You are on page 1of 528

Atlas of Emergency Neurosurgery

Atlas of Emergency Neurosurgery

Jam ie S. Ullm an, MD, FAANS, FACS


Associate Professor, Dep ar t m en t of Neu rosurger y
Hofst ra Nor th Sh ore-LIJ Sch ool of Medicin e
Director of Neurot rau m a
Nor th Sh ore Un iversit y Hospit al
Man h asset , New York
P.B. Raksin, MD, FAANS
Assist an t Professor, Depar t m en t of Neurosu rger y
Ru sh Un iversit y Medical Cen ter
Director, Neurosu rger y ICU
Ch ief, Sect ion Neu rot raum a & Neurocrit ical Care
Joh n H. St roger Jr Hospit al of Cook Coun t y
(form erly Cook Cou n t y Hospit al)
Ch icago, Illin ois
Medical Illustrato r: Jennifer Pryll

Th iem e
New York St u t tgar t Deh li Rio de Jan eiro

Execut ive Editor: Tim othy Hiscock


Man aging Editor: Elizabeth Palu m bo
Director, Editorial Ser vices: Mar y Jo Casey
Editorial Assist an t: Haley Paskalides
Product ion Editor: Heidi Grauel
In ternat ion al Product ion Director: An dreas Sch aber t
Vice Presiden t , Editorial an d E-Produ ct Developm en t: Vera Spilln er
In ternat ion al Market ing Director: Fion a Hen derson
In ternat ion al Sales Director: Louisa Turrell
Director of Sales, Nor th Am erica: Mike Rosem an
Sen ior Vice Presiden t an d Ch ief Operat ing O cer: Sarah Van derbilt
Presiden t: Brian D. Scan lan
Prin ter: Asia Paci c O set
Library o f Co ngress Catalo ging-in-Publicatio n Data
Atlas of em ergency neurosurger y / [edited by] Jam ie Ullm an , P.B. Raksin .
p. ; cm .
In clu des bibliograph ical referen ces an d in dex.
ISBN 978-1-60406-368-4 ISBN 978-1-60406-369-1 (eISBN)
I. Ullm an , Jam ie, editor. II. Raksin , P. B. (Pat ricia B.), editor.
[DNLM: 1. Em ergen ciesAtlases. 2. Neurosurgical Procedu resm eth odsAtlases. 3. Cen t ral Ner vou s System surger yAtlases.
4. Cen t ral Ner vous System Diseasessurger yAtlases. 5. Cran iocerebral Traum asurger yAtlases.
6. Spin al Cord Injuriessurger yAtlases. 7. Spin al Injuriessurger yAtlases. W L 17]
RD593
617.48dc23
2015005194
2015 Th iem e Medical Publish ers, In c.
Th iem e Pu blish ers New York
333 Seven th Aven u e, New York, NY 10001 USA, 1-800-782-3488
custom erser vice@th iem e.com
Th iem e Pu blish ers St u t tgart
R digerst rasse 14, 70469 St ut tgar t , Germ any, +49 [0]711 8931 421
custom erser vice@th iem e.de
Th iem e Pu blish ers Delh i
A-12, Secon d Floor, Sector -2, NOIDA -201301, Ut t ar Prad esh , In d ia, +91 120 45 566 00
custom erser vice@th iem e.in
Th iem e Pu blish ers Rio d e Jan eiro, Th iem e Pu blicaes Ltda.
Argen t in a Bu ilding 16th oor, Ala A, 228 Praia do Bot afogo Rio de Jan eiro 22250-040 Brazil, +55 21 3736-3631
Prin ted in Ch in a
54321
ISBN 978-1-60406-368-4
Also available as an e-book:
eISBN 978-1-60406-369-1
Im po rtant note : Medicin e is an ever-ch anging scien ce u n dergoing con t in u al d evelop m en t . Research an d clin ical experien ce are con t in u ally
exp an ding our know ledge, in par t icular our kn ow ledge of proper t reat m en t an d drug th erapy. Insofar as this book m en t ion s any dosage or
ap p licat ion , readers m ay rest assu red th at th e au th ors, editors, an d p u blish ers h ave m ade ever y e or t to en su re th at su ch referen ces are in
accordan ce w ith the state o f know ledge at the tim e o f pro ductio n o f the bo o k.
Never theless, th is does n ot involve, im ply, or express any guaran tee or respon sibilit y on th e par t of the publish ers in respect to any dosage
inst ruct ion s an d form s of applicat ion s st ated in th e book. Every use r is requested to exam ine carefully th e m an ufact urers lea et s
accom panying each drug and to ch eck, if n ecessar y in con sult at ion w ith a physician or specialist , w h eth er th e dosage sch edules m en t ioned
th erein or th e cont rain dicat ions st ated by th e m an ufact urers di er from th e st atem en t s m ade in th e presen t book. Such exam in at ion is
par t icularly im port an t w ith drugs th at are eith er rarely used or h ave been new ly released on th e m arket . Ever y dosage sch edule or ever y
form of applicat ion used is en t irely at th e users ow n risk an d respon sibilit y. Th e auth ors an d publishers request ever y user to repor t to th e
publish ers any discrepan cies or in accuracies n ot iced. If errors in th is w ork are foun d after publicat ion , errat a w ill be posted at w w w.th iem e.
com on th e product descript ion page.
Som e of th e product n am es, paten t s, and registered design s referred to in th is book are in fact registered t radem arks or propriet ar y n am es
even th ough speci c referen ce to th is fact is n ot alw ays m ade in th e text . Th erefore, th e appearan ce of a n am e w ith out design at ion as
proprietar y is not to be con st ru ed as a represen t at ion by th e publish er th at it is in th e public dom ain .

Th is book, in clu ding all par t s th ereof, is legally protected by copyrigh t . Any u se, exp loit at ion , or com m ercializat ion ou t side th e n arrow lim it s
set by copyrigh t legislat ion , w ithout th e publish ers con sen t , is illegal an d liable to prosecut ion . Th is applies in par t icular to ph otost at
reproduct ion , copying, m im eograph ing, preparat ion of m icro lm s, an d elect ron ic dat a processing and storage.

Contents

Fo rew o rd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Ackno w ledgm en ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Co ntributo rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
I Cerebral Traum a and Stro ke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 1: Surger y for Epidural an d Subdural Hem atom as
Shelly D. Tim m ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Chapter 2: Ch ron ic Subdural Hem atom as
Branko Skovrlj, Jonathan Rasouli, A. Stew art Levy,
P. B. Rak sin, and Jam ie S. Ullm an . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Chapter 3: Surger y for Cerebral Con t u sion s of th e Fron t al an d
Tem p oral Lobes, In clu ding Lobar Resect ion s
Pal S. Randhaw a and Craig Rabb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Chapter 4: Decom pressive Cran iectom y for In t racran ial Hyper ten sion an d
St roke, In clu ding Bon e Flap Storage in Abdom in al Fat Layer
Roberto Rey-Dios and Dom enic P. Esposito . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Chapter 5: Surger y for Cerebellar St roke an d Suboccipit al Traum a
Faiz U. Ahm ad and Ross Bullock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
Chapter 6: Elevat ion of Depressed Skull Fract ures
Anand Veeravagu, Bow en Jiang, and Odette A. Harris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
Chapter 7: Invasive Neurom on itoring Tech n iques
Mathieu Laroche, Michael C. Huang, and Geo rey T. Manley . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Chapter 8: Surgical Debridem en t of Pen et rat ing Injuries
Roland A. Torres and P. B. Rak sin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Chapter 9: Man agem en t of Traum at ic Neurovascular Injuries
Boyd F. Richards and Mark R. Harrigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Chapter 10: Man agem en t of Ven ou s Sin u s Inju ries
Laurence Davidson and Rocco A. Arm onda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

vi

Contents

II Spin al Em ergen cy Pro cedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169


Chapter 11: Applicat ion of Closed Spin al Tract ion
Nirit W eiss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Chapter 12: Em ergen cy Man agem en t of Odon toid Fract ures
Sanjay Yadla, Benjam in M. Zussm an, and Jam es S. Harrop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Chapter 13: Cer vical Burst Fract ures
Teresa S. Purzner, Jam es G. Purzner, and Michael G. Fehlings . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Chapter 14: Cer vical Facet Dislocat ion
Daniel Resnick and Casey Madura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Chapter 15: Classi cat ion an d Treat m en t of Th oracic Fract ures
Joseph Hsieh, Doniel Drazin, Michael Turner, Ali Shirzadi,
Kee Kim , and J. Pat rick Johnson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Chapter 16: Th oracolu m bar Fract ures
Michael Y. W ang and Brian Hood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Chapter 17: Spin al Epidu ral Com pression
Asha Iyer and Arthur Jenkins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
Chapter 18: Treat m en t of Acute Cauda Equin a Syn drom e
Harel Deutsch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
III No ntraum atic Em ergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Chapter 19: Rem oval of Spon tan eous In t racerebral Hem orrh ages
Just in Mascitelli, Yakov Gologorsk y, and Joshua Bederson . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Chapter 20: Su rger y for Acute In t racran ial In fect ion
P. B. Rak sin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
Chapter 21: Ven t ricular Sh un t Malfun ct ion
Sergey Abeshaus, Sam uel R. Brow d, and Richard G. Ellenbogen . . . . . . . . . . . . . . . . . . . . . . . . 349
Chapter 22: Pit uit ar y Apoplexy
Kalm on D. Post and Soriaya Mot ivala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
IV Em ergen cy Operatio ns in Co m bat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
Chapter 23: Com bat Cran ial Operat ion s
Leon E. Moores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
Chapter 24: Com bat-Associated Pen et rat ing Spin e Injur y
Corey M. Mossop, Christopher J. Neal, Michael K. Rosner, and
Paul Klim o Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
V Reco nstructive Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Chapter 25: Replacem en t of Cran ial Bon e Flap
Jam ie S. Ullm an . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
Chapter 26: Tech n iques of Alloplast ic Cran ioplast y
Erin N. Kiehna and John A. Jane Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
Chapter 27: Su rger y for Fron t al Sin u s Injuries
Abilash Haridas and Peter J. Taub . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444

Conte nts

VI Special Co nsideratio ns in Pediatric Em ergency Neuro surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457


Chapter 28: Sp ecial Con siderat ion s in th e Su rgical Man agem en t of
Pediat ric Trau m at ic Brain Inju r y
Anthony Figaji and P. David Adelson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .458
Chapter 29: Sp ecial Con siderat ion s in Pediat ric Cer vical Sp in e Inju r y
Paul Klim o Jr., Nelson Ast ur Neto, W illiam C. W arner Jr., and
Michael S. Muhlbauer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .470
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491

vii

Continuing Medical Education Credit


Information and Objectives

Objectives
1.
2.
3.
4.

Iden t ify n eurosurgical con dit ion s w h ich require em ergen t or urgen t in ter ven t ion
Evaluate th e various opt ion s for m an aging spin e t raum a in th e cer vical, th oracic, an d th oracolum bar region s.
Apply provided tech n iques w h en perform ing urgen t in ter ven t ion s for th e brain an d spin e
Recogn ize key issues of applying brain an d spin al t rau m a surgical tech n iques to m ilitar y an d pediat ric populat ion s.

Accreditation and Designation


Th e AANS is accredited by th e Accredit at ion Coun cil for Con t in uing Medical Edu cat ion (ACCME) to provide con t in uing m edical
edu cat ion for physician s.
Th e AANS design ates th is en during m aterial for a m a xim um of 15 AMA PRA Category 1 credit sTM. Physician s should claim on ly th e
credit s com m en surate w ith th e exten t of th eir part icipat ion in th e act ivit y.
Meth od of p hysician p ar t icip at ion in th e learn ing process for th is text book: Th e Hom e St u dy Exam in at ion is on lin e on th e AANS
w ebsite at: h t t p ://w w w.aan s.org/ed u cat ion /books/aon em ergen cy.asp
Est im ated t im e to com plete th is act ivit y varies by learn er, an d act ivit y equaled up to 15 AMA PRA Category 1 credits TM.

Release and Termination Dates


Origin al Release Date: 05/2/2015
CME Term in at ion Date: 05/2/2018

viii

Disclosure Information

Th e AANS con t rols th e con tent an d product ion of th is CME act ivit y an d at tem pts to en sure th e presen tat ion of balan ced, object ive
in form at ion . In accordan ce w ith th e St an dards for Com m ercial Support est ablish ed by th e Accredit at ion Cou n cil for Con t in u ing
Med ical Edu cat ion , au th ors, p lan n ing com m it tee m em bers, sta , an d any oth ers involved in plan n ing in edu cat ion con ten t an d th e
sign i can t oth ers of th ose m en t ion ed m u st disclose any relat ion sh ip th ey or th eir co-au th ors h ave w ith com m ercial in terest s w h ich
m ay be related to th eir con ten t . Th e ACCME de n es, relevan t n an cial relat ion sh ip s as n an cial relat ion sh ip s in any am ou n t occurring w ith in th e past 12 m on th s th at create a con ict of in terest .
Tho se (and the signi cant others o f tho se m entio ne d) w ho have disclo sed a relatio nship* w ith co m m ercial interests are
listed below .

Sam uel R. Browd, MD, PhD, FAANS

Aqueduct Neurosciences, Inc.,


Navisonics, Inc.

Stock Shareholder (Directly purchased?

Harel Deutsch, MD FAANS

Pioneer

Honorarium, Other Financial or Material Support

Richard G. Ellenbogen, MD, FAANS

NIH/NCI
NFL
Paul Allen Family

Grant - Universit y Research Support


Grant - Universit y Research Support, Other
Financial or Material Support
Consultants

Integra Medical

Consultants

Dom enic P. Esposito, MD, FAANS(L)

Michael G. Fehlings, MD, PhD, FAANS, FRCS Depuy Synthes, Medtronic

Consultants, Grant - Universit y Research Support

Anthony Figaji, MD

Codm an Johnson & Johnson, Integra


Neurosciences

Speakers Bureau

Abilash Haridas, MD

Uptodate, Hydrocephalus Pediatric

Honorarium

Jam es S. Harrop, MD, FAANS

Depuy Spine
Tejin, Globus Spine, AO SPine
Globus spine

Consultants
Other Financial or Material Support
Honorarium

Kee D. Kim, MD, FAANS

Stryker
LDR

Icon Interventional Systems


Lanx, Mesoblast

Consultants
Grant - Universit y Research Support, Other
Financial or Material Support
Consultants, Grant - Universit y Research Support,
, Other Financial o Grant - Universit y Research
Support r Material Support
Consultants
Grant - Universit y Research Support

Geof rey T. Manley, MD, PhD, FAANS

NIH, DoD
GE/ NFL

Grant - Universit y Research Support


Consultants

Shelly D. Tim mons, MD, PhD, FAANS

AO Neuro Resident Neurotrauma Course

Honorarium

Michael Turner, Md, PhD

Acuit y Surgical

Consultant

Michael Y. Wang, MD, FAANS

Depuy Spine
Aesculap Spine, Globus Medical
Neuro Consulting, LLC

Consultants, Other Financial or Material Support


Consultant
Other Financial or Material Support

Globus
Asubio

ix

Disclosure Information
*Relat ionship refers to receipt of royalt ies, consultantship, funding by research grant, receiving honoraria for educat ional services elsew here, or any other relat ionship to a com m ercial interest that provides su cient reason for disclosure.
Tho se (and the signi cant others o f tho se m entio ne d) w ho have repo rted they do not have any relatio nship w ith co m m ercial
interests:
Nam e :
Sergey Abesh au s, MD
P. David Adelson , MD, FAANS
Faiz U. Ah m ad, MD
Rocco A. Arm on da, MD, FAANS
Nelson Ast u r, MD
Josh u a B. Bederson , MD, FAANS
M. Ross Bu llock, MD, Ph D
Lau ren ce Davidson , MD, FAANS
Don iel Gabriel Drazin , MD
Yakov Gologorsky, MD
Mark R. Harrigan , MD, FAANS
Odet te Alth ea Harris, MD, MPH, FAANS
Brian Jam es Hood, MD
Josep h C. Hsieh , MD
Mich ael C. Hu ang, MD
Ash a Mu th uram an Iyer, MD
Joh n A. Jan e, Jr., MD, FAANS
Ar th u r L. Jen kin s III, MD, FAANS
Bow en Jiang, MD
J. Pat rick Joh n son , MD, FAANS
Erin Kieh n a, MD
Pau l Klim o, Jr., MD, FAANS
Math ieu Laroch e, MD
An d rew Stew ard Levy, MD
Ju st in Robert Mascitelli, MD
#

Educat ion al Con ten t Plan n ers.

