Prospective Randomized Controlled Study Comparing Decompressive Craniectomy with Watertight Duraplasty and without Watertight Duraplasty in Traumatic Brain Injury

Abstract Decompressive craniectomy (DC) is a life-saving procedure for refractory intracranial hypertension following traumatic brain injury (TBI). Despite its widespread use, there is no consensus regarding optimal dural management. Whether watertight duraplasty is necessary during DC remains controversial. The aim of the study is to compare clinical outcomes, postoperative complications, and cranioplasty-related outcomes following DC performed with and without watertight duraplasty in patients with TBI. This prospective randomized controlled study included 200 patients (15–65 years) undergoing unilateral DC for TBI between January 2020 and December 2022. Patients were randomized to DC with watertight duraplasty (n = 100) or non-watertight duraplasty (n = 100). Intraoperative parameters, postoperative complications, mortality, and functional outcomes using the Glasgow Outcome Scale (GOS) at 6 months were analyzed. Outcomes following subsequent cranioplasty were also assessed. Statistical analysis included unpaired t-tests and Fisher exact tests. Baseline demographic and clinical characteristics were comparable between groups. The non-watertight duraplasty group demonstrated significantly shorter operative time and lower intraoperative blood loss (p <0.001). Postoperative complication rates, including cerebrospinal fluid leak, wound infection, hydrocephalus, and subdural hygroma, did not differ significantly between groups (p = 0.65). Mortality was 24% in the watertight group and 28% in the non-watertight group. Functional outcomes at 6 months were similar, with no significant difference in GOS scores (p = 0.793). Cranioplasty-related operative metrics and complication rates were also comparable between groups. DC performed with or without watertight duraplasty yields similar postoperative complications, mortality, functional outcomes, and cranioplasty-related results in patients with TBI.