FIVE-L Classification of Bone Flap Handling in Decompressive Craniectomy

Decompressive craniectomy (DC) is a well-recognized intervention for the management of elevated intracranial pressure following severe traumatic brain injury, stroke, or other causes of malignant cerebral edema.[1] [2] [3] An important intraoperative consideration is how to handle the bone flap after removal.[4] Current strategies vary widely based on institutional resources, surgeon preference, and patient-specific factors.[5] [6] A novel classification system FIVE-L to standardize bone flap handling strategies, improve intraoperative decision-making, and support surgical education can help in following the patients. The FIVE-L classification has five grades (L1 to L5) and each one represents specific strategy of bone handling ([Fig. 1], [Table 1]).