Leon E. Moores, MD, FAANS


Corey Mich ael Mossop
Soriaya Mot ivala, MD
Mich ael S. Mu h lbau er, MD, FAANS
Ch ristoph er J. Neal, MD FAANS
Kalm on D. Post , MD, FAANS
Craig H. Rabb, MD, FAANS
Pat ricia B. Raksin , MD, FAANS#
Pal Ran dh aw a, MD
Jon ath an Rasou li, MD
Dan iel K. Resn ick, MD, FAANS
Roberto Rey-Dios, MD
Boyd Rich ards, DO
Mich ael K. Rosn er, MD, FAANS
Ali Sh irzadi, MD
Bran ko Skor vlj, MD
Peter J. Tau b, MD, FACS, FAAP
Rolan d A. Torres, MD, FAANS
Jam ie S. Ullm an , MD, FAANS#
An an d Veeravagu , MD
William C. Warn er, Jr., MD
Nirit Weiss, MD, FAANS
Sanjay Yadla, MD
Benjam in M. Zussm an , MD
Casey Madu ra, MD

Forew ord

Sim plicit y is the ult im ate sophist icat ion.


Leonardo da Vinci, circa 1519
Th is at las ed ited by Drs. Ullm an an d Raksin is clearly a ver y
valu able con t r ibu t ion to t h e n eu rosu rgical literat u re an d
m ay be best d escr ibed as a qu ick referen ce at las. Bot h of
t h e ed itors are exp er ien ced n eu rosu rgeon s w h o h ave h ad
d ecad es of exp er ien ce in t reat ing p at ien t s w it h h ead an d
sp in al inju r y. In t h is volu m e, t h ey h ave brough t toget h er
m any exp er t s in th e eld to d escr ibe t h eir ap p roach to t h e
sp ect r u m of t rau m at ic d isord ers t h at a ict t h e brain an d
sp in e.
Th e illust ration s are m agn i cen t an d th e text is direct an d
easy to follow. Th is st yle ensures that this book w ill be a valu-

able guide for both residen ts as w ell as for m ore experien ced
neurosurgeons. It w ill ser ve as a quick referen ce before one
em barks on treating a patient w ith a traum atic neurosurgical disorder, or in preparing to take an exam ination.
Alth ough th ere are oth er texts th at deal w ith n eurot raum a,
n on e of th em are as digest ible as th is on e. I could w ax eloquen t on th e m any m erit s of th is book. I dont n eed to. As
you sim ply ip th rough its pages, you w ill see for yourself
th at th is is a book w or th h avingn ot ju st to disp lay on you r
booksh elf, bu t to keep h an dy an d to u se on an ever yday basis. You w ill h ave n o t rouble pu t t ing it to good use.
Raj K. Narayan, MD, FACS, FAANS
Professor an d Ch airm an
Dep ar t m en t of Neu rosu rger y
Hofst ra Nor th Sh ore LIJ Sch ool of Medicin e an d
Director, Cu sh ing Neu roscien ce In st it u te
Man h asset , New York

xi

Acknow ledgments

We w ould like to ackn ow ledge an d th an k th e auth orskin d


colleagues, m en tors, an d dedicated residen t s an d fellow sfor
len ding th eir ext raordin ar y expert ise an d experien ce to th is
project .
We w ou ld like to th an k Dr. Mark Lin skey, past ch air of th e AANS
Publicat ion s Com m it tee, for support ing th e con cept of th is atlas, an d Dr. Jam es Rutka, th en AANS secretar y, for ch am p ion ing th is atlas to th e AANS Board of Directors. We are grateful to
th e AANS for it s gen erous gran tm atch ed by Th iem e Publish ers (to w h om w e are also gratefu l)to fu n d th e illu st rat ion s.
Th an ks also go to th e Execut ive Com m it tee of th e AANS/CNS
Sect ion on Neu rot rau m a an d Crit ical Care for its su p port an d
from w h ich m any of th e au th ors w ere selected . We are gratefu l
to Dr. Mich ael Feh lings for h is review an d cou n sel regarding th e
spin e top ics. We ackn ow ledge an d th an k th e Th iem e ed itorial
sta , past an d presen t , for th eir h ard w ork an d d edicat ion to
th is project .
Illu st rat ion s form th e backbon e of th is book an d, so, a sp ecial
th ank you goes to Jen n ifer Pr yll, our n e illust rator, for h er
t ireless e ort s in producing h igh -qualit y art w ork. Ms. Pr yll
dem on st rated an ext raordin ar y level of at ten t ion to detail an d
resp on siven ess to th e editors an d au th ors.

I (JSU) w an t to, p erson ally, dedicate th is book to m y daugh ter


Sara (fu t u re singer/dan cer, p ediat rician , an d/or n eu rosu rgeon )
an d m y h u sban d Mark for th eir love an d pat ien ce; m y d ear
fam ily; an d to th e AANS/CNS Sect ion on Neurot rau m a an d Critical Care, of w h ich I have been an Execut ive Com m it tee m em ber
for m ore th an 16 years an d prou d to be its Ch air (2014-2016).
I w ou ld also like to th an k m y co-ed itor, P.B. Raksin , for h er
collaborat ion , pat ien ce, an d diligen ce th rough ou t th e books
product ion a perfect m eld of m in d an d spirit . Fin ally, I w ould
like to th an k m y colleagues an d residen t s at th e Icah n Sch ool
of Medicin e at Moun t Sin ai for th eir support an d con t ribut ion s
to th is atlas an d over th e years; an d th e n e at ten ding an d
resid en t st a of th e Hofst ra Nor th Sh ore-LIJ Sch ool of Medicin e
w h o spen d long n igh t s on call t reat ing em ergen cy n eurosurgical pat ien t s.
I (PBR) w ou ld like to ackn ow ledge th e m any pat ien t s w h ose
adversit y h as in form ed an d en h an ced m y clin ical experien ce
(an d digit al im age collect ion ) in acute care n eurosurger y over
th e past t w o decades. I w ou ld also like to th an k m y co-editor,
Jam ie Ullm an , for invit ing m e to p ar t n er w ith h er in th is p roject
an d en t ru st ing m e to h elp execu te h er vision . An d, to m y w ife
Lisaw h o h eld dow n th e for t w h ile I pored over m an u script s
m y etern al grat it ude an d a ect ion (an d a prom ise to clean th e
o ce n ow th at th is task is com plete).
Jam ie S. Ullm an , MD, FAANS, FACS
P.B. Raksin , MD, FAANS

xii

Preface

Neu rosu rger y is n ot so sim ple. Drilling bu r h oles in th e em ergen cy depart m en t m ay relieve pressu re from an expan ding epidu ral h em atom a, but the ensuing un cont rolled arterial bleeding m ay resu lt in sign i can t blood loss, hypoten sion ,
an d death if on e is n ot skilled in h an dling th is sit u at ion . An d,
alth ough traum a m ay be on e of th e m ore com m on reason s
for em ergen t n eurosu rgical in ter ven t ion , acute care for n eu rosu rgical diseases is as w idely varied as the disciplin e itself.
The ver y eclect ic nat ure of th ese em ergen t and urgent con dit ion s cont in ually ch allenges the skills obtain ed during the long
n eu rosu rger y residen cy t rain ing period, dem an ding n ot on ly
broad kn ow ledge and evolving techn ical skills, but pre-, in tra-,
an d p ostoperat ive clin ical ju dgm en t th at can t ake a lifet im e to
m asterall for th e goal of im proving pat ien t outcom es.
Appreciat ion of th is w eigh t y t ask m ust be cou pled w ith th e idea
th at learn ing in n eurosurger y is a decidedly visual pursuit .
Neu rosu rgeon s-in -t rain ing st u dy an atom ic rep resen t at ion s,
dissect cadavers, an d obser ve th eir m en tors in th e operat ing
room . With clin ical exp erien ce an d kn ow ledge acqu isit ion ,
th ere even t ually com es th e abilit y to t ran slate th e w rit ten
w ords in a textbook in to m en t al im ages, or to im agin e on es
w aystep -by-step an d w ith variat ion sth rough a procedu re
before en tering th e operat ing th eater.
The true value of a surgical atlas, then, lies in the presentation: the
telling of a procedure in pictures. Historically, atlases h ave been
designed to guide the learner through interventions in a step w ise fashion. In 1960, Jam es Leonard Poppen, MD, published his
fam ed atlas entitled, An Atlas of Neurosurgical Techniques. This
tom e presen ted procedures in diagram m atic fashionuseful
to any neurosurgeon beginning to hone h is or her craft. In th at
spirit, and in the spirit of great surgical atlases such as Zollingers
Atlas of Surgical Operations, w e have set out to create a sim ilar
volum e devoted to em ergen cy n eurosurgical procedures.
Th is book w as w rit ten for n eurosurgeon s-in -t rain ing, as w ell
as for th ose already in p ract ice w h o desire to m eet th e ch allenge of w h atever com es in to th e em ergen cy depar t m en t .
Crit ical care pract it ion ers m ay also n d th is book ben e cial to un derstan ding th e surgical m an agem en t of n eurologic
con dit ion s th at w ill dem an d th eir m edical expert ise in th e
p ostop erat ive p eriod.

Th e book is divided in to six sect ion s. Sect ion I (Ch apters 110)
covers th e basic procedures th at form th e bread an d but ter of
cran ial n eu rosurger y for t raum a an d st roke, in cluding cran iotom ies for in t ra- an d ext ra-axial h em atom a, m an agem en t of
p en et rat ing inju ries, an d decom pressive cran iectom y. Excellen t ,
com preh en sive review s of n eurom on itoring an d m an agem en t
of n eurovascular inju ries com plem en t th ese ch apters.
Sect ion II (Ch apters 1118) focu ses on sp in al em ergen cy proceduresboth t raum at ic and n on t raum at ic. Th e im port an t role
of early surger y for acute t raum at ic spin e an d spin al cord in ju ries is in creasingly recogn ized; several ch apters are devoted
to operat ive m an agem en t of th ese injuries. W h ile open procedu res st ill predom in ate in th e em ergen cy m an agem en t of th ese
en t it ies, th e in creasing app licat ion of m in im ally invasive tech n iqu es in th is set t ing can n ot be ign ored. Ch apter 16 ou tlin es
th e m in im ally invasive approach to th oracolum bar t rau m a.
Non t rau m at ic em ergen cies, in clu ding ep id u ral sp in al com pression an d cau da equ in a syn drom e, are also addressed .
Sect ion III (Ch apters 1922) discu sses th e su rgical m an agem en t
of n on t rau m at ic em ergen cies in cluding spon t an eous in t racran ial h em orrh age, in t racran ial in fect ion , p it u it ar y apop lexy, an d
th e ever-h aun t ing ven t ricular sh un t m alfun ct ion . W h ile th e
sequ elae of an eu r ysm al ru pt u re som et im es requ ire em ergen t
su rgical in ter ven t ion , de n it ive m an agem en t often is u n dert aken m ore elect ively w ith in a 12- to 72-h our period. Th e tech n iqu e of an eu r ysm clip ping is th e su bject of several im p or tan t
tom es an d is beyon d th e gen eral scope of this atlas. Sim ilarly,
w h ile su rger y for rupt ured arterioven ous m alform at ion s is often deferred for a period of t im e to perm it resorpt ion of h em orrh age, p at ien ts m ay presen t w ith life-th reaten ing acute bleed s
th at n ecessitate em ergen t in ter ven t ion for relief of m ass e ect .
Th ese clin ical scen arios are addressed in Ch apter 19.
W h ile on ly a select few neurosurgeon s h ave part icipated in th e
th eater of w ar, w e felt it w ould be valuable to in clu de a sect ion
addressing em ergen cy in ter ven t ion s for n eu rologic inju ries in
com bat (Sect ion IV, Ch apters 23 an d 24). Key lesson s learn ed
over th e past t w o decades of con ict h ave led to in creased su rvival from th ese d evast at ing inju ries. With th e loom ing th reat
of terrorism , w e m ust be prepared to apply th ese tech n iques in
civilian populat ion s sh ould th e n eed arise.

xiii

xiv

Preface
Sect ion V (Ch apters 2527) en com p asses basic ten et s of recon st ruct ive su rger y. Th e m an agem en t of fron tal sin us injuries requ ires a com bin at ion of acu te care an d recon st ru ct ive
ap proach es. Any con sid erat ion of decom pressive cran iectom y
w ou ld n ot be com plete w ith ou t a discu ssion of it s n at u ral con sequ en ce: th e n eed for addit ion al, m ostly elect ive, su rger y
to restore th e cran iu m to it s origin al p rotect ive p u rpose. Th e
in form at ion p rovided is design ed to h elp th e su rgeon n ish
th e job.
Fin ally, Sect ion VI (Ch apters 28 an d 29) con siders con cern s speci c to th e t reat m en t of h ead an d spin al injuries in th e pediat ric
popu lat ion , in cluding steps for th e recon st ru ct ive repair of lep tom en ingeal cyst s. Th ese ch apters are d esign ed to h igh ligh t key
di eren ces in th e acute, an d delayed, m an agem en t of injuries in
ch ildren as com pared w ith adu lt s.
Th e ch apters follow a st an dardized form at . In t roductor y
com m en t ar y for each topic is follow ed by an accoun t ing of
in dicat ion s for n eurosurgical in ter ven t ion an d preprocedu ral
con siderat ion s. Th e operat ive procedure form s th e core of each
sect ion . For th e readers conven ien ce, w e design ed th is book to
keep illu st rat ion s an d p rocedu ral step s in close proxim it y. In

add it ion , m any step s are rep eated across ch apters (w ith variat ion ) to keep m ost of th e ch apters self-con t ain ed. Many of th e
procedural steps are accom pan ied by pearlsaddit ion al w isdom from th e su bject exper ts, geared tow ard en h an cing an
operat ions success an d avoiding com plicat ion s. Each ch apter
con cludes w ith a discussion of postoperat ive m an agem en t an d
special con siderat ion s relevan t to th at top ic. Referen ces are kept
to a m in im um .
As th e pract ice of n eu rosurger y is as m uch an ar t as it is a scien ce, th ere w ill be n u an ces an d app roach es p referable to each
in dividu al surgeon , an d th ere are often several w ays to accom plish th e sam e goal. Th e procedures outlin ed in th is book
represen t th e best pract ices of th e various au th ors an d can be
m odi ed based on su rgeon exp erien ce, preferen ce, an d p at ien t
ch aracterist ics. An d, alth ough w e h ave m ade ever y at tem pt
to provide a com preh en sive over view of th e m ost com m on ly
en cou n tered em ergen cy p rocedu res, it is in evit able th at oth er
em ergen cy con dit ion s w ill arise th at fall ou t side th e scope of
th is project . It is our h ope th at th e in form at ion presen ted in
th is book w ill ser ve as a platform upon w h ich to build st rategies for t reat ing m ore com p lex or less com m on em ergen cy
presen t at ions.
Jam ie S. Ullm an , MD, FAANS, FACS
P.B. Raksin , MD, FAANS

