5 patients who survived less than 2 months
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Neurosurgery 1992-98 August 1992, Volume 31, Number 2 320 Hair and Neurosurgery Special Report
Preparation of skin and hair for surgery No hair was removed in preparation for surgery. When practical (about 75% of the cases), patients were instructed to bathe (preferably shower) and shampoo with 4% w/v chlorhexidine (Hibiclens, Stuart Pharmaceutical, Wilmington, DE) once within the 24 hours before surgery; children were bathed and shampooed preoperatively by parents or nurses. The final preparation of all patients' skin and hair was done in the operating room after anesthetic induction. The entire operative region was scrubbed energetically for at least 8 minutes (usually timed) with undiluted 4% chlorhexidine (usually Hibiclens). A brush was used only if dirt, debris, or desquamated skin was visible; otherwise all scrubbing was done with gauze surgical sponges and gloved hands. For cranial operations, all hair on the scalp that was sufficiently long to reach the operative site was shampooed vigorously; for most patients, the entire scalp and all scalp hair, however long, was shampooed. The area of scalp that had to be scrubbed and shampooed in patients with hair was much larger than the area customarily shaved and scrubbed. The entire surgical area (skin and hair) was then irrigated with 70% isopropyl alcohol while being gently massaged to assist in removing the remaining visible soap. If the hair was sufficiently long, while still wet with alcohol, it was parted along the proposed incision line with a sterile comb or hemostat and then secured with sterile elastic bands or hemostats. Skin and hair were dried by pressing a surgical towel (cloth or paper) against the scrubbed area. If the upper face was to be prepared, as in craniofacial procedures, the eyelids were sutured closed after a generous portion of an ophthalmic ointment was placed beneath the eyelids; the scrub was continued over the face, with less vigorous scrubbing over and around the eyes; no alcohol was used about the eyes. In approximately 95% of cases, the attending neurosurgeon was present for the scrub and supervised or did the scrubbing. For planned scalp incisions, the operative field was usually draped, exposing approximately 2 cm of skin, and the edges of the towels (usually cloth) were stapled to the skin; occasionally, a much larger area of hairy scalp was left exposed. Occlusive plastic adherent drapes were not used routinely on the scalp. For less hairy regions (e.g., abdomen, neck, and spine), larger areas of skin were left exposed by the drapes, and, in these locations, an occlusive adherent plastic drape (not containing iodophor) was used routinely. Management of hair during surgery Hair was ignored during operative procedures. No case was encountered in which the surgeon considered hair removal to be necessary for technical reasons, i.e., the thickness and length of the hair did not interfere with the surgical procedure. If hair fell
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into the operative field (some hairs entered almost every operative wound), it was pushed aside; loose (unattached) hairs were removed when encountered. Loose hair, which had a tendency to be identified in the operative field immediately after the skin incision and during the closing process, was removed from the field. During the process of closing the scalp, it was usually necessary to push hair aside and often necessary to wet (bacitracin irrigation solution) the hair to keep it aside; long hair had less tendency to enter the field than did hair of a few centimeters length. While closing the galea aponeurotica or subcutaneous tissues, particular attention was given to the avoidance of trapping hair in the surgical knots. Scalp edges were approximated with staples (except in premature children). After all staples were applied, the surgeon reinspected the wound millimeter by millimeter to identify and to remove any hairs caught in the closure and also to assure proper alignment of the skin edges. Relatively nonhirsute areas were usually approximated with surgical adhesive strips. Vacuum drainage (usually a 7-mm Jackson-Pratt drain) was used for all except six of the patients who underwent craniotomy; the drain always exited via a separate stab wound and remained in position for approximately 24 hours; drainage sites were not sutured after the drain was removed. A dry turban dressing was used for all scalp incisions, however small; tape was never applied to hair. Antibiotic ointment was not used on surgical wounds or drain sites. Dressings were removed usually on the second or third postoperative day, except on patients in whom there was concern about molestation of the wound, e.g., young children and patients with impaired consciousness or retardation. When cranial dressings were removed, the hair usually had the appearance of containing residual chlorhexidine containing soap. Surveillance of wounds The wounds of all surviving hospitalized patients were examined by the surgeon, house officer, or both at least once (usually daily after the second postoperative day) during the first postoperative week. Most patients were repeatedly evaluated during hospitalization and were followed for months after discharge from the hospital. Patients with cerebrospinal fluid (CSF) shunts were never discharged from follow-up. Every attending neurosurgeon and house officer was made aware that this surgeon was to be notified if there was suspicion of a wound infection in any of this surgeon's patients. Definitions Wounds were prospectively classified according to the definitions of Cruse and Foord and the CDC guidelines (18,26,27), with slight modification in wording for a clearer application to neurosurgical procedures. A clean wound is one in which no infection is encountered; there is no major break in sterile technique and no entry into a cavity, such as the nasopharynx, trachea, or abdominal viscus. A clean-contaminated wound is one in which a hollow
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after surgery were excluded. Five patients, most from early in the period of accrual, were shaved by an assistant not familiar with this surgeon's routine; these patients have been excluded.
