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J Neurosurg 115:670678, 2011

670 J Neurosurg / Volume 115 / October 2011

MOST patients undergoing neurosurgical proce-dures dread the commonly performed preopera-tive hair removal. Nevertheless, many neuro-

surgeons insist on removing the patients hair before sur-gery. They claim that this routine prevents postoperativeinfections and decreases the risk of overlooking woundsor lacerations after head trauma. Moreover, they arguethat preoperative hair removal facilitates accurate plan-ning of the incision, attachment and/or removal of thedrapes, and closure of the wound.

However, since the 1980s several reports have been

published indicating that preoperative shaving may in-crease the risk of postoperative infections due to a changeor loss of protective skin ora and/or bacterial coloniza-tion of the shaved area caused by the razor-induced mi-crotrauma.21,22,28

We systematically reviewed the current literature onpreoperative shaving before neurosurgical procedures,and in this study we discuss the role of shaving preced-ing craniotomies, bur hole procedures, spine surgery, andimplantation surgery in both adults and children.

Methods

Literature Search Strategy

Two reviewers (M.L.D.B. and J.v.B.) searched Pub-Med, Embase, and the Cochrane Database of SystematicReviews up to September 8, 2009, using an electronicsearch strategy ([ OR ] AND [ OR ]) supple-mented by hand searching the bibliographies of articles re-trieved by the electronic search. We restricted this reviewto published data. Only papers written in English, Dutch,

French, or German were considered for this review. Titlesand abstracts of retrieved citations were screened, and po-tentially suitable studies were read in full by both review-ers. Relevant data were extracted and disagreements wereresolved by discussion. The following inclusion criteriawere used: 1) studies reporting on consecutive patient se-ries in which either one predened preoperative shavingpolicy was used or in which different policies were com-pared; and 2) studies describing postoperative wound in-fections and other serious (infectious) complications.

Critical Appraisal

The authors aimed for a critical appraisal of the ar-

ticles guided by a simplied classication regarding level

Neurosurgery and shaving: whats the evidence?

A review

*MARIKEL. D. BROEKMAN, M.D., PH.D.,1,2JANNEKEVANBEIJNUM, M.D.,3WILCOC. PEUL, M.D., PH.D.,3ANDLUCAREGLI, M.D., PH.D.1,2

1Department of Neurosurgery, and 2Rudolf Magnus Institute of Neuroscience, University Medical Center

Utrecht; and 3Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands

Many neurosurgeons remove their patients hair before surgery. They claim that this practice reduces the chanceof postoperative surgical site infections, and facilitates planning, attachment of the drapes, and closure. However,most patients dread this procedure. The authors performed the rst systematic review on shaving before neurosurgicalprocedures to investigate whether this commonly performed procedure is based on evidence. They systematically re-viewed the literature on wound infections following different shaving strategies. Data on the type of surgery, surgery-related infections, preoperative shaving policy, decontamination protocols, and perioperative antibiotics protocolswere collected. The search detected 165 articles, of which 21 studiesinvolving 11,071 patientswere suitable forinclusion. Two of these studies were randomized controlled trials. The authors reviewed 13 studies that reported onthe role of preoperative hair removal in craniotomies, 14 on implantation surgery, 5 on bur hole procedures, and 3 onspine surgery. Nine studies described shaving policies in pediatric patients. None of these papers provided evidencethat preoperative shaving decreases the occurrence of postoperative wound infections. The authors conclude thatthere is no evidence to support the routine performance of preoperative hair removal in neurosurgery. Therefore,properly designed studies are needed to provide evidence for preoperative shaving recommendations.(DOI: 10.3171/2011.5.JNS102003)

KEYWORDS neurosurgical procedure shaving hair removal

surgical wound infection

Abbreviation used in this paper:RCT = randomized controlledtrial.

*

Drs. Broekman and van Beijnum contributed equally to thiswork.

See the corresponding editorial in this issue, p 669.

http://thejns.org/doi/abs/10.3171/2011.4.JNS11369http://thejns.org/doi/abs/10.3171/2011.4.JNS11369

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of evidence6 as follows: Level I, data from randomizedcontrolled trials (RCTs); Level II, data from nonrandom-ized concurrent cohort studies; Level III, data from non-randomized cohort studies using historical controls; andLevel IV, data from prospective (IVa) or retrospective(IVb) case series.

Data Extraction

Both reviewers extracted the following details fromthe included articles: type of surgery; data on (wound)infections related to surgery; implantation; preoperativeshaving policy (no, partial, or complete shaving); preop-erative decontamination protocol (for example, shampoowith 4% wt/vol chlorhexidine); and perioperative antibi-otics protocol.