Contributors

Sergey Abeshaus, MD
Dep ar t m en t of Neu rosu rger y
Seat tle Ch ildrens Hospit al
Seat tle, Wash ington
P. David Adelso n , MD, FACS, FAAP
Director
Dian e an d Bru ce Halle En dow ed Ch air in
Pediat ric Neu roscien ces
Ch ief, Pediat ric Neurosurger y
Barrow Neurological In st it ute at Ph oen ix
Ch ildrens Hospit al
Ph oen ix, Arizon a
Faiz U. Ahm ad, MD, MCh
Assistan t Professor of Neu rosu rger y
Em or y Un iversit y
Grady Mem orial Hospit al
Atlan ta, Georgia
Ro cco A. Arm o nda, MD
Division of Neurosurger y
Walter Reed Nat ion al Militar y Medical Cen ter
Beth esda, Mar ylan d
Nelso n Astur Neto, MD
Dep ar t m en t of Or th op edic Su rger y
Cam p bell Clin ic Or th op aedics
Mem p h is, Ten n essee
Jo shua Bederso n , MD
Professor an d Ch air
Dep ar t m en t of Neu rosu rger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
Sam uel R. Brow d, MD, PhD
Director
Dep ar t m en t of Neu rosu rger y an d On cology
Cen ter for In tegrat ive Brain Research
Seat tle Ch ildrens Hospit al
Harbor view Medical Cen ter
Un iversit y of Wash ington Medical Cen ter
Seat tle, Wash ington

Ro ss Bullo ck, MD, PhD


Professor of Neurosurger y
Un iversit y of Miam i
Director, Clin ical Neurot raum a
Jackson Hospital
Miam i, Florida
Laurence Davidso n, MD
St a Neu rosu rgeon
Division of Neurosurger y
Walter Reed Nat ion al Militar y Medical Cen ter
Beth esda, Mar ylan d
Harel Deutsch, MD
Associate Professor of Neurosu rger y
Ru sh Un iversit y Medical Cen ter
Ch icago, Illin ois
Do niel Drazin, MD
Dep ar t m en t of Neu rosu rger y
Cedars Sin ai Medical Cen ter
Los Angeles, Californ ia
Richard G. Ellen bogen , MD, FACS
Professor an d Ch airm an
Dep ar t m en t of Neu rological Su rger y
Un iversit y of Wash ington
At ten ding Neurosurger y
Harbor view Medical Cen ter
Seat tle Ch ildrens Hospital
Seat tle, Wash ington
Do m enic P. Espo sito, MD, FACS, FAANS
Professor of Neurosurger y (Ret .)
Un iversit y of Mississip pi
Neurosurgical Con su ltan ts, LLC
Jackson , Mississipp i
Michael G. Fehlings, MD, PhD, FRCSC
Neurosurgeon
Division of Neurosurger y
Toron to Western Hospital
Toron to, On tario, Can ada

xv

xvi

Contributors
Antho ny Figaji, MD
Professor an d Head
Pediat ric Neurosurger y
Un iversit y of Cap e Tow n
In st it ute for Ch ild Health
Red Cross Ch ildrens Hospital Cape Tow n
Cap e Tow n , Sou th Africa
Yakov Go lo go rsk y, MD
At ten ding in Neurosurger y
Mou n t Sin ai Medical Cen ter
New York, New York
Abilash Haridas, MD
Assistan t Professor of Neu rosu rger y
Wayn e State Un iversit y Sch ool of Medicin e
Pediat ric Neurosurger y
Cerebrovascu lar Neu rosu rger y
Ch ildrens Hospital of Mich igan
Det roit , Mich igan
Mark R. Harrigan , MD
Associate Professor
Un iversit y of Alabam a Medical Cen ter
Birm ingh am , Alabam a
Odette A. Harris, MD, MPH
Associate Professor of Neu rosu rger y
Director of Brain Inju r y
Stan ford Sch ool of Medicin e Hosp it al an d Clin ics
Stan ford, Californ ia
Jam es S. Harro p, MD
Professor of Or th opedic an d Neurological Su rger y
Director, Sp in e an d Periph eral Ner ve Su rger y
Th om as Je erson Un iversit y
Ph iladelph ia, Pen n sylvan ia
Brian Ho o d, MD
Major USAF, MC
Assistan t Professor of Clin ical Medicin e
Un iform ed Un iversit y of Health Scien ces
San An ton io Milit ar y Medical Cen ter
San An ton io, Texas
Jo seph Hsieh, MD
Assistan t Professor
Th e Vivian L. Sm ith Dep art m en t of Neu rosu rger y
Th e Un iversit y of Texas Health Cen ter
Houston , Texas
Michael C. Huang, MD
Assistan t Clin ical Professor of Neu rological Su rger y
Un iversit y of Californ ia, San Fran cisco
San Fran cisco Gen eral Hospital an d Traum a Cen ter
San Fran cisco, Californ ia
Asha Iyer, MD
Residen t in Neu rosu rger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York

Jo hn A. Jane Jr., MD
Associate Professor of Neu rosu rger y an d Pediat rics
Pediat rics Division Director
Un iversit y of Virgin ia
Ch arlot tesville, Virgin ia
Arthur Jenkins, MD, FACS
Associate Professor of Neu rosu rger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
Bow en Jiang, MD
Resid en t in Neu rosu rger y
Joh n s Hopkin s Hospital
Balt im ore, Mar ylan d
J. Patrick Jo hnso n , MD, MS, FACS
Director of Sp in e Edu cat ion an d Neu rosu rger y Spin e
Fellow sh ip Program
Depar t m en t of Neurosurger y
Cedars Sin ai Medical Cen ter
Th e Sp in e In st it u te Fou n dat ion
Los Angeles, Californ ia
Professor of Neu rosurger y
UC Davis Medical Cen ter
Sacram en to, CA
Erin N. Kiehna, MD
Assist an t Professor of Neu rosu rger y
Ch ildrens Hospital Los Angeles
Los Angeles, Californ ia
Kee Kim , MD
Associate Professor an d Ch ief
Depar t m en t of Spin al Neurosurger y
Co-director, Sp in e Cen ter
Un iversit y of Californ ia, Davis Sch ool of Medicin e
Sacram en to, Californ ia
Paul Klim o Jr., MD, MPH
Associate Professor of Neu rosu rger y
Un iversit y of Ten n essee
Associate, Sem m es-Mu rp h ey Neu rologic & Sp in e In st it u te
Mem ph is, Ten n essee
Mathieu Laro che, MD, MSc, FRCSC
Assist an t Professor of Neu rosu rger y
Un iversit y of Mon t ral
Neu rosurgeon
Hpital du Sacr- Coeu r de Mon t ral
Mon t ral, Qu bec, Can ada
A. Stew art Levy, MD
Neu rosurgeon
St . An th ony Hosp ital
Ch ief of Neurosurger y
Cen t u ra Neu roscien ce & Spin e
Lakew ood, Colorado
Casey Madura, MD
Resid en t in Neu rosu rger y
Un iversit y of Wiscon sin Hospital an d Clin ics
Madison , Wiscon sin

Contributors
Geo rey T. Manley, MD, PhD,
Professor in Residen ce an d Vice Ch airm an
Dep ar t m en t of Neu rological Su rger y
Co-Director an d Prin cip al Invest igator
Brain an d Spin al Inju r y Cen ter (BASIC)
Ch ief of Neurosurger y
San Fran cisco Gen eral Hospit al
Un iversit y of Californ ia, San Fran cisco
San Fran cisco, Californ ia
Justin Mascitelli, MD
Residen t in Neurosurger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
Leo n E. Mo o res, MD, MS
Professor of Neurosu rger y
Virgin ia Com m onw ealth Un iversit y
Professor of Surger y an d Pediat rics
Un iform ed Ser vices Un iversit y
CEO, Pediat ric Specialists of Virgin ia
Director of Pediat ric Neuroscien ces
In ova Health System
Fairfax,Virgin ia
Co rey M. Mo sso p, MD
Neurosu rger y Ser vice
Walter Reed Nat ion al Militar y Medical Cen ter
Silver Sp ring, Mar ylan d
So riaya Motivala, MD
Assistan t Professor of Neu rosu rger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
Michael S. Muhlbauer, MD
Dep ar t m en t of Pediat ric Neu rosu rger y
Sem m es-Murph ey Neurologic & Spin e In st it ute
Clin ical Assistan t Professor
Un iversit y of Ten n essee
Le Bon h eur Ch ildrens Hospital
Mem p h is, Ten n essee
Christo pher J. Neal, MD
Neurosu rger y Ser vice
Walter Reed Nat ion al Militar y Medical Cen ter
Beth esda, Mar ylan d
Kalm o n D. Po st, MD
Professor an d Ch airm an -Em erit us
Dep ar t m en ts of Neu rosu rger y, On cological Scien ces,
Medicin e, En docrin ology, Diabetes, an d Bon e Disease
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
Jam es G. Purzner, MD
Residen t in Neurosurger y
Un iversit y of Toron to
Toron to Western Hospit al
Toron to, On t ario, Can ada

Teresa S. Purzner, MD
Residen t in Neu rosurger y
Un iversit y of Toron to
Toron to Western Hospital
Toron to, On tario, Can ada
Craig Rabb, MD
Professor of Neurosurger y
Director
Neurot raum a Program
OU Physician s Neurosurger y
Oklah om a Cit y, Oklah om a
P.B. Raksin, MD, FAANS
Assistan t Professor, Depar t m en t of Neurosurger y
Ru sh Un iversit y Medical Cen ter
Director, Neurosu rger y ICU
Ch ief, Sect ion Neurot raum a & Neurocrit ical Care
Joh n H. St roger Jr Hospital of Cook Cou n t y (form erly Cook
Cou n t y Hospital)
Ch icago, Illin ois
Pal S. Ran dhaw a, MD
Residen t in Neu rosurger y
Un iversit y of Colorado
Au rora, Colorado
Jo nathan Raso uli, MD
Residen t in Neu rosurger y
Icah n Sch ool of Medicin e at Mou n t Sin ai
New York, New York
Daniel Resnick, MD, MS
Professor an d Vice Ch airm an
Residen cy Program Director
Co-Director, Sp in al Su rger y Program
Dep ar t m en t of Neu rological Su rger y
Un iversit y of Wiscon sin Sch ool of Med icin e an d Pu blic
Health
Mad ison , Wiscon sin
Ro berto Rey-Dio s, MD
Assistan t Professor of Neurosurger y
Un iversit y of Mississip pi Medical Cen ter
Jackson , Mississipp i
Boyd F. Richards, DO
Dep ar t m en t of Neu rological Su rger y
St . Joh n Providen ce Health System
Mich igan Spin e an d Brain Su rgeon s
South eld, Mich igan
Michael K. Ro sner, MD
Ch ief of Neurosurger y In tegrated Ser vice
Assistan t Professor
Un iform ed Ser vices Un iversit y
Walter Reed Nat ion al Militar y Medical Cen ter
Wash ington , DC
Ali Shirzadi, MD
Neurosurgeon
South Bay Brain an d Spin e
San Jose, Californ ia

xvii

xviii

Contributors
Branko Skovrlj, MD
Residen t in Neu rosu rger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York

An an d Veeravagu, MD
Ch ief Residen t in Neurosu rger y
Stan ford Un iversit y
Stan ford, Californ ia

Peter J. Taub, MD, FACS, FAAP


Professor of Su rger y an d Pediat rics
Associate Director, Residen cy Train ing Program
Ch ief, Cran iom axillofacial Su rger y
Co-Director, Cleft an d Cran iofacial Cen ter
Mou n t Sin ai Medical Cen ter
New York, New York

Michael Y. Wang, MD
Depar t m en t s of Neu rological Surger y & Reh abilitat ion
Medicin e
Un iversit y of Miam i
Miller Sch ool of Medicin e
Miam i, Florida

Shelly D. Tim m o ns, MD, PhD, FACS, FAANS


Clin ical Associate Professor of Neurosurger y
Tem ple Un iversit y
Director of Neu rot rau m a
Associate Director for Neu roscien ces Adu lt ICU, GMC
Residen cy Program Director
Geisinger Health System
Danville, Pen n sylvan ia
Ro land A. To rres, MD
Ch airm an of Neurosurger y
Alaska Nat ive Med ical Cen ter
An ch orage, Alaska
Michael Turn er, MD, PhD
Neurosurgeon
Frisco Spin e
Frisco, Texas
Jam ie S. Ullm an , MD, FAANS, FACS
Associate Professor, Dep art m en t of Neu rosu rger y
Hofst ra North Sh ore-LIJ Sch ool of Medicin e
Director of Neu rot rau m a
Nor th Sh ore Un iversit y Hospital
Man h asset , New York

William C. Warner Jr., MD


Depar t m en t of Orth opaedics
Cam p bell Clin ic Orth op aedics
Mem ph is, Ten n essee
Nirit Weiss, MD
Assist an t Professor of Neu rosu rger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
Sanjay Yadla, MD, MPH
Depar t m en t of Neurosurger y
Alexian Broth ers Neu roscien ces In st it u te
Elk Grove Village, Illin ois
Benjam in M. Zussm an, MD
Resid en t in Neu rosu rger y
Un iversit y of Pit tsbu rgh
Pit t sbu rgh , Pen n sylvan ia

Cerebral Trauma and Stroke

Surgery for Epidural and Subdural


Hematomas
Shelly D. Tim m ons

Introduction

Preprocedure Considerations

Rapid evacu at ion of ext ra-axial h em atom as after t rau m a can


be a life-saving in ter ven t ion . W h ile th ere is n o absolute cuto t im e after w h ich pat ien t s fare w orse, m any st udies h ave
dem on st rated bet ter outcom es w ith earlier evacu at ion . Surgical plan n ing m u st take in to con siderat ion th e presen ce of oth er
in t racran ial lesion s an d th e p at ien ts clin ical stat u s. Th e presen ce of p olyt rau m a, th e p at ien ts h em odyn am ic st at u s,1 an d th e
p resen ce of coagu lopathy m u st be con sidered an d addressed
w h ile n ot delaying surgical in ter ven t ion .