Antibiotics All except 8 patients received prophylactic antibiotics intravenously, beginning when the iv was started in the operating room and continuing for approximately 24 hours. Patients undergoing operations for CSF diversion received vancomycin (40 mg/kg/d), unless there was a history of allergy. Other patients usually received cefazolin. Patients with clean-contaminated or contaminated wounds received antibiotics for longer periods. All wounds were irrigated with bacitracin solution (approximately 50,000 units per half liter of saline) at least once and usually multiple times. RESULTS The distribution of the 638 neurosurgical procedures by age, sex, and type of surgical procedure is displayed in Table 2. All seven infections in this series (1 craniotomy and 6 shunt procedures) occurred among the 595 clean procedures (Tables 1 and 4). No surgical wound infection occurred among the 6 clean-contaminated or the 37 contaminated cases. The overall rate of surgical wound infections in this series was 1.1% (Tables 1 and 3). The one surgical infection among the 313 cranial cases was almost certainly not related to the preparation of the skin. The craniotomy that became infected was for acute subdural hematoma and was done as an extreme emergency and complicated by diffuse intravascular coagulopathy; a few days after the operation, the patient partially opened the surgical wound with his fingernails and Staphylococcus aureus was cultured from the wound at the time of a second cranial procedure 5 weeks later. The overall
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infection rate for cranial cases was 0.3%; however, the infection rate that reasonably may be attributed to the preparation of the skin was zero. No infections occurred among the 124 spinal procedures. The 218 procedures for CSF diversion had an overall infection rate of 2.7%. One of the six shunt infections cannot be attributed to a problem with preparation of the skin; that infection was related to erosion of hardware through the overlying scalp. Inconsistent with the technique for nearly all of the other patients in the series, two other patients who developed shunt infections had their skin prepared with chlorhexidine solution that had been diluted considerably (amount not documented). None of the patients who developed infections had a preoperative bath or shampoo with chlorhexidine. In none of the infected cases was there evidence for preexisting infection or a break in sterile technique, but these possibilities cannot be excluded. Twenty operative procedures, 6 of which were CSF diversions, were performed within the 2 months before the close of this study. Although most surgical wound infections (including CSF shunt infections) are apparent within 2 months after surgery, some CSF shunt infections and rare postoperative wound infections may appear months or even years after cranial or spinal procedures (28). It is possible that additional infections in the patients of this series could appear in the future, as is true for all published series. DISCUSSION Interpretation of data The neurosurgical wound infection rates in prospectively accrued patients whose skin was prepared without removal of hair compares very favorably with the best published infection rates for patients whose skin preparation included shaving (Table 5). Although not proving that leaving the hair intact for neurosurgical procedures is superior to shaving, this study does make it reasonable to believe that hairy skin, including scalp, can be cleaned sufficiently well to make the risk of surgical wound infection insignificantly different from the lowest values reported from the best of the recently reported series in which it is reasonable to believe that all patients were shaved. It should be noted that the infection rates in the series herein reported were from consecutively accrued patients of a single neurosurgeon operating under a variety of conditions in multiple hospitals and almost always with house officers. Two of the 7 infections in this series were very unlikely to have been related to the preparation of the operative site but may have been prevented by more attention to surgical wounds--one by either better planning of the surgical incision or by preventing the child from lying on the shunt system postoperatively and the other by better postoperative protection of the surgical wound. The cause of the other 5 postoperative infections--each a CSF shunt revision-is not clear; although two of these patients were scrubbed with a relatively dilute solution of chlorhexidine, attribution of these infections to this
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cavity, such as the nasopharynx, is entered. Most of the clean-contaminated operations were so classified on the basis of entering the nasopharynx as part of a craniofacial reconstruction or exposure of a frontonasal neoplasm (Table 1). A contaminated wound is one within an area of acute inflammation (not pus), a traumatic wound less than 4 hours old, a CSF shunt infection (without pus), and operations associated with a major break in sterile technique. In this series, most of the contaminated cases were so classified because of an infected CSF shunt or on the basis of a traumatic open wound. A dirty or infected wound is one in which pus is identified and/or there is reason to believe that organisms causing postoperative infection were within the operative field before the operation (this includes all traumatic wounds 4 or more hours old). Consistent with the CDC guidelines, a wound was classified as infected if pus was identified within the wound or if the attending surgeon believed the wound to be infected; stitch abscesses requiring no mechanical intervention and no antibiotics were not classified as surgical wound infections (26). A positive culture was not required except for the diagnosis of CSF shunt infections. Infection presenting within a year after a previous shunt infection with the same organism was considered to be an inadequately or unsuccessfully treated first infection and not a second infection.
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of whether patients received prophylactic antibiotics. This study includes no prospective randomized control, and therefore the data are meaningful only in comparison with published data. Strict comparisons of rates of surgical wound infection are not valid (51) because of important differences among the series, e.g., diagnostic case mix, use of prophylactic antibiotics (types, doses, etc.), surgical procedures and techniques, criteria for diagnosis of infection, and the intensity, objectivity, and duration of surveillance for infection and even methods of calculation (67). There is a tendency to think that all observed differences in infection rates reflect real differences but this is not necessarily true. Confidence intervals (which can be calculated from data provided by authors) reflect the extent to which values are reliable; the extensive overlap in confidence intervals from a sampling of reports is apparent in Tables 5 and 6. The number of "Cases Needed to Identify Difference" (last column of Tables 5 and 6) is a calculated estimate of the magnitude of the task (i.e., number of cases) that would be required in a prospective study to meaningfully compare the apparent differences between this study and various published values. For example, a prospective randomized study designed to compare a sample of patients undergoing craniotomy as managed and reported here (0.3% infection rate) with a sample of patients as managed and reported by Cartmill et al. (13) (0.7% infection rate) would require approximately 21,000 cases to have a 90% chance of identifying the difference at the 5% confidence level, in a one-tailed test (59). Therefore, given the magnitude (and other practical considerations) of a study that could meaningfully compare/differentiate small observed differences in infection rates, it is unlikely that such a study will be done in the near future, if ever. Until and unless such studies are done, we have no compelling basis for concluding that nonshaving is superior to shaving, or vice versa, and therefore we must examine the less direct, but not necessarily less valuable, evidence. Neurosurgical literature on removing hair For patients undergoing a craniotomy, Zentner et al. (68) found that 5.5% of 237 patients having a standard wet shave, 3.2% of 93 patients having a dry shave, and 2.8% of 145 patients having their hair removed by clippers developed a surgical infection (differences not significant at 5% level). Scherpéreel et al. (54) briefly reported on 1000 craniotomies in which only a 1- to 2-cm strip was shaved along the proposed incision line and found an infection rate of 0.6%; however, the report contains little detail, no definition of infection, and only minimal information on the technique, types of cases, and their follow-up. Shaving only along the proposed incision line, at first consideration, seems to be a compromise between shaving and nonshaving, but, because the skin nearest the incision is the skin most likely to contribute to floral contamination of the wound, shaving the area of surgical incision probably exposes the patient to the full risk of shaving or worse.