Results

The electronic searches of PubMed and Embase de-tected 165 articles, of which 21 studiesinvolving 11,071patientswere suitable for inclusion (Fig. 1).1,35,79,1114,1620,2325,27,28 Two of these studies were RCTs (Level I evi-dence).5,8A short overview of the included articles is pre-sented in Tables 13, describing the following aspects: lev-el of evidence; number of patients included; perioperativemanagement regarding shampooing, disinfection, shaving,and antibiotics; and infection rates.

Elective Craniotomies

Thirteen studies reported on infection rates afterelective craniotomies.3,4,7,8,1113,19,20,23,24,27,28 Two of thesestudies focused on skull base surgery (Table 1).7,13 In 7studies, other procedures besides craniotomies were de-

scribed.3,4,11,19,24,27,28 In 2 studies, infection rates could notbe calculated for craniotomies separately.3,27

Ratanalert et al.19reported no signicant differencein the occurrence of infection after selecting patientsfor either a nonshaving or a shaving policy based on onesurgeons preference. Three infections (4%) occurred inunshaved patients: 2 cases of supercial incision site in-fections and 1 patient with meningitis caused by Cory-nebacteriumspecies. In shaved patients, 7 infections oc-curred, including 4 supercial infections. Three patientsdeveloped meningitis, and 1 of them died. A random-ized study reported on 20 patients in which every otherpatient beginning with the rst was prepared for surgery

without shaving. No infection occurred in either group.8

Additionally, no infections occurred after 57 shavelessprocedures, including at least 24 craniotomies.4Anotherstudy reported on various procedures, including 87 shave-less craniotomies without any infections afterward.24Sheinberg and Ross23 reported a complete absence ofwound infections after adopting a so-called shavelesspolicy. Unfortunately, the exact number of craniotomieswas not presented, but included 115 procedures for tumor,trauma, and aneurysm surgery, and an unknown numberof additional craniotomies.

Scherpereel20reported a series of 4655 neurosurgicalpatients (excluding shunt procedures) in whom a mini-mal shaving policy was adopted. Twenty-two infections

(0.5%) occurred in 20 patients (0.4%). One patient dieddue to meningitis 15 days after evacuation of subduralhematoma. In another series, Kumar et al.12described 1wound infection (2%) after prospective investigation ofwound infections following elective cranial surgery inadults at an institution with a minimal shaving policy.A recently published retrospective series27 on shavelesscranial surgery reported an infection rate of 1% (7 of632 patients, including 298 craniotomies). Unfortunately,infection rates could not be calculated for separate pro-cedures. One patient who was treated for a parasagittalmeningioma suffered from epi- and subdural empyema.This was evacuated and the bone ap was removed. Sub-

sequently, he was treated with intravenous antibiotics. Ina series of 215 patients,11which included 91 craniotomiesperformed without shaving, 1 patient developed a subga-leal and epidural abscess after resection of a meningioma,necessitating revision of the wound. Winston28concludedthat neurosurgery can be safely performed without shav-ing hair. Only 1 patient (0.4%) developed a wound infec-tion following an emergency craniotomy for an acute sub-dural hematoma. However, this patient partially openedthe wound with his ngernails.

An infection rate of 1% (2 of 175 patients) after skullbase surgery was reported by Gil et al.,7with no differ-ence between clean (2%) and contaminated (1%) proce-dures that involved entry into the nasal cavity or parana-

FIG. 1. Algorithm for electronic search strategy.

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sal sinuses. Moreover, no infections occurred in proce-dures that were considered nonsterile (traumatic woundsor infections). After comparing their results to those re-ported in the literature, the authors concluded that theirinfection rate after skull base approaches (1%) was simi-lar to or less than the published rates (median 7%, range1%30%). Miller et al.13 concluded that there was nosignicant difference between infection rates for shaved(6%) versus unshaved (7%) patients who underwent anintracranial skull base procedure. None of the includedpatients had a severe infection that required intravenousantibiotics or intraoperative debridement. No differencewas found between shaved and unshaved patients regard-ing either minor infections (4% in both groups) or moder-ate infections (2% in shaved vs 3% in unshaved patients).

