J. Neurosurg. / Volume 29 / November, 1968 Aluminum Cranioplasty Technical Note Santuet P. W. BLACK, M.D., Catvin C. M. KaMt, MD, AND WaRAEN P. SioHTS, Jn, M.D. Section of Neurological Surgery, University of Misouri Medical School, Columbia, Miswuri Lumen has several qualities that ree- AN emf the tpt full etc It malleable edly cent, extant to coroson, combines ight neo with stength, andi inexpensive, There dre only the reports, however of shaving been uted for ereniopasy, andthe most ee cent of thowe was 0 yetrs ago" in 1958, believing ito be etalium, we used an aluminum plate for the Best tne ie was identied. postoperatively by aay ‘The patent was examined priodialy for 3 Jeart He did well the cramoplasty wes, and Bull is eniely satisfactory. We then ven tured to use dlominom more often in. lected cases These ae our hnigs ‘Technical Considerations The aluminum plate used in this study was the Fox eye shield (Fig. 1 left).* Itis a shallow, oval, bowl measuring 6 7.5 em, These dimensions need not limit the size of the defect that can be covered, as itis possi- ble to weld two or more plates together using the “heliare” process. Ease of trim- ‘ming and moulding allow the plate to be fashioned to the size and shape needed, even to matching a plane as contoured as the su- pra-orbital ridge (Fig. 1 right). An individ- ual plate is 0.064 em (0.025 in.) thick an ‘weighs 5.6 gm, Abundant perforations mini- mize the entrapment of fuid about it. ‘At 80°F, 5 in. Ibs of energy, or 52.5 Ibs of static load, were needed to indent a test crown. When tested, the plate was supported only by its flanges. The smaller the piece of ‘metal and the more it conforms to the con: tour of the supporting structure, the greater is the energy required to deform it an equal Spectroscopic analysis showed the alumi- Received for publication March 26, 1968 Obtained fram V. Mueller and Co, Chicago, Iinois Other surgial supply ‘companies aso Cary We know of no otber preformed sluma um plate num of this plate to contain ao: sicon 16%, copper 0.6%, ion 0.5%, and waers of manganese, mapiesiam, chromium, ta sium, and nickel “The onlay techague of craniopasty was used Inn instance nag the pla inet Contact wih the brain (Fig. 2), Ifthe dure had. beon “opened, was closed” belore proceeding: if destroyed, a subsiute sed When there was a chance of infection era: ioplasy was delayed. Sik stares ouly wer sed 0 secure the pt. tink Experience Sinty-one patients have beea trated with aluminum cranioplasty. the defect was the fest of trauma’ in 41. ates, while burt oes or defects le bythe removal of sll tumors accounted or 20. In 17 of the trauma cases eranopiety was dope at the inital debridement, while in'24 1 was de layed. Although the age of patients ranged from 2 months to 67 years, fe was manly & young group. ‘All ease, with but one exception, were cxamined or” reported” on during the, 6 Ions after hospalzaton; there were no Complains related tothe cranioplaty. Some atin have bon followed for year; most have tetured to the care of ei family doctor, while four with brain tumors ae dead Postuaumatic seizures occured in four patients, anda stated before the aluminum Eramoplasy. If tbe brain injury was minor, phenobarbital was given during hospitals: thon and fora month or two theteatr: i se- ‘ere, anticonvulsants were continued a igi ‘ted. Elecroencephalograms were obtained on 13 patients afer the aluminum was io send. No itrference was detected No plate was rejected by the patient sues, tnd no eflsions were noted. Three plats, however, were, removed surgically. {woof thee ‘covered tonal bun bales and were removed upon re-elevatiog the Bone 562 —eAluminum C: fap in the treatment of recurrent brain tumor. They had been in place 26 months in nt and 6 months in the other, Each cenmeshing it implanted for 6 mont!s P joining the pla contained 710 parts per million dry weight ‘aluminum, Analysis was made by emis: sion flame spectrophotometry using a. prc mixed nitrous oxide-acetylene lame." The third plate removed was from a 28-Ib child who fell approximately 3 feet and landed on hit head. The 4.5» %.3 cm piece of alumi dented. It hed bee in of the plates. removed place 10 months: inserted. None children weed replace- do not ment. indented Discussion The main virtues of an aluminum plat a cranioplasty material are its malleability nd radiolucency. In the latter regard, alumi- num compares favorably with stainless steel,”* 0.007 in, tantalum,” and titanium. is also strong for its weight. A direct bl ill indent this plate, but our tests showed that the energy needed to deform it was equal to that required to deform a 0.015 in ntalum plate of the same size."