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cause seems tenuous. The shunt infection rate may be the most sensitive indicator of the effectiveness of any technique in removing bacteria from the operative field in preparation for surgery because of the following: 1) infection rates for shunting procedures are typically higher than the rates for other neurosurgical procedures; and 2) the most common organisms causing shunt infections are thought to be introduced at the time of surgery from the patient's skin (4). Six of the 7 infections in this series were in patients who underwent CSF diversion (shunt operations), giving a 2.7% infection rate. The favorableness of this value is apparent when it is compared with the published shunt infection rates in the last decade, most of which are between 5 and 38% (see a review of the literature on shunt infections by Quigley et al. [51]). It is more meaningful, however, to compare the results of this study, not with the average rate or with the range of published values, but with the better (i.e., lower) infection rates (Table 6). Infection rates have been reported to be much higher for premature infants, children with myelomeningocele, and the internalization of extraventricular drains; the series reported here contained at least 36 cases in these three categories, only one of which became infected. It is reasonable to believe that clean cases are at less risk of infection than are clean-contaminated and contaminated cases and therefore the absence of surgical wound infections among the 6 cleancontaminated and 37 contaminated cases is somewhat surprising. This observation may reflect the small number of cases in these groups plus the effectiveness of antibiotics that were administered for approximately 48 hours in the clean-contaminated cases and often longer in the contaminated cases. The possibility that the chlorhexidine was responsible for the low surgical wound infection rate in this series, independent of hair removal, cannot be excluded. Chlorhexidine (undiluted 4% solution) was used to prepare the skin in all patients in this sample; chlorhexidine has a residual bacteriocidal effect on the skin (44). A preoperative shampoo with chlorhexidine has been shown to significantly reduce the density of transient flora on the scalp (37) as well as other parts of the body (6,11,12,24,25) for up to 6 days (39) . There is no basis for postulating whether other agents would have resulted in equivalent infection rates. The postoperative infection rates for general surgery are also reported to be reduced by chlorhexidine (30). Prophylactic antibiotics, particularly in operations for CSF diversion (shunt procedures), are very widely used by neurosurgeons; however, the purists can claim justifiably that their value is not proven. Although not the subject of this investigation or analysis, the patients in this study received prophylactic antibiotics intravenously; also their wounds and all implanted hardware were irrigated with a solution of antibiotic. A sampling of published infection rates for craniotomy, with and without prophylactic antibiotics, can be seen in Table 5. Clearly the 0.3% infection rate of this study compares very favorably with the published results, regardless
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and open wounds receiving prophylactic antibiotics). In a review of the literature on preparation of the skin for surgery, Masterson (40) states, "The only reason to remove hair from the operative site is if it interferes mechanically with accurate, anatomic approximation of the wound." The same author states, "There is no room for misinterpreting the data; removing hair with a razor increases the wound infection rate in almost all the reports." Interestingly in veterinary surgery, which requires an incision through densely hairy skin in almost all procedures in mammalians, hair is usually removed by clipping (49) because shaving is often impractical and is thought to increase the risk of wound infection. Microbiology There are two populations of bacteria on the skin, usually designated as resident and transient (see reviews of skin bacteriology by Masterson (40), Montes and Wilborn (43), and Noble (45)). All flora on hair are transients. The transient flora vary greatly in kind and in population density. Kligman (35) found 5.04 × 105 (geometric mean) aerobic bacteria on the nondandruff scalp and 9.22 × 105 on the dandruff scalp; about 90% of these are coagulase-negative Staphylococcus nonaureus (41). The resident flora on the skin are rarely pathogenic (55) but are predominantly diptheroids and gram-positive rods (Corynebacterium and Propionibacterium) (40). Interestingly, Propionibacterium acnes is the dominant bacteria in oily regions of the skin-forehead, scalp, and sebaceous glands of hair follicles (40) . Price (50) demonstrated that "in any given area of skin, degree of hairiness has little if any relation to size of bacterial flora." Also bacterial flora on hair is influenced little if any by the length of hospitalization or by antibiotics (8). The goal of preparing the skin for surgery is to prevent surgical infection by minimizing the transient population of bacteria, particularly pathogenic bacteria (38,39). As a practical point, the surgeon can not sterilize the skin (destroy all bacteria on and within it) in preparation for surgery because about 20% of bacteria on or within skin and its appendages, i.e., the resident population, are inaccessible to the effects of surgical scrubs and antiseptics; for the scalp, this number may be closer to 50% (55). Bacteria within the skin, particularly oily regions, "are protected from disinfection by lipids, especially at the mouths of follicles, or by overlying portions of the stratum corneum," according to Selwyn and Ellis (55). It is reasonable, however, to strive for disinfection of the skin (removal of all pathogenic organisms) because bacteria enter all surgical wounds to such an extent that cultures from clean surgical wounds just before closure are often positive, yet few of these wounds become infected (37,64). Most studies assessing the effectiveness of eliminating bacteria from the skin have necessarily addressed only the transient population because this population is more easily quantified than the resident population. Nearly all transient bacteria, in contrast to resident bacteria, are eliminated during the process of preparing the skin (scalp or other) for surgery.
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Literature from other surgical disciplines Published surgical series composed predominantly or totally of nonneurosurgical cases support the position that shaving hair in preparation for surgery either raises the risk or, at best, may not increase the risk of infection. In 1980, Cruse and Foord (18) reported on 62,939 prospectively studied surgical wounds and found the infection rate among the 42,054 clean wounds to be 2.5% when the operative site was shaved with a razor, 1.4% when shaved with an electric razor, and 0.9% when there was no shaving or clipping; they concluded that "Shaving the operation site increased the infection rate of clean wounds". In a prospective study on 406 patients undergoing abdominal surgery, Court-Brown (16) concluded that "Skin shaving before operation increased the wound infection rate ..." In a prospectively randomized study of 1013 patients undergoing elective surgery, Alexander et al. (1) observed that those whose hair was clipped had significantly fewer infections than did those who were shaved and they concluded that "Preoperative shaving is deleterious, and the practice should be abandoned." In 1982, Balthazar et al. (3) reported a prospective randomized study of 200 patients who underwent elective herniorrhaphy and found no significant difference in infections between those shaved and those whose hair was removed with clippers. The presence of hair did not increase the risk of infection in patients undergoing transurethral surgery (22). In 2850 patients whose hair was removed by clipping (no shaving), Olson et al. (47) found an infection rate (1%) that was insignificantly different from that of the previous 3 years when all hair was removed by shaving. Seropian and Reynolds (56) discovered, in 406 general surgical cases, a nearly tenfold difference in surgical infection rates (5.6% versus 0.6%) between shaved patients and patients whose hair was removed by depilatory; in another 155 patients in whom no hair was removed, the infection rate was also 0.6%. In a prospective study, Westermann and Malottke (66) reported five postoperative wound infections (2%) in 249 patients whose hair was removed by a depilatory cream and 18 infections (6.5%) in 278 patients who were shaved in preparation for surgery. They concluded that "the razor preparation has a definite adverse effect" and "bacterial liberation and growth after razor preparation injury is responsible for this adverse effect." In a prospective study, Howell and Morgan (32) observed no wound infections in 68 scalp lacerations repaired without the removal of hair. Although Mackenzie (39) accepted, without explanation, that shaving was necessary for surgery on the scalp, he warned that "This minor procedure is not without hazard." As long ago as 1922, it was observed that obstetrical infections were more common in women who were shaved than in those not shaved (34). Thompson and Ashley (62) analyzed the complications in 922 consecutive facelift procedures, which require incisions within or near the hairy scalp (these procedures are often done without shaving), and found only three infections (excluding stitch abscess
Argument for shaving I have been unable to find any primary source to support shaving in preparation for surgery, but this does not mean that there is no rationale for the traditional practice. The argument that hair should be
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removed to speed the surgical closure probably has validity but is rarely mentioned by the practitioners of shaving, and the time lost in closure is probably less than the time spent in shaving. If the removal of hair for surgery is viewed as a ritual, then it might be argued, weakly I believe, that rituals, even neurosurgical ones, that are important to the practitioner become important to the patient by affecting the practitioner's performance. Clearly, adhesive tape can be applied and removed more easily from hairless skin. CONCLUSIONS The data from this study strongly support the notion that skin, including the scalp, can be prepared safely for neurosurgical procedures without removing the hair. This is consistent with the microbiological literature and with observations from other surgical disciplines indicating that shaving increases the risk of surgical wound infection. Hair is relatively easily rendered free of bacteria, and hair does not interfere with removing bacteria from the underlying skin. There is no theoretical reason and no bacteriological, epidemiological, or even titillating empirical data to support the contention that hair increases bacterial contamination of neurosurgical wounds or that its removal reduces the risk of infection. In a properly prepared clean surgical field, wound sepsis can be attributed rarely if ever to the patient's hair that is near or within the operative site. The founding fathers of neurosurgery shaved their patients as did our revered teachers and we, in imitation of them, have continued the ritual. But what is gained by all of this labor by neurosurgeons and their assistants, by the expense of shaving paraphernalia and additional time in the operating suite, and by our patients' losing an important part of their body image? The answer is, at best, the satisfying of a tradition and, at worst, an increase in the risk of infection. Caveat A surgeon planning to operate without removing hair is strongly encouraged to note the details in the sections "Preparation of skin and hair for surgery" and "Management of hair during surgery." The technique described therein differs importantly from the usual technique for preparing shaved skin. Failing to properly cleanse the hair and scalp, preparing only a small surgical field, or leaving hair violating the surgical closure can be predicted to result in a contaminated surgical wound and an increase in the risk of infection. Received, November 4, 1991. Accepted, January 15, 1992. Reprint requests: Ken R. Winston, M.D., Box B467, The Children's Health Center, 1950 Ogden Street, Denver, CO 80218. REFERENCES: (1-68) 1.
Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ: The influence of hair-
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Hair has a macroscopically smooth surface even though it appears scaly on electron microscopy; for most bacteriological considerations, hair is nonporous, but it does efficiently trap particles, including microorganisms from the environment (45), presumably by electrostatic charge. Hair offers bacteria no mechanical sanctuary, in contrast to hair follicles and sebaceous glands that protect bacteria within the skin from all but the most destructive mechanical and chemical approaches. Clearly pathogenic bacteria can reside on hair, but physicians and nurses are much more likely to have S. aureus in their hair and in much greater numbers than are outpatient controls or hospitalized patients (8); the reports on surgical infections from hair-borne bacteria deal with bacteria from the hair of physicians and nurses (21). Although it is reasonable to believe that bacteria from patients' hair can be a source of infection, Price, in 1938, demonstrated that in areas of well-washed skin the hairs are sterile (50). It is reasonable, therefore, to believe that bacteria on hair are easily removed by the mechanical and chemical preparation of the underlying skin. Also there is no evidence that the presence of hair impairs the removal of bacteria from the underlying skin. If surgical wound infection rates are lower in patients retaining their hair, then we must conclude that either 1) the process of shaving affects the skin in a way that makes wounds more susceptible to infection or 2) the hair itself exerts some protective effect, perhaps by diminishing bacterial contamination via mechanically attracting bacteria before they enter the wound. The mechanism whereby shaving raises the risk of infection was addressed in experiments by Hamilton et al. (29) who, via scanning electron microscopy, demonstrated that preoperative shaving with a razor produces multiple parallel slices in the skin that are not apparent to the naked eye; it is well known that a razor will occasionally produce grossly visible cuts. These authors postulated that "skin commensals or transient bacteria lodge in the microscopic injuries caused by the razor ... multiply and later infect the wound." It has been known for many years that shaving days or even several hours before an operation raises the risk of infection (17,18,56), and this is thought to be the result of bacterial colonization of the exudate from the multitude of microscopic cutaneous wounds along the surgical incision line. Seropian and Reynolds (56) found a wound infection rate of 3.1% if razor preparation immediately preceded surgery, 7.1% if the preparation was done up to 24 hours before surgery, and 20% when the preparation was done more than 24 hours before surgery. Interestingly, depilatory agents may cause a lymphocytic reaction in the dermis (29), and some patients have cutaneous allergic responses to these agents.
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35.
John A. Persing Charlottesville, Virginia This is a fascinating article that seems to debunk an accepted concept that shaving is required to create a clean field for neurosurgery. This report contains a great deal of material that would not necessarily be accessible to neurosurgeons and presents it in a comprehensive fashion. Clearly, prevention of surgery-related infections is of major concern. This report demonstrates the effectiveness of one set of approaches to a number of specific issues. The author describes in some detail his rationale for not shaving the hair, which is quite convincing. On the other hand, the shaved pate is certainly esthetically pleasing and facilitates the design and execution of skin incisions. Despite this, the article certainly suggests that this technique might be
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COMMENTS In this study, Dr. Winston demonstrates that with a regimen of preoperative shampooing and intravenous antibiotics, both cranial and spine surgery may be performed without shaving hair, but with infection rates that are comparable with previously published rates. As the author reports, the study is not a prospective randomized study that would allow the conclusion that his regimen is superior to other regimens of shaving and antibiotics, but it does indicate that the approach does not lead to higher infection rates when compared with previously reported studies where shaving was routine. The author correctly points out, as well, that he has not demonstrated that the regimen proposed is the best regimen available, citing the possibility that different antibiotics and/or cleansing agents are more effective. Is there any advantage, then, for leaving the hair unshaven at the wound site? Certain facts, brought to light by Dr. Winston's overview of the topic, indicate that there are some theoretical advantages to avoiding shaving the patient's hair preoperatively. Avoidance of microtrauma to the skin, caused by shaving, probably reduces the likelihood of infection, although the infection rate differences between the methods of hair/skin preparation described are relatively small. Potentially, it may take time to prepare the patient for surgery if the hair is not shaved. However, the primary reason for not shaving hair is that the patient's image of him or herself after the operative procedure with hair intact is better preserved, and surprisingly, greatly appreciated by the patients and their families. This advantage must be balanced against the technical annoyance of having hair get into the wound, making it more time consuming to suture the scalp. Weighed against this minor technical inconvenience and observing no higher rates of surgical infection with hair preservation, I believe, as Dr. Winston does, that hair removal is not advantageous and probably counter-productive to the goal of rapid rehabilitation of the patient.
