Hydrogen peroxide

Hydrogen peroxide irrigation is commonly utilised in neurosurgical procedures and non-neurosurgical procedures for its bacteriocidal and hemostatic effect ¹⁾.

Anatomical pieces that are preserved using formaldehyde allow us to undertake high-quality skull base studies. However, extensive drilling is often necessary, which can lead to damages to the dura mater and thus arachnoid. Formaldehyde and hydrogen peroxide can soften the bone which in turn, can be easily cut with a scalpel or removed with a curette. After having discovered this technique by chance, the aim of Florian et al. from the Department of Neurosurgery, CHU Angers France, was to establish a study protocol of the skull base dura mater without the use of the drill. 10 heads were set with a 10% formalin solution then injected with colored latex. 5 were then subsequently bleached with 20% hydrogen peroxide solution (HPS). (1) Macroscopic modification of the bone, dura mater, arachnoid and brain; (2) Histological study; (3) CT scans and (4) calcium concentration screenings were studied weekly. After several weeks (mean 6.1, range 5-8 weeks) all HPS specimens were flexible, similar to rubber in consistence. Geometrical bone cuts could be made while preserving all the surrounding anatomical structure (cranial nerves, dura mater and vascular elements). Histologically, the dural and bone structure are preserved. The HPS cadavers appear to be radiologically demineralized. They note a significant calcium concentration augmentation in HPS solution after 1-months, 6-weeks and 2 months compared to Day-0. The softening of the bone, probably caused by decalcification from the use of corrosive chemicals present in hydrogen peroxide solution, can ease the cutting of the skull base geometrically, which is useful for anatomical and workshop studies ²⁾.

Its action is due to the large quantity of reactive oxygen species (ROS) liberated during its contact with the (neural) tissues and the exotermic chemical reaction ³⁾ , however it has been associated with devastating complications such as tension pneumocephalus, oxygen embolism and even dysrhythmias. ^{4) 5)}.

Cardiovascular complications are not rare with an incidence of 3%. Special reference is given to the occurrence of the trigeminocardiac reflex (TCR) in this context ⁶⁾.

Kleffman et al, present the case of an 81-year-old female patient who underwent lumbar spine surgery (microsurgical decompression) in an external hospital. H2O2 was used during the procedure. The patient was transferred to our hospital. She remained unconscious postoperatively, with progressive loss of brainstem reflexes. CT showed intraduraland extradurally trapped air ascending intradural from the operated lumbar segment up to frontal lobe. MRI demonstrated severe brainstem lesions on T2- and diffusion weighted magnetic resonance imaging. The patient died 10 days after surgery. Autopsy was not performed.

This case demonstrates a fatal complication with ischemic brainstem lesions and pneumocephalus following use of hydrogen peroxide. Therefore, H2O2 should only be used in cases without any signs of dural injury ⁷⁾.

Patankar et al., report a case of air-embolism and subsequent ischaemic damage to the brain following intra-operative irrigation with hydrogen peroxide within a closed cavity of a spinal cold abscess of tuberculous origin. Copious amount of undiluted hydrogen peroxide irrigation was deployed under moderate pressure to clean-up the abscess cavity. Post-operatively, the patient developed seizures followed by clinical and radiological features of brain ischaemia ultimately resulting in a fatal outcome ⁸⁾.