Radiographic Imaging

Indications
Su rgical in ter ven t ion is app ropriate for epidural hem atom as

(EDH) w ith th e follow ing ch aracterist ics 2


Glasgow Com a Scale (GCS) score
8 an d an isocoria
operat ing room as soon as p ossible
Hem atom a volu m e 30 cm 3
Hem atom a volu m e , 30 cm 3 bu t accom p an ied by:
Th ickn ess 15 m m
Midlin e sh ift 5 m m
GCS 8
Focal m otor de cit
E aced cistern s
Deteriorat ing n eu rologic st at u s
Su rgical in ter ven t ion is ap prop riate for subdural hem atom as
(SDH) w ith th e follow ing characterist ics 3
Th ickn ess 10 m m
Midlin e sh ift 5 m m
Th ickn ess , 10 m m an d m idlin e sh ift , 5 m m but accom p an ied by:
Neu rologic w orsen ing by 2 or m ore poin t s on th e GCS
Asym m et ric pupils
Fixed an d dilated pupils
In t racran ial pressure (ICP) 20 m m Hg

Com puted tom ography (CT) is essen t ial to evaluate for:


Th e p resen ce an d size of ext ra-axial h em atom a
Degree of m idlin e sh ift
Ap p earan ce of p erim esen cep h alic cistern s
Presen ce of oth er sp ace-occu pying lesion s
Preoperative im aging (Fig. 1.1).

Medications
Preoperat ive an t ibiot ics: eith er a ceph alosporin or van com y

cin (if pen icillin allergic) sh ould be given .


Th e pat ien t sh ould be given seizure prophylaxis at earliest
opport un it y after arrival to th e h ospit al. Eviden ce-based
gu id elin es su p p or t th e u t ilizat ion of an t iconvu lsan ts for
7 days in pat ien t s follow ing t raum at ic brain injur y.4
Fresh frozen plasm a an d/or oth er blood product s/factors
sh ou ld be adm in istered p reop erat ively an d in t raop erat ively
as n eeded to correct coagu lopathy.

Operative Field Preparation


Th e h ead m ay be posit ion ed on a dough n ut or h orsesh oe

h ead h old er, rath er th an a th ree-pin ion h ead h older, to facilit ate m ore rapid progression to brain decom pression .
The operative eld should be prepared using an iodine-based
sterile prep solution, provided the patient has no iodine allergies.
Th e use of ch lorh exidin e is con t roversial; product in ser t in form at ion bars th e u se for p rocedu res exp osing th e cerebral
m en inges. In cases w ith kn ow n bet adin e or iodin e allergies,
ch lorh exidin e or alcoh ol prep can be u sed.
Th e in cision s are m arked an d, after n al sterile draping, in lt rated w ith 1% lidocain e w ith epin eph rin e 1:100,000.

Surgery for Epidural and Subdural Hem atom as

Fig. 1.1ad CT scan is the modalit y m ost commonly utilized in the perioperative set ting. (a) Epidural hematomas demonstrate a characteristic
convex shape (due to adherence of the dura at the suture lines) and are t ypically accompanied by a (b) fracture (arrow). (c) Subdural hematomas
by contrast, are not bound by sutures and assume a crescentic appearance, layering over the convexit y. (d) A small subdural hematoma may be
accompanied by disproportionate mass e ect and midline shift.

I Cerebral Traum a and Stroke

Operative Procedure
Positioning (Fig. 1.2a, b)

Figure

Procedural Steps

Pearls

Fig. 1.2

(a, b) The head is turned so


as to expose the operative
hemicranium. The patient
whose neck has not yet been
cleared can be positioned
in the cervical collar by
placing a bolster under the
ipsilateral shoulder and the
ipsilateral arm across the
chest. Pressure points should
be padded appropriately.
The head may be placed on
a foam or gel doughnut to
expedite positioning.

Discuss positioning with the anesthesiology team . The endotracheal tube (ETT) should

exit the contralateral side of the m outh if placed orally, and should be secured in place
using tape, ETT collar, etc. The eyes should be protected from corneal abrasion by placing
ointm ent under each lid and taping the lids shut.
Allowance for central venous catheters, peripheral intravenous catheters, and arterial
lines should be m ade, with these positioned toward the anesthesiology team if possible.
Foley catheters should always be placed and should be accessible to the anesthesia team .
Pin xation may also be used, but positioning on a doughnut or horseshoe head holder
m ay expedite decompression of the brain.
The head should be positioned just at or slightly overhanging the end of the table and the
sterile craniotomy drape placed so that it hangs vertically to facilitate drainage of irrigation
by gravit y. Final draping should exclude the anesthesia setup, using a vertical drape.
An exit site for a subgaleal drain should be included in the area exposed by the sterile draping.
Reverse Trendelenburg positioning m ay be used to provide elevation of the head to help
reduce cerebral edem a.

Surgery for Epidural and Subdural Hem atom as

Skin Incision (Fig. 1.3)

Figure

Procedural Steps

Pearls

Fig. 1.3

The skin incision


should be planned to
create a craniotomy
su cient to access
the entire hematoma.
The question mark
or reverse question
mark incision
(illustrated here)
is used commonly
to access large
traumatic extra-axial
hematomas.

Other skin incisions m ay be utilized to evacuate sm aller hematom as. However, before

com mit ting to a m ore lim ited exposure, consideration should be given to the degree of brain
swelling anticipated.
When using a question m ark incision, care should be taken not to place the incision too close to
the pinna of the ear. A m argin of at least 1 cm should be used. Likewise, the vertical lim b of the
incision should be placed at least 1 cm anterior to the tragus. The scalp m ay be elevated o of
the underlying bone and retracted out of the way.
Scalp clips m ay be applied to the scalp edges to aid in hem ostasis.
Prior to opening the scalp over the temporalis m uscle, an instrum ent m ay be passed over
the m uscle fascia and the skin divided down to the level of the instrum ent with a scalpel. The
temporalis m ay then be divided in parallel with the incision using Bovie cautery.
Branches of the super cial and m iddle temporal arteries may be encountered and m ay be
ligated and divided sharply, or cauterized with the bipolar cautery.

I Cerebral Traum a and Stroke

Subcutaneous Dissection (Fig. 1.4)

Figure

Procedural Steps

Pearls

Fig. 1.4

For rapid opening, the


temporalis muscle may be
elevated simultaneously
w ith the scalp ap.

The temporalis m uscle m ay be elevated o of the underlying bone using a sharp

periosteal elevator, such as a Langenbeck, or using the Bovie cautery.


The musculocutaneous ap should be protected from strangulation by placing dry
sponges (counted) behind the ap, which is then secured using shhooks. A sponge
soaked with irrigation infused with epinephrine m ay be placed on the undersurface of the
galea and m uscle to aid in hemostasis.
Bipolar cautery m ay be used sparingly on scalp and m uscle vessels, taking care not to
shrink the galea.

Surgery for Epidural and Subdural Hem atom as

Craniotomy (Fig. 1.5a, b)

Figure

Procedural Steps

Pearls

Fig. 1.5

(a) Bur holes are placed at the perimeter of the planned


bone ap, leaving su cient bony margins so that the plating
hardw are is not located immediately under the skin incision
at closure.

After creation of the bur holes using a high-speed

A no. 3 Pen eld dissector is used to strip the dura o of the


undersurface of the bone at each bur hole. If possible, the
Pen eld should be used to make a communication, in this
same plane, betw een adjacent bur holes. The high-speed drill
attachment is converted to a cutting bit w ith a footplate and
used to connect each pair of bur holes circumferentially.

The bone ap should be secured in place w ith a nger prior to


making the nal cut.

drill, bone wax is applied to the raw bone edges


where necessary. Excess wax is rem oved, along with
any obstructive bone edges deep in the bur holes,
with a cup curet te.
A larger instrum ent, such as a Langenbeck periosteal
elevator, m ay be used to elevate the ap, as long
as the underlying dura is protected from the sharp
edge of the instrum ent. The explanted bone ap
should be cleared of hem atom a and blood and
placed in irrigation infused with antibiotics on the
back table until ready to be replaced.
Center holes may be m ade later in the bone ap for
epidural tack-up sutures.

(b) As the bone ap is elevated o of the center dura, again


using a no. 3 Pen eld, the edge of the ap should be securely
grasped and eventually removed from the exposure.

I Cerebral Traum a and Stroke

Evacuation of Epidural Hematoma (Fig. 1.6)

Figure

Procedural Steps

Pearls

Fig. 1.6

As the bone ap is elevated, an epidural


hematoma w ill be appreciated immediately
in the extradural space. This may be
removed using irrigation and suction.

Evacuation of an epidural hem atom a will often yield both organized

The source of bleeding should be


addressed as quickly as possible, utilizing
bipolar cautery on the vessel itself, and/or
bone w ax on the foramen spinosum w here
the vessel enters the cranium.

hem atom a and liquid blood. The hem atom a is often adherent to the
bleeding vessel, com monly the m iddle m eningeal artery in the anterior
temporal area. This, in turn, m ay be associated with a fracture of the
squam ous portion of the temporal bone.

Other sources of epidural hem atom as m ay be handled sim ilarly. Venous


epidural hem atom as sometim es require application of gel foam soaked
in throm bin and gentle pressure, or Bovie cautery or bone wax to
bleeding bone edges.

Surgery for Epidural and Subdural Hem atom as

Dural Opening (Fig. 1.7)

Figure

Procedural Steps

Pearls

Fig. 1.7

The dura is opened w idely enough to allow


access to as much of the subdural space as
possible in the craniotomy exposure.

For curvilinear incisions, at least 1 cm of dura should be left bet ween the

The initial dural opening may be made


w ith a no. 11 scalpel. The dural edges
may then be grasped w ith ne -toothed
forceps, elevated, and the remainder of the
opening performed w ith ne Metzenbaum
or tenotomy scissors. Occasionally, if the
brain is very edematous, the opening
may be made w ith a no. 11 scalpel over a
groove director.

durotomy and the bone edge to prevent retraction, causing di cult y


with closure. If the brain is signi cantly edem atous and the dura is taut,
relaxing incisions m ay be m ade in the perim eter of a curvilinear incision
to prevent strangulation of the underlying brain by the dural edge.
The dural edges should be secured with 4-0 braided nylon sutures, and
held in place with m osquito hem ostats, either to gravit y or secured to
the drapes without undue tension.
The dural ap or aps should be weighted with hem ostats in order to
prevent shrinkage during the procedure as m uch as possible.
Dural vessels m ay be coagulated with the bipolar at the edges of the cut
dura.

I Cerebral Traum a and Stroke

Evacuation of Subdural Hematoma (Fig. 1.8)

Figure

Procedural Steps

Pearls

Fig. 1.8

The subdural
hematoma (SDH) is
seen overlying the
surface of the brain
and is evacuated w ith
irrigation and suction.

The source of any SDH should be sought. The source is often a cortical surface vein or artery.

10

SDHs occasionally m ay em anate directly from a surface contusion.


Gentle irrigation with sterile saline should be used and the entire perim eter of the
dural exposure explored with adequate lighting to ensure that the hem atom a has been
completely evacuated. A brain retractor blade m ay be used to gently depress the brain
during this phase. Well-form ed hematom as m ay be grasped with biopsy forceps and gently
elevated from the brain surface while ushing the area with ample irrigation.
If an active bleeding source is identi ed (which is not always possible), the bleeding should
be stopped with bipolar electrocautery, gelatin sponge soaked in throm bin, and gentle
pressure with a cot ton pat tie. The site should be irrigated again to ensure no active bleeding
prior to dural closure.

Surgery for Epidural and Subdural Hem atom as

Dural Closure (Fig. 1.9)

Figure

Procedural Steps

Pearls

Fig. 1.9

After adequate evacuation of


the hematoma, the dura is
closed w ith 4-0 braided nylon
suture.

Closure of the dura should be a ected in a watertight fashion if possible. Over the

Epidural tack-up sutures are


placed through small drill
holes placed around the
perimeter of the craniotomy.
A central epidural tacking
stitch may be brought out
through tw o holes drilled in
the bone ap.

convexit y, watertight closure is not imperative. The dura may be closed with simple
running, running-locking, or interrupted sutures.
For large dural defects not am enable to prim ary closure due to shrunken dura, torn
or adherent dura (com m on in the elderly), and/or brain swelling, a variet y of dural
substitute m aterials are available. The dura m ay be patched with suturable graft
m aterials or autograft from the patients own galea or m uscle fascia, or closed with
graft m aterials alone.
Prior to placing the nal few sutures, the subdural space should be irrigated a nal
tim e. When a large subdural potential space rem ains (as in the case of an elderly
patient and/or one with a slack brain), a sm all am ount of irrigation m ay be left in the
subdural space to lessen the risk of extensive postoperative pneum ocephalus.

11

I Cerebral Traum a and Stroke

Bone Flap Replacement (Fig. 1.10)

12

Figure

Procedural Steps

Pearls

Fig. 1.10

Follow ing evacuation of either an


epidural or subdural hematoma, the
bone ap is replaced in its anatomic
position, using a cranial plating
system. The central epidural tacking
stitch is secured.

Many t ypes of cranial plating system s, with a variet y of plate shapes

and sizes, are available. These are generally m ade of titanium , which is
nonm agnetic, allowing for later m agnetic resonance im aging.
Resorbable plates and screws are available for children. Alternatively, the
bone ap m ay be replaced with silk suture to avoid rigid xation in the
growing skull.

Surgery for Epidural and Subdural Hem atom as

Drain Placement (Fig. 1.11)

Figure

Procedural Steps

Pearls

Fig. 1.11

For large aps, a subgaleal drain


may be used to lessen the risk of
postoperative subgaleal hematoma.

The drain should exit from a separate stab incision, formed with a trocar or
no. 11 knife, and should be secured at its skin exit site with a nylon stitch.
The drain is at tached to bulb suction.