Table 2. General Characteristics of the Sample
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Table 1. Distribution of Cases and Wound Infections by Hospital
Table 4. Cases with Surgical Wound Infections
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Table 3. Distribution of Surgical Wound Infections by Type of Surgical Procedure
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Table 5. Neurosurgical Wound Infection Rates for Cranial Proceduresa
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Table 6. Neurosurgical Wound Infection Rates for Cerebrospinal Fluid Diversion (Shunt)a
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convenient handle while they tried to incise (nonsurgically) Macedonian throats (19). The English word barber is thought to have derived from a Sanskrit word meaning unintelligible or stammerer (48) . Individuals willing to deal with human hair, probably foreigners who garbled the local language, were the obvious choice for handling such other unsavory jobs as attending wounds and extracting teeth. It is reasonable to believe that these early barbers, possessing better shaving skills than surgical techniques, combined their skills--or perhaps never viewed them as separate--when dealing with wounds. Shaving gained a theological buttress and became even more closely tied to bodily wounds and blood in 1092 as a consequence of a decree forbidding monks from wearing beards; this decree gave rise to a profession serving the purpose of shaving and therapeutically bleeding monks (58). In 1461, Edward IV incorporated the Company of Barber-surgeons and later Henry VIII changed the name to Company of Barbers and Surgeons, with the former restricted to hairdressing and dentistry and the latter being more involved with blood letting and the management of wounds. In 1886, Gustav Neuber wrote that the skin in the operative area should be shaved to allow careful washing of the area. In 1895, Carl Beck (5) stated, "The field of operation must invariably be shaved if there is the slightest evidence of the presence of hairs." According to Victor Horsley (31), "The day before the operation, the patient's head is shaved ... "and Harvey Cushing (20) wrote," The scalp, which may have been shampooed, is shaved just before the operation ... ." Concerning the prevention of surgical wound infections, the guidelines of the Centers for Disease Control (27) list no indication for removing hair and state "Unless hair near the operative site is so thick that it will interfere with the surgical procedure, it should not be removed." On the subject of shaving, the guidelines state "If hair removal is necessary, it should be done either by clipping or using a depilatory rather than shaving." PATIENTS AND METHODS Patients Prospectively kept records on all patients who were operated on by one neurosurgeon between July 1, 1988, and November 1, 1991, are the basis for this report. The operations were performed in seven hospitals (designated A-G in Table 1) in Denver, Colorado. Surgical residents were actively involved in the preoperative, operative, and postoperative care of all patients except those of hospitals F and G (Table 1). The attending neurosurgeon was present and scrubbed for each case. Dirty or infected cases were excluded, i.e., patients presenting with suppurative wounds, but clean-contaminated and contaminated cases were included (see below). The following operative procedures were excluded: tracheotomy, insertion of intracranial pressure monitor, and percutaneous ventriculostomy, unless these were part of a larger operative undertaking. Also the 5 patients who survived less than 2 months
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Neurosurgery 1992-98 August 1992, Volume 31, Number 2 320 Hair and Neurosurgery Special Report
Preparation of skin and hair for surgery No hair was removed in preparation for surgery. When practical (about 75% of the cases), patients were instructed to bathe (preferably shower) and shampoo with 4% w/v chlorhexidine (Hibiclens, Stuart Pharmaceutical, Wilmington, DE) once within the 24 hours before surgery; children were bathed and shampooed preoperatively by parents or nurses. The final preparation of all patients' skin and hair was done in the operating room after anesthetic induction. The entire operative region was scrubbed energetically for at least 8 minutes (usually timed) with undiluted 4% chlorhexidine (usually Hibiclens). A brush was used only if dirt, debris, or desquamated skin was visible; otherwise all scrubbing was done with gauze surgical sponges and gloved hands. For cranial operations, all hair on the scalp that was sufficiently long to reach the operative site was shampooed vigorously; for most patients, the entire scalp and all scalp hair, however long, was shampooed. The area of scalp that had to be scrubbed and shampooed in patients with hair was much larger than the area customarily shaved and scrubbed. The entire surgical area (skin and hair) was then irrigated with 70% isopropyl alcohol while being gently massaged to assist in removing the remaining visible soap. If the hair was sufficiently long, while still wet with alcohol, it was parted along the proposed incision line with a sterile comb or hemostat and then secured with sterile elastic bands or hemostats. Skin and hair were dried by pressing a surgical towel (cloth or paper) against the scrubbed area. If the upper face was to be prepared, as in craniofacial procedures, the eyelids were sutured closed after a generous portion of an ophthalmic ointment was placed beneath the eyelids; the scrub was continued over the face, with less vigorous scrubbing over and around the eyes; no alcohol was used about the eyes. In approximately 95% of cases, the attending neurosurgeon was present for the scrub and supervised or did the scrubbing. For planned scalp incisions, the operative field was usually draped, exposing approximately 2 cm of skin, and the edges of the towels (usually cloth) were stapled to the skin; occasionally, a much larger area of hairy scalp was left exposed. Occlusive plastic adherent drapes were not used routinely on the scalp. For less hairy regions (e.g., abdomen, neck, and spine), larger areas of skin were left exposed by the drapes, and, in these locations, an occlusive adherent plastic drape (not containing iodophor) was used routinely. Management of hair during surgery Hair was ignored during operative procedures. No case was encountered in which the surgeon considered hair removal to be necessary for technical reasons, i.e., the thickness and length of the hair did not interfere with the surgical procedure. If hair fell
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into the operative field (some hairs entered almost every operative wound), it was pushed aside; loose (unattached) hairs were removed when encountered. Loose hair, which had a tendency to be identified in the operative field immediately after the skin incision and during the closing process, was removed from the field. During the process of closing the scalp, it was usually necessary to push hair aside and often necessary to wet (bacitracin irrigation solution) the hair to keep it aside; long hair had less tendency to enter the field than did hair of a few centimeters length. While closing the galea aponeurotica or subcutaneous tissues, particular attention was given to the avoidance of trapping hair in the surgical knots. Scalp edges were approximated with staples (except in premature children). After all staples were applied, the surgeon reinspected the wound millimeter by millimeter to identify and to remove any hairs caught in the closure and also to assure proper alignment of the skin edges. Relatively nonhirsute areas were usually approximated with surgical adhesive strips. Vacuum drainage (usually a 7-mm Jackson-Pratt drain) was used for all except six of the patients who underwent craniotomy; the drain always exited via a separate stab wound and remained in position for approximately 24 hours; drainage sites were not sutured after the drain was removed. A dry turban dressing was used for all scalp incisions, however small; tape was never applied to hair. Antibiotic ointment was not used on surgical wounds or drain sites. Dressings were removed usually on the second or third postoperative day, except on patients in whom there was concern about molestation of the wound, e.g., young children and patients with impaired consciousness or retardation. When cranial dressings were removed, the hair usually had the appearance of containing residual chlorhexidine containing soap. Surveillance of wounds The wounds of all surviving hospitalized patients were examined by the surgeon, house officer, or both at least once (usually daily after the second postoperative day) during the first postoperative week. Most patients were repeatedly evaluated during hospitalization and were followed for months after discharge from the hospital. Patients with cerebrospinal fluid (CSF) shunts were never discharged from follow-up. Every attending neurosurgeon and house officer was made aware that this surgeon was to be notified if there was suspicion of a wound infection in any of this surgeon's patients. Definitions Wounds were prospectively classified according to the definitions of Cruse and Foord and the CDC guidelines (18,26,27), with slight modification in wording for a clearer application to neurosurgical procedures. A clean wound is one in which no infection is encountered; there is no major break in sterile technique and no entry into a cavity, such as the nasopharynx, trachea, or abdominal viscus. A clean-contaminated wound is one in which a hollow
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after surgery were excluded. Five patients, most from early in the period of accrual, were shaved by an assistant not familiar with this surgeon's routine; these patients have been excluded.