* Alum , and more me, evokes a foreign body reaction r, the resulting scar tissue has helped ¢ plates and has not impaired hem cosmetically Co im, as does any implanted met han si Howe sion is a hazard. This process occurs Shae 563, ranioplasty 2A aluminum plate covers the larger skull A silver clip was placed at operation to some degre with any metal implanted in living tissues. Aluminum, under ordinary atmospheric conditions, is protected from corrosion by the formation of a thin, trans- parent, tenacious layer of surface oxide. Metal ions are prevented from migrating from the aluminum, and the transfer of electrons from the metal to an oxidizing agent is also blocked.* The coating provides protection even under mildly abnormal con- ditions. But when used for cranioplasty the plate is in contact with the extracellular fluid, one of the most corrosive of substances that is not a frank acid or alkali. Further- more, near a hematoma or dead tissue the pH can fall to as low as 5.5. In such an en Vironment the film of aluminum oxide may form soluable compounds, protection fails, electrons are lost to oxidizing agents, and564 Samuel P. W. Black, Calvin C, M. Kam and Warren P. Sights, Jr. metal ions migrate into the surrounding tissue." The presence of other metals tends to hasten the process. While corrosion was not obvious in the three plates removed from our patients, emission flame spectropho- tometry showed that it had occurred in the case so examined. ‘The significance of a corrosive factor lies in the work done on experimental epilepsy. Aluminum, in the form of alumina cream or as a powder applied to the brain of animals, has been effective in producing seizures.*.** ‘The sequence of structural and physiological changes causing the fits has not been es- tablished. It appears that it is the metal itself rather than the consequences of its operative placement that is responsible. Interference with the enzymatic processes of the neuron is probably the basic etiological factor.** Clinically then, owing to the transfer of metal ions to adjoining tissue, it is prudent to assure separation of aluminum from the brain. We have been careful to do this. No seizures have started in our patients after the cranioplasty, although it is possible that complications may still arise. We do not necessarily favor aluminum over other cranioplasty materials. Our find- ings indicate that, subject to the qualifica- tions mentioned, this metal is useful in the repair of small skull defects. Summary Aluminum in the form of the readily available Fox eye shield has been used for the repair of small skull defects in 61, se- lected patients over the past 10 years. The results have been cosmetically and function- ally satisfactory. ‘The virtues of this aluminum plate are its extreme radiolucency, the ease of trimming and molding, and its strength combined with lightness. Care has been taken not to have the metal in contact with the brain owing to reports of aluminum-induced seizures in ani- mals. Our patients have had no seizures that could be attributed to the use of aluminum. ‘Acknowledgments We are indebted to Professor C. A. Stevens of the College of Engineering and to Professors E. E. Pickett and S. R. Koirtyohann of the College of Agriculture for their help with the examination and testing of the materials men- tioned in the text References 1, Boots, J. A, and tive of tur of the fone te ote operation; recovery” Ann, Surge Bone Wt. Surg., 1958, 40-A:853-869. "a rrpal implants 7. dent Rens 1966043: a implants, J. dent. Res,, 1966, 45: 1660-1661. —T . Lamnorre, A. de aluminium spacer les pertes de substance du crine. Anals Soc. belge Chir, 1894-1895, 2:445-450, . Penrneiy, W., and Jaseen, H. Epilepsy and the functional anatomy of the human brain. Boston: Little, Brown & Co., 1954, 896 pp. (See pp. 220-222). . Pore, A., Mons, A. A., Jasren, H., ELuorr, PENFIELD, W. Histochemical key. Proc. Ass. Res. nerv, ment, Dis., 1947, 26:218-233. ee 5. Reeves, DL. Cr . ms Eanes © Thoma 198019 peep Scorn, My Wras. H. andé Murmieas Pe Long ‘erm evaluation of stainless steel eranio- plasty. Surgery Gynec. Obstet, 1962, 113% Fie Simrsox, D. Titanium in ’ Neworrg. 1965, 1292-293. ee ‘Tonner, 0. A.’ Tantalum and repeated trauma. J. Neurosurg, 1982, 9:100- 19.