13

I Cerebral Traum a and Stroke

Closing

Pat ien ts w ith severe inju ries w ill likely h ave addit ion al in -

If m ass e ect h as been relieved adequ ately an d th e brain is

slack (creat ing dead sp ace in w h ich blood m ay accu m u late


postoperat ively), th e pat ien ts en d-t idal CO2 level sh ould be
allow ed to rise gradu ally to 30 to 35 m m Hg (rough ly equ ivalen t to p CO2 of 35 to 40 m m Hg) d u ring closu re.
If ongoing coagu lopathy is obser ved, m easu res sh ou ld be t aken to correct clot t ing p aram eters in t raop erat ively.
Sterile salin e irrigat ion is ut ilized in th e in t radu ral space.
After du ral closu re, cop iou s am ou n t s of sterile salin e in fu sed
w ith an t ibiot ic solu t ion (e.g., bacit racin ) are used to irrigate
th e w oun d.
Tem poralis m uscle and fascia are reapproxim ated w ith 0-gauge
braided absorbable suture. The galea is closed w ith interrupted,
inverted, 2-0 braided absorbable suture. As the scalp closure
proceeds, the scalp clips m ay be rem oved successively, by
spreading w ith the scalp clip applier or a hem ostat.
Th e skin m ay be closed w ith nylon or oth er n on braided sut ure, or w ith st aples. Extern al su t ure is requ ired on th e scalp,
as th ere is n ot a w ell-develop ed su bcu t icu lar layer.
Th e w ou n d m ay be dressed in a variet y of w ays. Th e auth or
prefers to apply a st rip of n on adh eren t pet rolat um gauze over
su t u res or st ap les to p reven t p u lling. Th is base dressing, in
t urn , is covered w ith n arrow gau ze ban dages to absorb m in or
oozing postoperat ively. Th e dressing is secured w ith st retchy
dressing t ape, applied un der sligh t tension to assist in cision al
h em ostasis. St rip s of dressing tape m ay be u sed to follow th e
cur vat ure of th e h ead parallel to th e in cision for close adh eren ce. Th e dressing is rem oved after 24 h ou rs, an d th e pat ien t
is allow ed to clean se th e w oun d w ith m ild soap an d w ater.

vasive n eu rom on itoring (an ICP, extern al ven t ricu lar drain ,
brain t issue oxygen m on itor, or a com bin at ion th ereof) to
gu ide m an agem en t . Invasive h em odyn am ic m on itoring (arterial lin e, cen t ral ven ous lin e, Sw an -Gan z cath eter) m ay be
in dicated to assist m an agem en t in crit ically ill pat ien t s.
Drain s sh ou ld be m on itored for ou t pu t ever y 4 h ou rs for th e
rst 8 h ou rs an d th en ever y 8-h ou r sh ift .
Th e in cision an d/or dressing sh ould be m on itored for bleeding in it ially, an d for er yth em a, exudate, an d /or edem a subsequen t to th e in it ial postoperat ive period.

Medication
Postop erat ive an t ibiot ics are con t in u ed for 24 h ou rs u n less

th ere w as gross con t am in at ion presen t at th e t im e of surger y,


in w h ich case th is period m ay be exten ded.
Seizu re prop hylaxis sh ou ld be con t in u ed for a total of 7 days
for p at ien ts w ith EDH or SDH. Th e presen ce of d ocu m en ted
seizu res m ay p rovide an in dicat ion to con t in u e th erapy beyon d th is w in dow.
Hyperosm olar th erapym an n itol an d/or hyper ton ic salin e
m ay be in dicated for ICP con t rol dep en d ing on th e clin ical
pict ure.
Sedat ion an d /or n eu rom u scu lar p aralyt ics m ay be in dicated
to assist ICP con t rol depen ding on th e clin ical pict ure.
Pressor support m ay be n ecessar y to m ain tain adequate cran ial perfu sion pressu re d ep en ding on th e clin ical pict u re.
Ongoing coagu lopathy sh ou ld be corrected w ith fresh frozen
plasm a or oth er appropriate blood product s/factors.

Radiographic Imaging

Postoperative Management
Monitoring

Postop erat ive im aging (Fig. 1.12).

Further Management
Drain s are rem oved on th e rst p ostop erat ive day, provid ed

Th e pat ien t sh ou ld be m on itored in th e post-an esth esia care


u n it (recover y room ), progressive care un it , or in ten sive
care un it w ith frequen t n eurologic ch ecks, occurring at least
h ou rly in it ially. Th e p at ien ts preoperat ive st at us an d p ostoperat ive course w ill dict ate th e t im ing of t ran sit ion to less
in ten sive m on itoring.

14

input h as slow ed su cien tly. If th ere is sign i can t out p ut , rem oval m ay be d elayed an oth er 1 to 2 days.
Th e dressing is rem oved an d th e w oun d is clean sed w ith
w arm w ater an d m ild soap or sh am p oo after 24 h ou rs.
Skin su t u res or st ap les are rem oved on or abou t p ostop erat ive day 10 to 14.

Surgery for Epidural and Subdural Hem atom as

b
Fig. 1.12a, b Axial CT images demonstrating resolution of (a) epidural hematoma and (b) subdural hematoma.

Special Considerations
Preoperat ive plan n ing is im port an t in th e m an agem en t of t raum at ic SDHs. Plan n ing for p ossible decom p ressive cran iectom y
m u st often be in corp orated in to th e p osit ion ing, in cision , an d
bon e ap creat ion (see Ch apter 4). Pat ien t s w h o are likely to
require th e bon e ap to be left out in clude th ose w ith m idlin e
sh ift ou t of p roport ion to th e th ickn ess of th e SDH, th ose w ith
e aced cistern s, th ose w ith blu n t vascu lar inju r y or isch em ia to
th e a ected h em isph ere, or th ose w ith a sign i can t am oun t of
u n derlying con t u sion .

References
1. Bu llock MR, Ch esn u t RM, Clifton GL, et al. Man agem en t an d
progn osis of severe t raum at ic brain injur y. J Neu rot raum a 2000;
17:449597
2. Bu llock MR, Ch esn u t R, Gh ajar J, et al. Su rgical m an agem en t of
acute epidural h em atom as. Neurosurger y 2006;58:S7S15
3. Bu llock MR, Ch esn u t R, Gh ajar J, et al. Su rgical m an agem en t of
acute subdural h em atom as. Neurosurger y 2006;58:S1624
4. Bu llock et al. An t iseizu re p rop hylaxis. In : Guidelin es for th e
Man agem en t of Severe Traum at ic Brain Injur y, 3rd ed. J Neurot raum a 2007;24:S8386

15

16

Chronic Subdural Hematomas


Branko Skovrlj, Jonathan Rasouli, A. Stew art Levy, P.B. Rak sin, and Jam ie S. Ullm an

Introduction

Indications

Ch ron ic su bdu ral h em atom a (CSDH) is on e of th e m ost com m on ly t reated n eu rosu rgical disord ers in th e w orld. Th e 2006
Am erican Associat ion of Neurological Surgeons procedural survey rep or ted over 43,000 bu r h oles perform ed for th e evacu at ion of ext ra-axial (subdural/epidural) h em atom as.1 Th e m ost
com m on pat ien t ch aracterist ics are elderly m ales w ith or w ith out a h istor y of h ead t rau m a.2,3 Addit ion al risk factors in clu de a
h istor y of alcoh olism , th e p resen ce of an in tern al cerebrosp in al
u id (CSF) sh u n t , an d acqu ired or congen it al bleeding d iath esis.4 CSDHs are often u n ilateral, bu t p resen t as bilateral in ap p roxim ately 16 to 25%of cases.3,5 Th e m ost com m on presen t ing
sym ptom s in clu de h eadach e, ataxic gait , con fu sion , ap h asia,
an d variou s n on speci c com p lain t s. If th e CSDH is large an d
causes sign i can t m ass e ect , paresis, seizure, an d com a m ay
en su e. Mort alit y st at ist ics var y am ong in st it u t ion s, bu t gen erally range from 5 to 16%.6,7
Several th eories exist to exp lain th e p ath ogen esis of CSDH.
The prevailing hypoth esis is th at m ost start as acute subdural
bleeds th at t rigger a local in am m ator y respon se in th e surroun ding m en inges. In am m at ion t riggers th e m igrat ion of broblast s, w hich th en create m em bran es th at organ ize th e clot
an d secrete vascu lar en doth elial grow th factor (VEGF) th at , in
t urn , prom otes th e form at ion of capillaries w ith in th ese m em bran es.8 Over t im e, th ese m em bran e capillaries bleed an d preven t th e blood from being reabsorbed. Hem oglobin even t u ally
is broken dow n in to h em osiderin , leading to th e ch aracterist ic
ap p earan ce of CSDH on com pu ted tom ograp hy (CT)/m agn et ic
reson an ce (MR) im aging (Fig. 2.1).
Man agem en t of CSDH t yp ically involves su rgical evacu at ion
of th e clot an d placem en t of post surgical drains to preven t reaccum ulation of blood in th e subdural space. In part icular, th e use
of drain s after bur h ole evacuat ion of CSDH has been sh ow n to
redu ce both recu rren ce an d m ort alit y at 6 m on ths.9 Several op erat ive ap proach es are available. Bu r h ole drain age is perform ed
m ost com m on ly. A m in i-cran iotom y m ay augm en t visu alizat ion of th e subdural space. W hen th e radiograph ic appearan ce
is favorable, bedside p roceduressuch as m in im ally invasive
t w ist drill cath eter placem en t or suct ion evacu at ion can be
u sed to good e ect . In addit ion to th ese su rgical tech n iques,
several sm all st u dies h ave suggested th at dexam eth ason e
therapy m igh t sh ow som e prom ise in t reat ing CSDH.10,11 New er
p h arm acological t reat m en t , such as th e u se of t ran exam ic acid
(an an t ith rom bolyt ic agen t), is invest igat ion al.12 CSDH recu rren ce rates var y am ong in st it u t ion s, bu t gen erally range from
8 to 16%.13,14 Several st udies h ave suggested that CSDH recurren ce rates are h igh er w ith bilateral CSDH, w ith large volum es
of pn eum oceph alus after evacuat ion , an d w ith use of an t icoagu lat ion th erapy.13,14

All Procedures
Su bacu te or ch ron ic su bdu ral h em atom a w ith m axim u m

th ickn ess . 10 m m an d/or m idlin e sh ift . 7 m m


Su bacu te or ch ron ic su bd u ral of any th ickn ess cau sing m ass
e ect , m idlin e sh ift , or n eu rologic sign s an d sym ptom s.

Minimally Invasive
Favorable CT im aging ch aracterist icsa un iform ly isoden se

or hypoden se collect ion in th e subdural spaceare presen t .


Th is suggest s th e subdural h em atom a is su cien tly lique ed
to perm it drain age via a ven t riculostom y cath eter.
The presence of an isodense, or even slightly hyperdense,
ground glass appearance is not necessarily a contraindication
to catheter drainage. This ph enom enon is seen som etim es in
the set ting of a subacute or acute on chronic subdural hem atom a, often w ith a gradual gradient from anterior hypodensit y
to posterior hyperdensit y (re ecting dependen t acute blood
m ixed w ith th e predom inantly ch ronic hem atom a). These
usually can be drained e ectively w ith a bedside catheter or
suction evacuation procedure.
A sm all am oun t of acute, hyperden se subdural blood w ith in a
larger, m ostly ch ron ic, hypoden se collect ion is n ot n ecessarily a con t rain d icat ion .
W h ile adequate drain age can be ach ieved even in th e presen ce of a few su bdu ral m em bran es, exten sive m em bran es
an d m u lt iple layers of su bdu ral h em atom a (SDH) of d i eren t
ages or den sit ies m ay p ose a ch allenge. Bur h ole drain age or
cran iotom y sh ould be con sidered in th is set t ing.

Preprocedure Considerations
Radiographic Imaging (Figs. 2.1,
2.2, and 2.3)
X-ray: In gen eral, X-ray is a poor diagn ost ic tool for CSDH.

Occasion ally, a p lain lm of th e sku ll m ay reveal a calci ed


CSDH.15
CT: CT is t h e gold -st an dard im agin g m odalit y for d iagn osin g
CSDH. SDHs classically d e m on st rate a crescen t ic con gu rat ion , as t h e ir d ist r ibu t ion over t h e cor t ical convexit y is n ot
b ou n d ed by su t u re lin es (in con t rast to e p id u ral b lee d s).
Mass e ect , cor t ical b u cklin g, an d m id lin e sh ift m ay also

Fig. 2.1 Patient with subacute subdural hematoma with a so-called


hematocrit e ect with blood of di erent densities layering in a
dependent fashion. There is mass e ect causing mild shift and left
ventricular e acement. This patient was deemed a good candidate for
bur hole drainage.

ap p ear d ep e n d in g on t h e t h ickn ess an d size of t h e clot . Th e


ap p earan ce of blood on CT scan w ill ch an ge ove r t im e as
t h e blood p rod u ct s age (Table 2 .1); su bacu te blood ap p ears
isod e n se an d ch ron ic blood , h yp od en se relat ive to brain .
Th e d egree of m id lin e sh ift an d t h ickn ess of su bd u ral blood
are u sefu l rad iograp h ic m arke rs to assist clin ical d e cision

Chronic Subdural Hem atom as

m akin g regard in g op erat ive in te r ve n t ion . Non con t rast CT


u su ally is ad e qu ate to assess t h e age of t h e blood p resen t ,
an d t h erefore, t h e likelih ood t h at it w ill be d rain ed su ccessfu lly via m in im ally invasive or op e n m ean s. Con t rast -en h an ce d im agin g sh ou ld be con sid ere d if t h e re is con cer n for
su bd u ral e m pyem a or for clar it y in t h e set t in g of a su bacu te
su bd u ral h em atom a t h at is isod en se w it h resp e ct to t h e
b rain t issu e. En h an cem e n t of cor t ical vein s h elp s to d e n e
t h e bou n dar y bet w ee n cor tex an d h em atom a. Con t rast m ay
also d em on st rate t h e p rese n ce of m e m b ran es.
MRI: Magn et ic reson an ce im aging (MRI) is sim ilarly sen sit ive an d sp eci c for diagn osing CSDH as CT scan ; it is p o ten t ially m ore sen sit ive in determ in ing size an d in ter n al
st r u ct u re.16 CT gen erally is p referred d u e to th e h igh cost
of MR im aging as w ell as th e t im e requ ired to p erfor m t h e
st u dy. Sim ilarly to CT scan n ing, th e ap p earan ce of su bd u ral
blood w ill also ch ange over t im e (Table 2.2). MRI m ay be
con sid ered for m ore det ailed evalu at ion of m em bran es an d
layers if th ere is con cern regard ing th e feasibilit y of cat h eter
d rain age.

Medications
In t raven ou s (IV) an t ibiot ics sh ou ld be given w ith in 1 h ou r

p rior to in cision . Th e u se of prophylaxis in th e set t ing of m in im ally invasive bedside p rocedu res is left to th e discret ion of
th e su rgeon .
An t iepilept ic drug prophylaxis sh ould be adm in istered.
Sedat ion for bed side procedu res sh ou ld be adm in istered w ith
caut ion . Min im ize dosing or avoid sedat ion , if possible, as pat ien t s w ith CSDH m ay be par t icularly sen sit ive to its e ects.
On e of th e ben e ts of th e bedside SDH drain age p rocedu re
is th e possibilit y to w it n ess rapid n eu rologic im p rovem en t

b
Fig. 2.2a, b Large right frontoparietal subdural hematoma causing mass e ect and right ventricular e acement. There are some septations within
the mixed densit y subdural. A small craniotomy was chosen to evacuate the collection.