Shunt Implantations or CSF Diversion

Fourteen reports provided information on the inu-ence of preoperative shaving of the head on postoperativeinfections in shunt implantation/CSF diversion surgery

(Table 2).1,3,4,9,11,14,1618,2325,27,28The rst group to study the effect of preoperative

shaving in shunt placement reported 6 wound infectionsin 218 CSF diversions (3%). Of these 6 infections, 1 wasnot related to the shaveless policy, but to erosion of hard-ware through the overlying scalp. In 2 cases, infectionmay have been due to excessive dilution of the chlorhexi-dine solution.28 Five groups reported similar infectionrates for shaveless shunt implantations.3,9,18,24,25

Siddique et al.24 found 1 infection (11%) in a ret-rospective series that included 9 shunt procedures per-formed in accordance with a shaveless policy. Similar in-fection rates were observed by Tang et al.25and Bekar etal.,3who observed a 7% (1 of 14 patients) and 11% rate ofinfections, respectively, in patients who underwent shave-less shunt implantation (the rates given for these studiesin the tables are overall rates; the procedures werentspecied separately). These numbers were in their pro-spective25and retrospective3series, and were comparableto those in the control (shaved) groups.

Horgan and Piatt9 reported an infection rate of 3%after a prospective study of 141 patients who underwentshaveless shunt implantation. This appeared to be slightlylower than in the retrospectively studied shaved controlgroup (7%). Ratanalert et al.18observed a greater differ-ence in infection rate between the unshaved group (6%,2 of 32 patients) and the shaved group (15%, 13 of 87

patients).One retrospective series on shaveless cranial surgery

reported an overall infection rate of 1% (7 of 632 patients,including 24 shunt implantations and 1 Ommaya reser-voir). Unfortunately, infection rates could not be recalcu-lated for shunt procedures alone because details on sur-gery types in the 5 patients who suffered from supercialincisional infections were not specied.27

Five studieswhich included various procedures,including shunt implantationsreported complete ab-sence of infections in the shunt-treated subgroup.1,4,11,16,23However, the number of included patients who underwentshunt procedures not preceded by shaving in these 5 stud-ies was low, ranging from 3 to 141 patients (Table 2).T

ABLE1:Studiesreportingonshavingpolicyandinfectionincraniotomies,

includingskullbasesurgery*(continued)

Authors&Year

Evidence

Level

No.of

Pts

(shavedvsu

nshaved)

PeriopManageme

ntRegardingShampooing,

Disinfection,

Shaving,

&ABs

InfectionRate

Tokimuraetal.,

2009

IVb

298(0vs298

)

unshaved:Day1,regularsham

poo;inOR,

0.5

%chlorhexidine-alcoholsolu

tion

ABs:usuallycefazolin;continuedfor1st24hrs

unshaved:1.1

%

(7of632)

*ABs=antibiotics;approx=approximately;BP=BritishPharmacopoeia;excl=exclud

ing;incl=including;OR=operatingroom;p

roc=procedure;Pts=patients.

Categoriesforlevelofevidence:I,RCTs;II,nonrandomizedconcurrentcohortstudies;III,nonrandomizedcohortstudiesusinghistoricalcontrols;IVa,prospectivecaseserieswithoutcontrols;and

IVb,retrospectivecaseserieswithoutcontrols.

Thesestudiesreportedonseveralproce

dures.

Overallinfectionratesonly;numberscou

ldnotbespeciedforcraniotomiesseparately.

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Two groups described the inuence of preoperativehair removal preceding implantation of depth electrodeson postoperative infections. In 2002, Miyagi and asso-ciates14published their retrospective analysis of 261 im-plantations in 221 patients. In 182 cases (199 implanta-tions) hair was not removed preoperatively. The remain-ing patients were shaved. In each group, 1 patient (0.5% vs2%) suffered from a postoperative scalp wound infection.Based on these results, the authors concluded that notshaving does not increase the risk of postoperative woundinfection. In response to this observation, Plaha and co-workers17reported their results after 161 implantations (in86 patients) performed at their center between 1994 and1997. In this group, they observed no head wound infec-tions and 1 chest wound infection (1%). Therefore, theyendorsed the conclusion drawn by Miyagi et al.

Bur Hole Procedures

Five studies reported on shaving policy preceding burhole procedures (Table 3).11,12,19,27,28One study reported 1

supercial incisional surgical site infection in a shaved pa-tient who underwent a biopsy procedure for a metastatictumor. No infections occurred in 18 patients who under-went a bur hole procedure without shaving.19These resultswere similar to those obtained in 3 other studies.11,12,28Inthe fth study, the infection rate for bur hole procedurescould not be calculated separately, but the overall infectionrate was low after surgery performed in accordance with ashaveless policy.27

Spine Surgery

Three studies reported on the role of preoperative hairremoval in spine surgery (Table 3).5,24,28elik and Kara5

randomized 789 patients to investigate the inuence of pre-operative shaving in spine surgery. In the unshaved group(418 cases), only 1 supercial postoperative infection oc-curred. In the group in which the surgical site was shavedpreoperatively, 4 postoperative infections occurred (p