Antibiotics All except 8 patients received prophylactic antibiotics intravenously, beginning when the iv was started in the operating room and continuing for approximately 24 hours. Patients undergoing operations for CSF diversion received vancomycin (40 mg/kg/d), unless there was a history of allergy. Other patients usually received cefazolin. Patients with clean-contaminated or contaminated wounds received antibiotics for longer periods. All wounds were irrigated with bacitracin solution (approximately 50,000 units per half liter of saline) at least once and usually multiple times. RESULTS The distribution of the 638 neurosurgical procedures by age, sex, and type of surgical procedure is displayed in Table 2. All seven infections in this series (1 craniotomy and 6 shunt procedures) occurred among the 595 clean procedures (Tables 1 and 4). No surgical wound infection occurred among the 6 clean-contaminated or the 37 contaminated cases. The overall rate of surgical wound infections in this series was 1.1% (Tables 1 and 3). The one surgical infection among the 313 cranial cases was almost certainly not related to the preparation of the skin. The craniotomy that became infected was for acute subdural hematoma and was done as an extreme emergency and complicated by diffuse intravascular coagulopathy; a few days after the operation, the patient partially opened the surgical wound with his fingernails and Staphylococcus aureus was cultured from the wound at the time of a second cranial procedure 5 weeks later. The overall
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infection rate for cranial cases was 0.3%; however, the infection rate that reasonably may be attributed to the preparation of the skin was zero. No infections occurred among the 124 spinal procedures. The 218 procedures for CSF diversion had an overall infection rate of 2.7%. One of the six shunt infections cannot be attributed to a problem with preparation of the skin; that infection was related to erosion of hardware through the overlying scalp. Inconsistent with the technique for nearly all of the other patients in the series, two other patients who developed shunt infections had their skin prepared with chlorhexidine solution that had been diluted considerably (amount not documented). None of the patients who developed infections had a preoperative bath or shampoo with chlorhexidine. In none of the infected cases was there evidence for preexisting infection or a break in sterile technique, but these possibilities cannot be excluded. Twenty operative procedures, 6 of which were CSF diversions, were performed within the 2 months before the close of this study. Although most surgical wound infections (including CSF shunt infections) are apparent within 2 months after surgery, some CSF shunt infections and rare postoperative wound infections may appear months or even years after cranial or spinal procedures (28). It is possible that additional infections in the patients of this series could appear in the future, as is true for all published series. DISCUSSION Interpretation of data The neurosurgical wound infection rates in prospectively accrued patients whose skin was prepared without removal of hair compares very favorably with the best published infection rates for patients whose skin preparation included shaving (Table 5). Although not proving that leaving the hair intact for neurosurgical procedures is superior to shaving, this study does make it reasonable to believe that hairy skin, including scalp, can be cleaned sufficiently well to make the risk of surgical wound infection insignificantly different from the lowest values reported from the best of the recently reported series in which it is reasonable to believe that all patients were shaved. It should be noted that the infection rates in the series herein reported were from consecutively accrued patients of a single neurosurgeon operating under a variety of conditions in multiple hospitals and almost always with house officers. Two of the 7 infections in this series were very unlikely to have been related to the preparation of the operative site but may have been prevented by more attention to surgical wounds--one by either better planning of the surgical incision or by preventing the child from lying on the shunt system postoperatively and the other by better postoperative protection of the surgical wound. The cause of the other 5 postoperative infections--each a CSF shunt revision-is not clear; although two of these patients were scrubbed with a relatively dilute solution of chlorhexidine, attribution of these infections to this
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cavity, such as the nasopharynx, is entered. Most of the clean-contaminated operations were so classified on the basis of entering the nasopharynx as part of a craniofacial reconstruction or exposure of a frontonasal neoplasm (Table 1). A contaminated wound is one within an area of acute inflammation (not pus), a traumatic wound less than 4 hours old, a CSF shunt infection (without pus), and operations associated with a major break in sterile technique. In this series, most of the contaminated cases were so classified because of an infected CSF shunt or on the basis of a traumatic open wound. A dirty or infected wound is one in which pus is identified and/or there is reason to believe that organisms causing postoperative infection were within the operative field before the operation (this includes all traumatic wounds 4 or more hours old). Consistent with the CDC guidelines, a wound was classified as infected if pus was identified within the wound or if the attending surgeon believed the wound to be infected; stitch abscesses requiring no mechanical intervention and no antibiotics were not classified as surgical wound infections (26). A positive culture was not required except for the diagnosis of CSF shunt infections. Infection presenting within a year after a previous shunt infection with the same organism was considered to be an inadequately or unsuccessfully treated first infection and not a second infection.
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of whether patients received prophylactic antibiotics. This study includes no prospective randomized control, and therefore the data are meaningful only in comparison with published data. Strict comparisons of rates of surgical wound infection are not valid (51) because of important differences among the series, e.g., diagnostic case mix, use of prophylactic antibiotics (types, doses, etc.), surgical procedures and techniques, criteria for diagnosis of infection, and the intensity, objectivity, and duration of surveillance for infection and even methods of calculation (67). There is a tendency to think that all observed differences in infection rates reflect real differences but this is not necessarily true. Confidence intervals (which can be calculated from data provided by authors) reflect the extent to which values are reliable; the extensive overlap in confidence intervals from a sampling of reports is apparent in Tables 5 and 6. The number of "Cases Needed to Identify Difference" (last column of Tables 5 and 6) is a calculated estimate of the magnitude of the task (i.e., number of cases) that would be required in a prospective study to meaningfully compare the apparent differences between this study and various published values. For example, a prospective randomized study designed to compare a sample of patients undergoing craniotomy as managed and reported here (0.3% infection rate) with a sample of patients as managed and reported by Cartmill et al. (13) (0.7% infection rate) would require approximately 21,000 cases to have a 90% chance of identifying the difference at the 5% confidence level, in a one-tailed test (59). Therefore, given the magnitude (and other practical considerations) of a study that could meaningfully compare/differentiate small observed differences in infection rates, it is unlikely that such a study will be done in the near future, if ever. Until and unless such studies are done, we have no compelling basis for concluding that nonshaving is superior to shaving, or vice versa, and therefore we must examine the less direct, but not necessarily less valuable, evidence. Neurosurgical literature on removing hair For patients undergoing a craniotomy, Zentner et al. (68) found that 5.5% of 237 patients having a standard wet shave, 3.2% of 93 patients having a dry shave, and 2.8% of 145 patients having their hair removed by clippers developed a surgical infection (differences not significant at 5% level). Scherpéreel et al. (54) briefly reported on 1000 craniotomies in which only a 1- to 2-cm strip was shaved along the proposed incision line and found an infection rate of 0.6%; however, the report contains little detail, no definition of infection, and only minimal information on the technique, types of cases, and their follow-up. Shaving only along the proposed incision line, at first consideration, seems to be a compromise between shaving and nonshaving, but, because the skin nearest the incision is the skin most likely to contribute to floral contamination of the wound, shaving the area of surgical incision probably exposes the patient to the full risk of shaving or worse.