17

I Cerebral Traum a and Stroke


w h en m in im al or n o sedat ing m edicat ion s are used. Th is
st an ds in con t rast to th e d elayed em ergen ce som e (often
elderly) pat ien t s exp erien ce after bur h ole drain age u n der
gen eral an esth esia. Bu r h ole p roced u res in th e op erat ing
room can be perform ed u n der con scious sedat ion or gen eral an esth esia as p er su rgeon p referen ce or pat ien t toleran ce. Cran iotom ies t yp ically are p erform ed u n d er gen eral
an esth esia.

Operative Field Preparation


Th e h air overlying th e a ected h em isph ere is clipped w ith

Fig. 2.3 CT scan of a patients head with a homogenous right hemispheric


subdural hematoma and right to left midline shift. This case was selected
for t wist drill craniostomy.

Table 2.1 CT appearance of subdural blood over time 17

18

Time

Appearance relative
to brain parenchyma

Hyperacute (, 24 hours)
Acute (12 days)
Subacute (213 days)
Chronic (. 14 days)

Hypo-/isodense
Hyperdense
Isodense
Hypodense

elect ric clippers.


Sterile skin prep arat ion is perform ed w ith p ovidon e iodin e
or ch lorh exidin e.
Th e plan n ed in cision sites are in lt rated w ith 1% lidocain e
w ith 1:100,000 epin eph rin e.
Available im aging sh ou ld be st u died carefu lly to determ in e
th e ideal en t r y poin t for th e t w ist drill cran iostom y. Th e
target is alm ost alw ays m ore lateral th an th e t ypical in sert ion site for a ven t ricu lostom y or in t racran ial pressure (ICP)
m on itor.

Table 2.2 MR appearance of subdural blood over time 18


Time
Hyperacute (, 24 hours)
Acute (13 days)
Early subacute (37 days)
Late subacute (813 days)
Chronic (. 14 days)

T1

T2

Hypo-/isointense
Hypo-/isointense
Hyperintense
Hyperintense
Hypointense

Hyperintense
Hypointense
Hypointense
Hyperintense
Hyptointense

Chronic Subdural Hem atom as

Operative Procedure
Bur Hole Drainage
Positioning and Skin Incision (Fig. 2.4a, b)

Figure

Procedural Steps

Pearls

Fig. 2.4

The patient is positioned supine on a donut or a horseshoe, w ith


the head rotated approximately 30 degrees to the contralateral
side. A shoulder roll is placed longitudinally beneath the ipsilateral
shoulder. The back of the bed is elevated slightly.

For bilateral procedures, the head is kept in

Bur Holes (Right)


Tw o incisionseach approximately 3 cm in lengthare planned along
a line that bisects the interval betw een midline and superior temporal
line. The anterior incision is positioned just anterior to coronal suture
and the posterior incision, over the parietal eminence.
Small Craniotomy (Left)
A lazy S incision is begun from approximately 1 cm below the
superior temporal line extending superiorly approximately 2 cm
lateral to the midline in the parietal region approximately 1 cm
posterior to the coronal suture. The incision can be further tailored to
the location and size of the hematoma.

a neutral position.
Trace out a reverse question m arkt ype
incision over the a ected hem isphere. This
will facilitate a m ore extensive opening, if
necessary. The planned bur hole incision
sites should fall along the superior lim b of
the question m ark.
If the CT appearance of the extra-axial uid
is both hypodense and homogeneous, it
m ay be possible to drain the collection
through a single bur hole.

19

I Cerebral Traum a and Stroke

Incisions and Bur Holes/Craniotomy (Fig. 2.5)

20

Figure

Procedural Steps

Fig. 2.5

A no. 10 blade is used to open each incision to the level of pericranium. The
pericranium is opened w ith Bovie electrocautery and sw ept to either side
w ith a periosteal elevator. For the craniotomy, scalp clips are applied to the
scalp edges. The temporalis is incised and is re ected w ith the skin incision.
Self-retaining retractors are placed.

Pearls

Bur Holes (Right)


Place a single bur hole at each incision site, using a round or matchstick bur,
perforator, or acorn drill. Apply bone w ax to the bony edges as necessary.

Bur Holes
Bur holes should be 1.5 to 2 cm

Small Craniotomy (Left)


Place bur holes at the apices of the exposed calvarium. A footplate
attachment, dental tool, or Pen eld no. 3 is used to free the underlying
dura from the bone. Use the craniotome to create a small bone ap,
limited to the size of the opening.
The craniotome is used to create a roughly ovoid ap. The bone is
elevatedusing a blunt surgical tool to dissect any remaining dural
attachments to the undersurface of the boneand set aside in antibiotic
solution.

Craniotomy
Resistance m ay be encountered

in diam eter.

at the level of coronal suture,


where the dura is more rm ly
adherent to bone.
The bone ap will be 4 to 5 cm in
diam eter.

Chronic Subdural Hem atom as

Dural Opening (Fig. 2.6)

Figure

Procedural Steps

Pearls

Fig. 2.6

Bur Holes (Right)


Coagulate the exposed dura w ith bipolar electrocautery at each bur hole site.
Open the dura in a cruciate fashion w ith a no. 11 blade. Coagulate the dural
lea ets w ith bipolar electrocautery to prevent bleeding into the subdural space
and to ensure opening of the dura across the full surface area of the bur hole.
Upon opening the dura, there may be immediate expulsion of liquid
hematoma. If not, a membrane is likely present. The membrane should
be coagulated w ith bipolar electrocautery and opened sharply w ith a
no. 11 blade.

Bur Holes
The posterior site should be

Small Craniotomy (Left)


Drill holes circumferentially at the periphery of the craniotomy site.
Line the edges of the craniotomy site w ith thin strips of gelatin sponge
soaked in thrombin. Place epidural tacking stitches circumferentially w ith
4-0 braided nylon sutures.
Open the dura in a cruciate fashion, w ith a no. 11 blade, follow ed by
tenotomy scissors.
An outer membrane may be present upon opening of the dura. Usually, it is
possible to develop a distinct plane betw een the undersurface of the dura and
the membrane, using a dissector and cotton patties.
Re ect the resulting dural aps to each quadrant and secure them w ith
4-0 braided nylon sutures.

Craniotomy
When subdural hem atom a is

opened rst to encourage


gravitational drainage.
At tach one suction unit to a
Lukens trap prior to opening
the dura in order to facilitate
collection of a specimen for
pathology.

present, the dura will have a


bluish hue.
A 4-0 silk suture, passed
through the periosteal dural
layer, m ay be used to lift
the dura away from the
underlying structures to
facilitate opening.
The subdural m em brane
often has a brown-green hue.

21

I Cerebral Traum a and Stroke

Hematoma Evacuation (Fig. 2.7)

22

Chronic Subdural Hem atom as

Figure

Procedural Steps

Pearls

Fig. 2.7

Bur Holes (Right)


Once the initial egress of uid subsides, inspect each bur
hole site.
Provided the brain has not expanded to ll the subdural space,
a small red rubber catheter may be introducedunder direct
vision.
Gravity irrigation may be performed w ith lukew arm saline. A x
a 10- to 20-mL syringew ith the plunger removedto the open
end of the red rubber catheter. Elevate the syringe, ll the open
end w ith irrigation, and allow it to funnel through the catheter,
into the subdural space. Monitor the bur hole sites during
this process to ensure that there is communication w ithin the
subdural space betw een the tw o holes. Alternatively, the surgeon
may elect simply to ush irrigate betw een the tw o bur holes.
Reorient the catheter w ithin the subdural space as necessary to
permit access to additional hematoma.
Continue irrigation until the returning uid is predominantly
clear in all directions.

Additional holes m ay be placed along the

Small Craniotomy (Left)


Coagulate the surface of the membrane and open it w idely
w ithin the craniotomy eldw ith the bipolar and scissors.
There w ill be immediate expulsion of liquid hematoma. Collect
a specimen in the Lukens trap for pathology. (Consider taking a
specimen of membrane as w ell.)
Use bulb irrigation w ith lukew arm saline to ush additional clot
from the subdural space at the periphery of the craniotomy site.
Membranes and septations can be broken apart w ith bipolar
coagulation.
Irrigation w ith a red rubber catheter in a systematic,
circumferential fashion under the craniotomy edge is performed
until the returning uid is clear in all directions.
Address bleeding points along the membrane and cortical surface
w ith bipolar electrocautery and/or adjuvant hemostatic agents as
necessary.

The m embrane does not need to be cut

distal 2 to 3 cm of the red rubber catheter,


taking care not to sever the tubing.
If the uid introduced through one hole
does not exit the second hole, there m ay
be an additional m em brane that is lim iting
com m unication. Halt irrigation and reassess.
The red rubber catheter m ay be guided
in any direction where there is presum ed
to be hem atom a; however, if resistance
is encountered, do not force the catheter
into position. It is possible for the catheter
to penetrate brain parenchym a or to tear a
bridging vein, resulting in hem orrhage.
If acute hem orrhage is suspected (and the
uid does not clear with continued irrigation),
consideration m ust be given to conversion
from bur holes to a full craniotomy.

beyond the edges of the craniotomy. The


vascularized m embrane can bleed, and such
bleeding m ay be di cult to control if rem ote
from the craniotomy.
Craniotomy also facilitates ushing out of
m ore organized rests of hem atom a not
accessible via bur holes.
The inner m em brane, if present, is not
stripped from the surface of the brain due to
the risk of precipitating cortical bleeding.
It is important to control active bleeding.
Placing gelatin sponge soaked in thrombin in
small pieces or strips along the undersurface of
the bone can be helpful in stopping bleeding
from membranes in di cult-to-reach areas.

23

I Cerebral Traum a and Stroke

Drain Placement (Fig. 2.8)

24

Figure

Procedural Steps

Pearls

Fig. 2.8

Bur Holes (Right)


A small Jackson-Pratt drain or ventricular catheter may be
introduced into the subdural space at the frontal site and
advanced, over a Pen eld no. 3, until it is visualized at the
parietal bur hole. The drain can be advanced further if no
resistance is encountered.
Irrigate the bur holes w ith normal saline (using a syringe w ith
an angiocatheter tip) to ush out air w ithin the subdural space.
Cover each dural opening w ith a piece of gelatin sponge to
prevent further air or blood from entering the subdural space.

Bur Holes
On occasion, the brain expands to ll the

Small Craniotomy (Left)


A at or soft round small Jackson-Pratt drain is carefully placed in
the subdural space under direct visualization w ithout resistance
depending on how much brain expansion is encountered. The
dura is closed in an interrupted or running fashion. The cavity
is irrigated to remove most of the air. Gelatin sponge is placed
over the cavity prior to replacing the bone ap to prevent air and
blood from getting into the subdural space during closure.

Craniotomy
Compressed gelatin sponge can be used to

subdural space, leaving lit tle or no room for


a drain. In such circum stances, the risk of
placing a subdural drain may out weigh the
bene ts of ongoing drainage.

overlap the craniotomy edges especially if a


watertight dural seal cannot be achieved.
A subgaleal drain m ay be left in place as
needed to help prevent a postoperative
subgaleal hem atom a or leakage of
subgaleal blood into the subdural space.

Chronic Subdural Hem atom as

Closing

The galea and subcutaneous tissue are approxim ated in an in-

Su p er cial skin an d su bcu t an eou s bleeding is con t rolled

u sing bipolar elect rocauter y.


Th e in cision site is irrigated w ith an t im icrobial solut ion .
For th e sm all cran iotom y:
Th e bon e ap is secured to th e skull w ith t it an iu m plates
an d screw s. Th e su bd u ral drain sh ou ld exit via a bu r h ole.
It is som et im es n ecessar y to create a groove (w ith a m atch st ick bu r) on th e u n dersu rface of th e bon e ap at th e
bur h ole sitein order to avoid kin king of th e drain at it s
exit site.
Th e tem poralis m uscle, if breach ed, is reapproxim ated
u sing 2-0 braided nylon su t ures.

terrupted fashion using inverted 3-0 braided absorbable suture.


Th e skin is closed w ith staples or w ith 3-0 nylon su t ures in a
ver t ical m at t ress fash ion .
A 2-0 braided sut ure is placed in a pursest ring fash ion aroun d
th e su bdural drain exit site to an ch or th e drain to th e skin
an d seal th e sp ace arou n d th e drain , p reven t ing in adverten t
drain rem oval, as w ell as leakage of blood an d/or CSF from
th e drain site.
A sim ilar sut ure is placed aroun d th e subgaleal drain , if
p resen t , at its exit site.
Th e skin aroun d th e in cision s is clean ed of all blood products
an d su rgical d ebris.
A sterile dressing is applied.

25

I Cerebral Traum a and Stroke

Operative Procedure
Tw ist Drill Craniostomy
Positioning and Skin Incision (Fig. 2.9)

26

Figure

Procedural Steps

Pearls

Fig. 2.9

The patients head is positioned on a rm surface, such


as a folded blanket or gel donut, and turned 15 to
30 degrees to the contralateral side (60 degrees if a
more posterior parietal entry point is required). Make
a small stab incision at the desired insertion site w ith a
no. 15 blade. The entry point for the catheter insertion
is chosen over a relatively thick part of the SDH that is
safely accessible, usually in the frontal region, about 2 cm
in front of the coronal suture and 4 to 8 cm o midline.

Soft restraints are often necessary to prevent the

patient from inadvertently reaching into the sterile eld.


An assistant may be useful to stabilize the patients
head during the procedure, with hands placed gently on
either side of the patients jaw, under the drapes.
The ideal entry point is usually sim ilar to a
ventriculostomy entry point, but m ore lateral.
Occasionally, a predom inantly posterior SDH will require
a parietal entry point.

Chronic Subdural Hem atom as

Drilling (Fig. 2.10a, b)

Figure

Procedural Steps

Pearls

Fig. 2.10

(a) A hand-operated tw ist drill is positioned at the desired entry point


and a small hole is drilled through the skull. The tw ist drill can be
started in the usual perpendicular angle, but once the hole is started
and the drill bit is stable enough in the hole to not slide, the drill angle
can be carefully adjusted o the perpendicular angle and into the
direction in w hich you w ish the catheter to enter. Usually this means
tilting the drill tip posteriorly in order to angle the hole posteriorly,
thereby directing the catheter into the subdural space and tow ard the
posterior dependent portion of the chronic SDH collection.

Angling the drill helps to guide the

The dura is usually penetrated w ith the drill bit. Alternatively, a no. 11
blade or spinal needle can be used.

catheter into the subdural space sm oothly,


and also helps to avoid inadvertently
passing the catheter through the surface
of the brain. (b) The Kindt Drill t ype of
short straight-axis hand drill (Fig. 2.10b)
is ideally suited for facilitating precise
control of the drill position and angle;
this is done by using the dom inant
hand to t wist the drill while resting the
nondominant hand on the patients head
to stabilize the drill position and angle.

27

I Cerebral Traum a and Stroke

Catheter Placement (Fig. 2.11a, b)

28

Figure

Procedural Steps

Pearls

Fig. 2.11

A ventriculostomy-type catheter is inserted through the hole in


the skull and the dura and into the subdural space. (a) The w ire
stylet is used to advance the catheter through the dura. (b) As
soon as the catheter has passed through the dura, the catheter
should then be advanced o the stylet and soft passed into
the subdural space, to minimize the risk of advancing the
catheter into the brain parenchyma.

Choose a ventricular catheter with a larger inner

diameter (e.g., 1.51.9 m m ) and larger side hole


perforations to m axim ize the abilit y to drain
thicker CSDH contents.
Since the catheter is usually in place for only 12 to
48 hours, the author (ASL) usually does not tunnel
the catheter, but som e may prefer to do so.

Closing
Th e in sert ion site is closed aroun d th e cath eter w ith 3-0

m on o lam en t nylon su t u res, w h ich are also u sed to an ch or


th e cath eter in place.
Sin ce th e cath eter is usu ally in p lace for on ly 12 to 48 h ou rs,
th e au th or (ASL) prefers to place a closing st itch w h ere th e
cath eter exit s (w h ile th e site is st ill an esth et ized), so th at
it can be easily closed w h en th e cath eter is rem oved, w ith out th e n eed for open ing an oth er su t u re an d n eedle h older.
Tip: Place th is st itch prior to th e an ch oring st itch so you can
m ove th e cath eter aside an d p osit ion th e st itch w h ere th e
cath eter w ill be on ce it rela xes back in to posit ion . Th row a
su rgeons kn ot (t w o overh an d th row s in th e sam e d irect ion )
w ith ou t pu lling it t igh t , so th at th e sut ure w ill st ay in place,
an d you can easily p u ll it t igh t on ce th e cath eter is rem oved
(Fig. 2.12).
Dress th e site w ith a dr y gau ze dressing an d a h ead w rap.
Th e lat ter provides a secure dressing w ith w h ich to an ch or
th e extern al drain age t ubing. A com plex extern al ven t ricular
drain system is n ot required sin ce ICP w ill n ot be m easured; a
sim ple drain age collect ion bag is su cien t .

Postoperative Management
Monitoring
Pat ien t s are m on itored in an in ten sive care u n it to obser ve for

ch anges in n eurologic st at us an d h em odyn am ic param eters.


Seizu re act ivit y an d p ostop erat ive re-bleed are th e t w o
m ost com m on com p licat ion s.
Pat ien t s are m ain t ain ed relat ively at in bed (020 degrees)
u n t il th e drain s are rem oved .
Drains are rem oved in a sterile fashion, usually w ithin 48 hours.
All drain sites m ust be closed t ightly using 3-0 nylon su t ures to preven t egress of CSF an d/or en t r y of air.
Skin st ap les or su t u res are rem oved after 1 to 2 w eeks.

Tw ist Drill Craniostomy


Th e pat ien t is m on itored in th e in ten sive care un it , w ith

Fig. 2.12 The closing stitch. A suture is placed in position to serve as a


closing suture for after the catheter is removed. A surgeons knot (t wo
overhand throws in the same direction) is placed but not pulled tight
until after the catheter is removed, usually the next day.

Chronic Subdural Hem atom as

h ou rly n eu rologic ch ecks as long as th e d rain is in p lace, an d


u sually for 12 to 24 h ou rs after th e drain is discon t in u ed.
Th e h ead of th e bed is kept at to prom ote gravit y drain age of
th e SDH, an d to avoid n egat ive pressure aspirat ion of air back
in to th e su bdural space. Th e pat ien t can be log rolled side-tosid e. Ch anges in p osit ion m ay act u ally facilit ate drain age of
th e SDH. Th e pat ien t can be allow ed to raise th e h ead of th e
bed to 10 to 15 degrees for eat ing, if n eurologically in dicated.
Th e drain is placed to gravit y drain age, st art ing at or just
below th e pat ien ts ear (Fig. 2.13a), an d th e level is adjusted
to m ain t ain a steady drain age rate. It w ill becom e n ecessar y
to low er th e drain gradually (over several m in utes to several h ou rs) as th e p ressu re in th e su bdu ral sp ace decreases
(Fig. 2.13b). Th e auth or (ASL) prefers to adjust th e drain
level in order to m ain t ain an SDH drain age rate of app roxim ately 1 drop of SDH u id per secon d . Th is gives th e n u rses
a clear object ive goal in order to m ake safe an d app rop riate
adju st m en ts to th e drain level, an d resu lts in a slow, gradu al
evacu at ion of th e SDH. Pat ien t s seem to bet ter tolerate slow
drain age of th e SDH, w ith decreased risk of h eadach e, n au sea, n eu rologic d eteriorat ion , or con t ralateral h em orrh age.
Th e drain age collect ion bag w ill en d up at or n ear oor level
as th e last of th e SDH is drain ed; th e rate w ill d ecrease below
1 drop per secon d an d, ult im ately, stop.
W h en th e SDH drain age h as ceased or slow ed sign i can tly,
an d follow -u p CT dem on st rates ad equ ate drain age of th e SDH
(u sually 5090%), th e drain is rem oved. Th e skin is prepared
in a sterile fash ion . Th e cath eter-an ch oring sut u re is cu t free
from th e cath eter an d th e cath eter is rem oved, bu t th e st itch
itself is left in place in th e skin to keep th at part of th e in cision
closed. Th e previously placed closing sut u re is t ied t igh tly to
com plete th e closure of th e exit site.
In rare cases, xan th och rom ic-app earing CSF m ay con t in u e to
drain in de n itely. Th e drain sh ould be discon t in ued after 2 to
4 days, regardless of th e volum e of con t in u ed drain age, an d
follow -u p im aging w ill be requ ired to determ in e if any addit ion al th erapy is in dicated. Usually th e rem ain ing subdural
u id w ill resolve sp on t an eou sly over t im e (w eeks to m on th s),
an d a su bdu ral sh u n t is ver y rarely requ ired.

29

I Cerebral Traum a and Stroke

a
Fig. 2.13a, b (a) The drain collection bag is initially leveled with the drip chamber 0 mark at or just below the level of the patients ear. Note the
approximately 20-mL chronic subdural hematoma uid already in the drip chamber. (b) As more SDH is evacuated, and the pressure decreases in the
subdural space, the drip chamber is gradually lowered.

Medication
An t iconvu lsan ts are adm in istered for a tot al of 7 days.
For cran iotom ies an d bu r h oles, an t ibiot ics are con t in ued for

24 h ou rs postoperat ively.
Dexam eth ason e, in a 2-w eek tapering dose, m ay be u sed if
m ild exp an sion of th e residu al collect ion is n oted in th e postoperat ive period.
It is recom m en ded th at p at ien t s rem ain o an t icoagu lan t/
an t iplatelet agen ts u n t il th e residu al su bdu ral collect ion s
resolve.

Radiographic Imaging
A postop erat ive CT scan is perform ed to evalu ate th e exten t

30

of subdural h em atom a evacuat ion , as w ell as to exclude n ew


postoperat ive subdural or epidural h em orrh age (Figs. 2.14
an d 2.15).
For t w ist drill cran iostom ies, on ce SDH drain age h as slow ed
or ceased, a follow -up CT scan of th e h ead is obt ain ed (usually
th e n ext m orn ing) (Fig. 2.16).
Con sider a repeat CT scan about 3 days after drain rem oval to
evaluate for reaccum ulat ion .
Barring a ch ange in n eu rologic st at us, addit ion al CT scan s are
u su ally obtain ed at 2 to 4 w eeks, 2 to 3 m on th s, an d th en as
n eeded u n t il th e SDH is com pletely resolved.

Fig. 2.14 Postoperative CT scan of the patient in Fig. 2.1 undergoing


bur hole drainage with drain in place. There is pneumocephalus and
improvement in m ass e ect. The patient also has a smaller subacute
right parietal subdural collection which was treated conservatively.

Chronic Subdural Hem atom as

b
Fig. 2.15a, b (a) Postoperative CT of patient in Fig. 2.2 undergoing craniotomy for subdural evacuation. There is a Jackson-Prat t drain in the
subdural space and mild pneumocephalus with improvement in mass e ect. (b) Delayed scanning after drain removal revealed further decrease in
the residual collection.

Special Considerations
Su bdu ral reaccu m u lat ion is a kn ow n risk of op erat ive t reatm en t . Reop erat ion m ay be n ecessar y. A secon d reaccu m u lat ion
m ay requ ire su bd u ralperiton eal sh u n t ing (w ith ou t a valve),
w h ich m ost often resolves th is di cult problem .

W h ile the focus of th is chapter does n ot in clude the m edical


t reat m ent of subacute an d chron ic subdural h em atom as, it is
w orth m en t ion ing th e u se of cort icosteroids as an adju n ct to
surger y. Th e rat ion ale for th e u se of cort icosteroids is based on
the ant iangiogenic propert ies an d inh ibit ion of the in am m ator y
react ion , presum ed to play a key role in h em atom a form at ion
an d m ain ten an ce.1,2 Five obser vat ion al st u dies p rovide class III
eviden ce th at suggests th at t reat m en t w ith cort icosteroids for
CSDH m igh t be as safe an d e ect ive as su rger y, an d th erefore
ben e cial in th e t reat m en t of CSDH.3 How ever, n o ran dom ized
con t rolled t rials exam ining th e use of cort icosteroids for this in dicat ion have been publish ed. Prim ar y t reat m en t w ith an oral
an t i brin olyt ic, t ran exam ic acid, h as been dem on st rated to be
e ect ive in a sm all series.12
A su bd u ral su ct ion evacu at ion system is com m ercially available. Th is m in im ally invasive ap p roach h as in d icat ion s sim ilar
to t h e t w ist d r ill cran iotostom y, bu t d oes n ot involve p lacem en t of d evices w it h in t h e in t racran ial cavit y. Th e kit con t ain s
d et ailed in st r u ct ion s regard in g it s u se an d in ser t ion . Th is
tech n iqu e p rovid es yet an ot h er opt ion in t h e m an agem en t
of p at ien t s w it h CSDH an d o ers t h e p ossibilit y of im m ediate relief of p ressu re if a p at ien t becom es severely let h argic
or obt u n d ed .

References
Fig. 2.16 Post-drainage CT of patient in Fig. 2.3 shows a signi cant
decrease in the size of the chronic subdural hematoma, and decreased
midline shift. The tip of the subdural catheter can be seen in the subdural
space (arrow).

1. Nat ion al Neu rosu rgical Procedu ral St at ist ics. Rolling Meadow s,
IL: Am erican Associat ion of Neu rological Su rgeon s; 2006
2. Mori K, Maeda M. Su rgical t reat m en t of ch ron ic su bdu ral h em atom a in 500 con secu t ive cases: clin ical ch aracterist ics, surgical
ou tcom e, com plicat ions, an d recurrence rate. Neurol Med Ch ir
2011;41(8):371381

31

I Cerebral Traum a and Stroke


3. Hirakaw a T, Hash izu m e K, Fu ch in ou e T, Takah ash i H, Nom u ra K.
St at ist ical an alysis of chron ic subdu ral h em atom a in 309 adu lt
cases. Neurol Med Ch ir 1972;12(0):7183
4. Kaw am at a T, Takesh ita M, Ku bo O, Izaw a M, Kagaw a M, Takaku ra
K. Man agem en t of in t racran ial h em orrh age associated w ith an t icoagulan t th erapy. Surg Neurol 1995;44(5):438442
5. Robin son RG. Ch ron ic su bdu ral h em atom a: su rgical m an agem en t
in 133 pat ien t s. J Neurosurg 1984;61(2):263268
6. Miran da LB, Braxton E, Hobbs J, Qu igley MR. Ch ron ic su bdu ral h em atom a in th e elderly: n ot a ben ign disease. J Neurosurg
2011;114(1):7276
7. Ram ach an d ran R, Hegd e T. Ch ron ic su bdu ral h em atom ascau ses
of m orbidit y an d m ort alit y. Surg Neurol 2007;67(4):367372
8. Shono T, Inam ura T, Morioka T, Matsum oto K, Suzuki SO, Ikezaki K,
Iw aki T, Fukui M. Vascular endothelial grow th factor in chronic
subdural haem atom as. J Clin Neurosci 2001;8(5):411415
9. Santarius T, Kirkpatrick PJ, Ganesan D, et al. Use of drains versus no
drains after bur-hole evacuat ion of chronic subdural hem atom a: a
random ized controlled trial. Lancet 2009;374(9695):10671073
10. Delgado-Lop ez PD, Mar t in -Velasco V, Cast illa-Diez JM, et al.
Dexam eth ason e t reat m en t of ch ron ic su bdu ral h em atom a.
Neuroch irugia (Ast ur) 2009;20:346359
11. Su n TF, Boet R, Poon WS. Non -su rgical p rim ar y t reat m en t of
ch ron ic subdural h em atom a: prelim inar y result s of using dexam eth ason e. Br J Neu rosu rg 2005;19:327333

32

12. Kageyam a H, Toyooka T, Tsu zu ki N, Oka K. Non su rgical t reat m en t


of ch ron ic subdu ral h em atom a w ith t ran exam ic acid. J Neurosurg 2012;119:331337
13. Takayam a M, Ter u i K, Oiw a Y. Ret rospect ive st at ist ical an alysis
of clinical factors of recurren ce in ch ron ic subdural h em atom a:
correlat ion bet w een un ivariate an d m u lt ivariate an alysis. No
Sh in kei Geka 2012;40(10):871876
1 4 . St an ii M, Hald J, Rasm u sse n IA, et al. Volu m e an d d e n sit ies of ch ron ic su bd u ral h ae m at om a obt ain e d from CT im agin g as p re d ict ors of p ostop e rat ive re cu r re n ce: a p rosp ect ive
st u d y of 1 0 7 op e rat e d p at ie n t s. Act a Ne u roch ir 2 0 1 3;1 5 5 (2 ):
323333
15. Pap p am ikail L, Rato R, Novais G, Bern ardo E. Ch ron ic calci ed
subdural h em atom a: Case repor t an d review of the literat ure.
Surg Neu rol Int 2013;4:21
1 6 . Se n t u rk S, Gu zel A, Bilici A, Takm a z I, Gu zek E, Alu clu U,
Ceviz A. CT an d MR im agin g of ch ron ic su b d u ral h ae m ato m as: a com p arat ive st u dy. Sw iss Me d W kly 2010;140(23-24):
335340
17. Coh n DF, Avrah am i E, Ried er- Grossw asser I. Radiograp h ic
isoden se subdural h em atom as in com puterized tom ography.
Sch w eiz Med Woch ensch r 1981;111(12):427429
18. Tu rh im S. In t racerebral h em orrh age. In : Fron tera JA, ed. Decision Making in Neurocrit ical Care. New York: Th iem e Medical
Publish ers; 2009:3652

Surgery for Cerebral Contusions of


the Frontal and Temporal Lobes,
Including Lobar Resections
Pal S. Randhaw a and Craig Rabb

Introduction
Cerebral con t usion s are obser ved in up to 8.2% of all t raum at ic
brain injuries 1,2 an d are m ore com m on (1335% of pat ien ts) in
th e set t ing of severe t raum at ic brain injur y.1,37 W h ile con t usion s can occu r in alm ost any lobe, m ost occu r in th e fron t al an d
tem poral lobes.8,9 Most sm all lesion s w ill n ot require su rgical
in ter ven t ion 1,3,10,11 ; th e m ajorit y w ill reabsorb in 4 to 6 w eeks.