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cause seems tenuous. The shunt infection rate may be the most sensitive indicator of the effectiveness of any technique in removing bacteria from the operative field in preparation for surgery because of the following: 1) infection rates for shunting procedures are typically higher than the rates for other neurosurgical procedures; and 2) the most common organisms causing shunt infections are thought to be introduced at the time of surgery from the patient's skin (4). Six of the 7 infections in this series were in patients who underwent CSF diversion (shunt operations), giving a 2.7% infection rate. The favorableness of this value is apparent when it is compared with the published shunt infection rates in the last decade, most of which are between 5 and 38% (see a review of the literature on shunt infections by Quigley et al. [51]). It is more meaningful, however, to compare the results of this study, not with the average rate or with the range of published values, but with the better (i.e., lower) infection rates (Table 6). Infection rates have been reported to be much higher for premature infants, children with myelomeningocele, and the internalization of extraventricular drains; the series reported here contained at least 36 cases in these three categories, only one of which became infected. It is reasonable to believe that clean cases are at less risk of infection than are clean-contaminated and contaminated cases and therefore the absence of surgical wound infections among the 6 cleancontaminated and 37 contaminated cases is somewhat surprising. This observation may reflect the small number of cases in these groups plus the effectiveness of antibiotics that were administered for approximately 48 hours in the clean-contaminated cases and often longer in the contaminated cases. The possibility that the chlorhexidine was responsible for the low surgical wound infection rate in this series, independent of hair removal, cannot be excluded. Chlorhexidine (undiluted 4% solution) was used to prepare the skin in all patients in this sample; chlorhexidine has a residual bacteriocidal effect on the skin (44). A preoperative shampoo with chlorhexidine has been shown to significantly reduce the density of transient flora on the scalp (37) as well as other parts of the body (6,11,12,24,25) for up to 6 days (39) . There is no basis for postulating whether other agents would have resulted in equivalent infection rates. The postoperative infection rates for general surgery are also reported to be reduced by chlorhexidine (30). Prophylactic antibiotics, particularly in operations for CSF diversion (shunt procedures), are very widely used by neurosurgeons; however, the purists can claim justifiably that their value is not proven. Although not the subject of this investigation or analysis, the patients in this study received prophylactic antibiotics intravenously; also their wounds and all implanted hardware were irrigated with a solution of antibiotic. A sampling of published infection rates for craniotomy, with and without prophylactic antibiotics, can be seen in Table 5. Clearly the 0.3% infection rate of this study compares very favorably with the published results, regardless
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and open wounds receiving prophylactic antibiotics). In a review of the literature on preparation of the skin for surgery, Masterson (40) states, "The only reason to remove hair from the operative site is if it interferes mechanically with accurate, anatomic approximation of the wound." The same author states, "There is no room for misinterpreting the data; removing hair with a razor increases the wound infection rate in almost all the reports." Interestingly in veterinary surgery, which requires an incision through densely hairy skin in almost all procedures in mammalians, hair is usually removed by clipping (49) because shaving is often impractical and is thought to increase the risk of wound infection. Microbiology There are two populations of bacteria on the skin, usually designated as resident and transient (see reviews of skin bacteriology by Masterson (40), Montes and Wilborn (43), and Noble (45)). All flora on hair are transients. The transient flora vary greatly in kind and in population density. Kligman (35) found 5.04 × 105 (geometric mean) aerobic bacteria on the nondandruff scalp and 9.22 × 105 on the dandruff scalp; about 90% of these are coagulase-negative Staphylococcus nonaureus (41). The resident flora on the skin are rarely pathogenic (55) but are predominantly diptheroids and gram-positive rods (Corynebacterium and Propionibacterium) (40). Interestingly, Propionibacterium acnes is the dominant bacteria in oily regions of the skin-forehead, scalp, and sebaceous glands of hair follicles (40) . Price (50) demonstrated that "in any given area of skin, degree of hairiness has little if any relation to size of bacterial flora." Also bacterial flora on hair is influenced little if any by the length of hospitalization or by antibiotics (8). The goal of preparing the skin for surgery is to prevent surgical infection by minimizing the transient population of bacteria, particularly pathogenic bacteria (38,39). As a practical point, the surgeon can not sterilize the skin (destroy all bacteria on and within it) in preparation for surgery because about 20% of bacteria on or within skin and its appendages, i.e., the resident population, are inaccessible to the effects of surgical scrubs and antiseptics; for the scalp, this number may be closer to 50% (55). Bacteria within the skin, particularly oily regions, "are protected from disinfection by lipids, especially at the mouths of follicles, or by overlying portions of the stratum corneum," according to Selwyn and Ellis (55). It is reasonable, however, to strive for disinfection of the skin (removal of all pathogenic organisms) because bacteria enter all surgical wounds to such an extent that cultures from clean surgical wounds just before closure are often positive, yet few of these wounds become infected (37,64). Most studies assessing the effectiveness of eliminating bacteria from the skin have necessarily addressed only the transient population because this population is more easily quantified than the resident population. Nearly all transient bacteria, in contrast to resident bacteria, are eliminated during the process of preparing the skin (scalp or other) for surgery.
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Literature from other surgical disciplines Published surgical series composed predominantly or totally of nonneurosurgical cases support the position that shaving hair in preparation for surgery either raises the risk or, at best, may not increase the risk of infection. In 1980, Cruse and Foord (18) reported on 62,939 prospectively studied surgical wounds and found the infection rate among the 42,054 clean wounds to be 2.5% when the operative site was shaved with a razor, 1.4% when shaved with an electric razor, and 0.9% when there was no shaving or clipping; they concluded that "Shaving the operation site increased the infection rate of clean wounds". In a prospective study on 406 patients undergoing abdominal surgery, Court-Brown (16) concluded that "Skin shaving before operation increased the wound infection rate ..." In a prospectively randomized study of 1013 patients undergoing elective surgery, Alexander et al. (1) observed that those whose hair was clipped had significantly fewer infections than did those who were shaved and they concluded that "Preoperative shaving is deleterious, and the practice should be abandoned." In 1982, Balthazar et al. (3) reported a prospective randomized study of 200 patients who underwent elective herniorrhaphy and found no significant difference in infections between those shaved and those whose hair was removed with clippers. The presence of hair did not increase the risk of infection in patients undergoing transurethral surgery (22). In 2850 patients whose hair was removed by clipping (no shaving), Olson et al. (47) found an infection rate (1%) that was insignificantly different from that of the previous 3 years when all hair was removed by shaving. Seropian and Reynolds (56) discovered, in 406 general surgical cases, a nearly tenfold difference in surgical infection rates (5.6% versus 0.6%) between shaved patients and patients whose hair was removed by depilatory; in another 155 patients in whom no hair was removed, the infection rate was also 0.6%. In a prospective study, Westermann and Malottke (66) reported five postoperative wound infections (2%) in 249 patients whose hair was removed by a depilatory cream and 18 infections (6.5%) in 278 patients who were shaved in preparation for surgery. They concluded that "the razor preparation has a definite adverse effect" and "bacterial liberation and growth after razor preparation injury is responsible for this adverse effect." In a prospective study, Howell and Morgan (32) observed no wound infections in 68 scalp lacerations repaired without the removal of hair. Although Mackenzie (39) accepted, without explanation, that shaving was necessary for surgery on the scalp, he warned that "This minor procedure is not without hazard." As long ago as 1922, it was observed that obstetrical infections were more common in women who were shaved than in those not shaved (34). Thompson and Ashley (62) analyzed the complications in 922 consecutive facelift procedures, which require incisions within or near the hairy scalp (these procedures are often done without shaving), and found only three infections (excluding stitch abscess
Argument for shaving I have been unable to find any primary source to support shaving in preparation for surgery, but this does not mean that there is no rationale for the traditional practice. The argument that hair should be
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removed to speed the surgical closure probably has validity but is rarely mentioned by the practitioners of shaving, and the time lost in closure is probably less than the time spent in shaving. If the removal of hair for surgery is viewed as a ritual, then it might be argued, weakly I believe, that rituals, even neurosurgical ones, that are important to the practitioner become important to the patient by affecting the practitioner's performance. Clearly, adhesive tape can be applied and removed more easily from hairless skin. CONCLUSIONS The data from this study strongly support the notion that skin, including the scalp, can be prepared safely for neurosurgical procedures without removing the hair. This is consistent with the microbiological literature and with observations from other surgical disciplines indicating that shaving increases the risk of surgical wound infection. Hair is relatively easily rendered free of bacteria, and hair does not interfere with removing bacteria from the underlying skin. There is no theoretical reason and no bacteriological, epidemiological, or even titillating empirical data to support the contention that hair increases bacterial contamination of neurosurgical wounds or that its removal reduces the risk of infection. In a properly prepared clean surgical field, wound sepsis can be attributed rarely if ever to the patient's hair that is near or within the operative site. The founding fathers of neurosurgery shaved their patients as did our revered teachers and we, in imitation of them, have continued the ritual. But what is gained by all of this labor by neurosurgeons and their assistants, by the expense of shaving paraphernalia and additional time in the operating suite, and by our patients' losing an important part of their body image? The answer is, at best, the satisfying of a tradition and, at worst, an increase in the risk of infection. Caveat A surgeon planning to operate without removing hair is strongly encouraged to note the details in the sections "Preparation of skin and hair for surgery" and "Management of hair during surgery." The technique described therein differs importantly from the usual technique for preparing shaved skin. Failing to properly cleanse the hair and scalp, preparing only a small surgical field, or leaving hair violating the surgical closure can be predicted to result in a contaminated surgical wound and an increase in the risk of infection. Received, November 4, 1991. Accepted, January 15, 1992. Reprint requests: Ken R. Winston, M.D., Box B467, The Children's Health Center, 1950 Ogden Street, Denver, CO 80218. REFERENCES: (1-68) 1.
Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ: The influence of hair-
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Hair has a macroscopically smooth surface even though it appears scaly on electron microscopy; for most bacteriological considerations, hair is nonporous, but it does efficiently trap particles, including microorganisms from the environment (45), presumably by electrostatic charge. Hair offers bacteria no mechanical sanctuary, in contrast to hair follicles and sebaceous glands that protect bacteria within the skin from all but the most destructive mechanical and chemical approaches. Clearly pathogenic bacteria can reside on hair, but physicians and nurses are much more likely to have S. aureus in their hair and in much greater numbers than are outpatient controls or hospitalized patients (8); the reports on surgical infections from hair-borne bacteria deal with bacteria from the hair of physicians and nurses (21). Although it is reasonable to believe that bacteria from patients' hair can be a source of infection, Price, in 1938, demonstrated that in areas of well-washed skin the hairs are sterile (50). It is reasonable, therefore, to believe that bacteria on hair are easily removed by the mechanical and chemical preparation of the underlying skin. Also there is no evidence that the presence of hair impairs the removal of bacteria from the underlying skin. If surgical wound infection rates are lower in patients retaining their hair, then we must conclude that either 1) the process of shaving affects the skin in a way that makes wounds more susceptible to infection or 2) the hair itself exerts some protective effect, perhaps by diminishing bacterial contamination via mechanically attracting bacteria before they enter the wound. The mechanism whereby shaving raises the risk of infection was addressed in experiments by Hamilton et al. (29) who, via scanning electron microscopy, demonstrated that preoperative shaving with a razor produces multiple parallel slices in the skin that are not apparent to the naked eye; it is well known that a razor will occasionally produce grossly visible cuts. These authors postulated that "skin commensals or transient bacteria lodge in the microscopic injuries caused by the razor ... multiply and later infect the wound." It has been known for many years that shaving days or even several hours before an operation raises the risk of infection (17,18,56), and this is thought to be the result of bacterial colonization of the exudate from the multitude of microscopic cutaneous wounds along the surgical incision line. Seropian and Reynolds (56) found a wound infection rate of 3.1% if razor preparation immediately preceded surgery, 7.1% if the preparation was done up to 24 hours before surgery, and 20% when the preparation was done more than 24 hours before surgery. Interestingly, depilatory agents may cause a lymphocytic reaction in the dermis (29), and some patients have cutaneous allergic responses to these agents.
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35.
John A. Persing Charlottesville, Virginia This is a fascinating article that seems to debunk an accepted concept that shaving is required to create a clean field for neurosurgery. This report contains a great deal of material that would not necessarily be accessible to neurosurgeons and presents it in a comprehensive fashion. Clearly, prevention of surgery-related infections is of major concern. This report demonstrates the effectiveness of one set of approaches to a number of specific issues. The author describes in some detail his rationale for not shaving the hair, which is quite convincing. On the other hand, the shaved pate is certainly esthetically pleasing and facilitates the design and execution of skin incisions. Despite this, the article certainly suggests that this technique might be
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COMMENTS In this study, Dr. Winston demonstrates that with a regimen of preoperative shampooing and intravenous antibiotics, both cranial and spine surgery may be performed without shaving hair, but with infection rates that are comparable with previously published rates. As the author reports, the study is not a prospective randomized study that would allow the conclusion that his regimen is superior to other regimens of shaving and antibiotics, but it does indicate that the approach does not lead to higher infection rates when compared with previously reported studies where shaving was routine. The author correctly points out, as well, that he has not demonstrated that the regimen proposed is the best regimen available, citing the possibility that different antibiotics and/or cleansing agents are more effective. Is there any advantage, then, for leaving the hair unshaven at the wound site? Certain facts, brought to light by Dr. Winston's overview of the topic, indicate that there are some theoretical advantages to avoiding shaving the patient's hair preoperatively. Avoidance of microtrauma to the skin, caused by shaving, probably reduces the likelihood of infection, although the infection rate differences between the methods of hair/skin preparation described are relatively small. Potentially, it may take time to prepare the patient for surgery if the hair is not shaved. However, the primary reason for not shaving hair is that the patient's image of him or herself after the operative procedure with hair intact is better preserved, and surprisingly, greatly appreciated by the patients and their families. This advantage must be balanced against the technical annoyance of having hair get into the wound, making it more time consuming to suture the scalp. Weighed against this minor technical inconvenience and observing no higher rates of surgical infection with hair preservation, I believe, as Dr. Winston does, that hair removal is not advantageous and probably counter-productive to the goal of rapid rehabilitation of the patient.
Table 2. General Characteristics of the Sample
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Table 1. Distribution of Cases and Wound Infections by Hospital
Table 4. Cases with Surgical Wound Infections
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Table 3. Distribution of Surgical Wound Infections by Type of Surgical Procedure
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Table 5. Neurosurgical Wound Infection Rates for Cranial Proceduresa
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Table 6. Neurosurgical Wound Infection Rates for Cerebrospinal Fluid Diversion (Shunt)a