Indications
Guidelin es m ay assist clin ical decision m aking w ith respect

to w h ich con t u sion s m igh t requ ire su rgical in ter ven t ion .1
Operat ive in ter ven t ion is in dicated in th e set t ing of:
A fron t al or tem p oral con t u sion of greater th an 20 cm 3 in
volu m e an d associated w ith any of th e follow ing:
Glasgow Com a Scale (GCS) score 6 to 8
Midlin e sh ift at least 5 m m
Cistern al com pression

Any lesion calculated to be greater th an 50 cm 3 in volu m e


A paren chym al m ass lesion th at is associated w ith :
Progressive n eurologic declin e at t ribut able to th e lesion
Refractor y in t racran ial hyperten sion
Mass e ect on com p u ted tom ograp hy (CT) scan
A tem poral lobe h em atom a greater th an 30 m L, w ith or
w ith out any m idlin e sh ift or elevat ion of th e m iddle cerebral arter y. Th ese pat ien t s are part icularly at risk for
t ran sten torial h ern iat ion given th e lim ited space of th e
m idd le cran ial fossa.

Preprocedure Considerations
Radiographic Imaging
Non con t rast h ead CT is vit al in th e evalu at ion of all severe
t raum at ic brain injuries. CT allow s for an atom ic localizat ion of
su rgical path ology an d, in t u rn , facilitates p lan n ing of p at ien t
posit ion ing an d operat ive approach .
Pre o pe rative im aging (Fig 3.1).

a
Fig. 3.1a, b Axial CT images demonstrating (a) frontal and (b) temporal lobe cerebral contusions.

33

I Cerebral Traum a and Stroke

Medication

Choice of Surgical Approach

Th e au t h ors p refer t h e u se of van com ycin for an t ibiot ic

Tw o di eren t approach esbicoron al an d m odi ed pterion al

p rop hyla xis, p rovid ed t h e p at ien t d oes n ot h ave ren al failu re or any ot h er con t rain d icat ion s. Given t h e in creasin g
p revalen ce of m et h icillin -resist an t Staphylococcus aureus,
it is p ossible t h at t h e skin can or w ill be colon ized by t h is
m icroorgan ism .
An t ie p ile p t ic p rop h yla xis sh ou ld be p rovid e d . Fosp h e nyt oin m ay b e a d m in ist e re d in a loa d in g d ose of 1 7 t o 2 0 m g
p h e n yt oin e qu ivale n t s (PE)/kg in n on a lle r gic p at ie n t s w h o
are n ot on st a n d in g a n t ie p ile p t ic m e d icat ion ; a lt e r n at ely,
levet ira cet a m m ay b e ad m in ist e re d at a load in g d ose of
2 0 m g/kg.

are ou tlin ed in th e Operat ive Procedu re sect ion ; th e ch oice of


ap p roach w ill dep en d on th e site of th e path ology.
Bilateral or un ilateral, m ed ial con t u sion s of th e fron tal lobes
m ay be add ressed opt im ally by a bicoron al ap p roach .
A far lateral fron tal con t usion m ay be approach ed by a m odied pterion al ap proach .
Tem poral con t usion s gen erally can be approach ed via a m odi ed pterion al approach .

Operative Field Preparation


Alcoh ol prep is perform ed before th e applicat ion of povidone

34

iodin e or ch lorh exidin e.


Th e plan n ed in cision s are m arked an d in lt rated w ith 1%
lidocain e w ith 1:100,000 epin eph rin e.

Surgery for Cerebral Contusions of the Front al and Tem poral Lobes

Operative Procedure
Bicoronal Approach
Positioning (Fig. 3.2)

Figure

Procedural Steps

Pearls

Fig. 3.2

The patient is positioned supine, w ith the head in a


neutral, upright position. The head is stabilized w ith
May eld three -point xation. The head of bed is
elevated slightly.

Consider using a horseshoe headrest to facilitate m ore


rapid decompression in the em ergency set ting, or if a skull
fracture prevents use of a May eld three-point xation.

35

I Cerebral Traum a and Stroke

Skin Incision (Fig. 3.3)

Figure

Procedural Steps

Pearls

Fig. 3.3

Mark out a bicoronal incision, starting at the level of zygoma and extending
superiorly tow ard the midline, just posterior to the hairline. Carry the
incision across midline, in a mirror fashion, to the contralateral zygoma.

Scalp clips are applied to the skin

Initiate the skin opening w ith a no. 10 blade. Carry the incision dow n to the
pericranium above the superior temporal line and dow n to the temporalis
fascia in the temporal region.

36

edges to assist hemostasis.

Surgery for Cerebral Contusions of the Front al and Tem poral Lobes

Subcutaneous Dissection (Fig. 3.4)

Figure

Procedural Steps

Pearls

Fig. 3.4

The pericranium is opened w ith monopolar electrocautery, in line w ith


the scalp incision. The super cial temporal fascia and temporalis muscle
are opened, likew ise, using monopolar electrocautery. Pericranium
and muscle are advanced w ith a combination of periosteal elevator and
monopolar electrocautery. Leave the frontalis muscle intact if possible.

Special care m ust be taken to avoid

The myocutaneous ap is re ected anteriorly until the anterior middle


fossa and supraorbital areas are accessible. The ap is secured w ith
mini-tow el clips, hooks, or suture.

comprom ising the frontalis branch of the


facial nerve. Rem ain above the zygom a
when approaching the inferior aspect of
the incision.
A few rolled sponges are placed beneath
the ap as it is re ected and secured.

37

I Cerebral Traum a and Stroke

Bur Hole Placement (Fig. 3.5)

38

Figure

Procedural Steps

Pearls

Fig. 3.5

Bur holes are placed w ith a high-speed drill at the follow ing sites: just
above the root of zygoma; at the keyhole ; and just above superior temporal
line, anterior to coronal suture. An additional pair of holes are placed
straddling the midline, anterior to coronal suture. The base of each hole
is cleared w ith a curette. The dura is stripped from the undersurface of
the bone, locally and betw een each pair of holes, w ith a separator (e.g.,
Pen eld no. 3, Hoen, or similar).

Exercise particular care when stripping


the dural at tachments bet ween the
t wo param edian holes overlying the
sagit tal sinus.

Surgery for Cerebral Contusions of the Front al and Tem poral Lobes

Craniotomy (Fig. 3.6)

Figure

Procedural Steps

Fig. 3.6

The craniotome is used to connect each pair of bur holes circumferentially, taking
care to stay low in the frontal and temporal regions and making the nal cut in the
region of the superior sagittal sinus. The bone ap is carefully elevated aw ay from
the underlying dura and set aside in antibiotic solution.
Bone w ax is applied to the bony edges w here necessary. Bleeding along the
midline sagittal sinus may be controlled w ith a combination of brillar hemostatic
material, thrombin-soaked gelatin sponge, and hemostatic matrix sealant. If all
other measures fail, the superior sagittal sinus may be ligated anteriorly, at the
level of the crista galli.

39

I Cerebral Traum a and Stroke

Dural Opening (Fig. 3.7ac)

Figure

Procedural Steps

Pearls

Fig. 3.7

Pilot holes are drilled circumferentially at the periphery of the


craniotomy to create dural tack-up sites.

Dural tacking stitches help prevent the


formation of postoperative epidural hematomas.
However, do not take time at this point in the
procedure to place the actual stitches.

(a) The dural opening is initiated w ith a no. 15 blade and enlarged
w ith tenotomy scissors. A strip of moistened nonadherent bandage
or a cotton pattie may be introduced into the subdural space to
protect the underlying cortex. A trap-door type opening ( apped
tow ard the midline) provides w ide access to the frontal lobe. If access
to the temporal fossa is necessary and/or ligation of the sagittal
sinus anticipated, dural slits are made initially parallel to the anterior
portion of the sinus and the dural opening extending laterally and
inferiorly tow ard the middle fossa on either side. The dural aps are
secured under modest tension w ith 4-0 braided nylon stitches.

40

(b) It may be necessary to divide the superior sagittal sinus and falx
in order to achieve adequate decompression of the frontal lobes.
After release of the sinus, use a double ligature technique to occlude
the sinus, using a 2-0 polypropylene or nylon suture. Make a double
circular course across the falx, just below the level of the sinus,
and cinched tightly to occlude the sinus. Repeat this process w ith a
second stitch, anterior to the rst.

The sinus should be targeted for ligation and

(c) Sever the sinus between the ligatures and divide the subadjacent falx
in its entirety to complete the exposure.

Alternatively, ligation may be performed with

division at a point well forward of the coronal


suture (along the anterior one-third of the sinus).
The second needle pass should be m ore
super cial (within the falx) than the rst.

a hemostatic double surgical clip at the inferior


insertion of the sinus into the falx, near the
crista galli. At tention must be paid to ensure
that the clips cross the sinus completely.

Surgery for Cerebral Contusions of the Front al and Tem poral Lobes

Address the Contusion (Fig. 3.8a, b)

Figure

Procedural Steps

Pearls

Fig. 3.8

(a) Inspect the cortical surface. Select your site for entryan
area of obvious contusion or cortical disruption is ideal.

If the cortical surface appears undisturbed, consider

Cauterize the super cial vessels and pia mater at the


planned entry site. Use a no. 11 or no. 15 blade to open the
pia. Approach the hematoma cavity in the subpial plane w ith
a combination of gentle suction and bipolar electrocautery.

(b) Upon entry to the hematoma, suction out any liquid


clot and remove solid clot in a piecemeal fashion. Continue
evacuation of hematoma until gliotic brain is visible on all sides.

the use of ultrasound to localize the m ost super cial


extent of the hem atom a.
A handheld m alleable retractorintroduced over
a saline-moistened 1- 3 3-cm cot ton pat tie (to
protect the friable tissue along the cavit y wall)m ay
assist visualization during contusion resection and
hem ostasis.
Always be mindful of position relative to the anterior
horn of the lateral ventricular while evacuating
hem atom a from deep subcortical spaces. Avoid entry
to the ventricle if feasible.

41

I Cerebral Traum a and Stroke

Anterior Frontal Lobectomy (Fig. 3.9)

42

Figure

Procedural Steps

Pearls

Fig. 3.9

In the event that the frontal lobe is extensively contused, consideration


may be given to a frontal lobectomy. The margin of resection w ill depend
on the size and appearance of contused frontal lobe. Alternatively, if
contusion is di use, one may begin the cortical incision 7 to 8 cm from
the frontal pole and extend laterally to the level of the lesser w ing of
the sphenoid. If it is desired to avoid entry into the lateral ventricle, the
medial aspect of the cortical incision should be made w here the tw o
frontal lobes are clearly separate.

In the set ting of signi cant


intraoperative or anticipated
postoperative swelling, consider
frontal polectomy to ensure adequate
decompression.

Surgery for Cerebral Contusions of the Front al and Tem poral Lobes

Modi ed Pterional Approach


Positioning (Fig. 3.10)

Figure

Procedural Steps

Pearls

Fig. 3.10

The patient is placed on the table in a supine position. The


head is turned 60 to 90 degrees aw ay from the side of the
approach to help provide better surgical visualization. A roll
is placed longitudinally beneath the ipsilateral shoulder. The
head is stabilized w ith a three -pinion head holder.

If the cervical spine has not been cleared, m aintain

the rigid collar and rotate head and body as a unit


(a larger shoulder roll m ay be necessary) to provide
the necessary exposure.
A horseshoe headrest may decrease tim e to
decompression in the em ergent set ting.

43

I Cerebral Traum a and Stroke

Skin Incision (Fig. 3.11)

Figure

Procedural Steps

Pearls

Fig. 3.11

Hair is clipped with an electric razor over the hemicranium of interest.

Preserve the frontalis branch of the

A reverse question marktype incision (i.e., trauma ap) is planned, starting 1 cm


anterior to the external auditory meatus and within 1 cm of the superior aspect
of the zygoma, extending posteriorly toward the parietal eminence and curving
superiorly toward the midline, ending just behind the hair line.
The incision is initiated with a no. 10 blade and carried down to the level of
pericranium superiorly and temporalis fascia inferiorly. Scalp clips are applied to
the skin edges.

44

facial nerve as well as the m ain trunk


of the super cial temporal artery.

Surgery for Cerebral Contusions of the Front al and Tem poral Lobes

Subcutaneous Dissection (Fig. 3.12)

Figure

Procedural Steps

Pearls

Fig. 3.12

The pericranium and temporal fascia and muscle are opened in line w ith the
scalp incision, using monopolar electrocautery.

Som e advocate m obilizing the

The resulting myocutaneous ap is dissected subperiosteally and advanced


forw ard until the root of zygoma and keyhole are visible. The ap is secured
w ith mini tow el clips, hooks, or suture.

temporalis o the superior


aspect of the zygom atic arch by
approxim ately 1 to 2 cm .

45

I Cerebral Traum a and Stroke

Bur Hole Placement (Fig. 3.13)

46

Figure

Procedural Steps

Fig. 3.13

Bur holes are placed w ith a high-speed drill at the follow ing sites: just above
the root of zygoma; at the keyhole ; over the parietal eminence ; and at a point
1 cm lateral to the midline and anterior to coronal suture. The base of each
hole is cleared w ith a curette. The dura is stripped from the undersurface of
the bone, locally and betw een each pair of holes, w ith a separator (e.g., no. 3
Pen eld, Hoen, or similar).

Surgery for Cerebral Contusions of the Front al and Tem poral Lobes

Craniotomy (Fig. 3.14)

Figure

Procedural Steps

Pearls

Fig. 3.14

The craniotome is used to connect each pair of bur holes circumferentially. It may
be necessary to thin the bone crossing the sphenoid ridge w ith a bur. A no. 3
Pen eld or small, curved periosteal may be introduced along the posterior
margin of the craniotomy to initiate elevation of the bone ap aw ay from the
underlying dura. Once removed, the bone ap is set aside in antibiotic solution.

Temporal exposure m ay be

The dural surface is irrigated. Branches of the middle meningeal artery observed
on the exposed dural surface are coagulated w ith bipolar electrocautery.

Bone w ax is applied to the bony edges w here necessary.

augm ented by rem oval of


additional bone with a Leksell
rongeur until ush with the
middle fossa oor and anterior
temporal dura.
Pay particular at tention to any
open air cells at the temporal
bone m argins. Pack and seal any
observed opening.

47

I Cerebral Traum a and Stroke

Dural Opening (Fig. 3.15)

48

Figure

Procedural Steps

Pearls

Fig. 3.15

Pilot holes are drilled circumferentially at the periphery of the


craniotomy to create dural tack-up sites.

Do not take tim e at this point in the procedure to

A reverse Cshaped dural ap (re ected onto the sphenoid ridge)


is planned.

The dural opening is initiated over the frontal area with a no. 15
blade and enlarged with tenotomy scissors. A strip of moistened
nonadherent bandage or a cotton pattie may be introduced into
the subdural space to protect the underlying cortex. The dural ap
is secured under modest tension with 4-0 braided nylon stitches.

Allow a dural m argin of at least 0.5 cm with respect

place the tacking stitches unless active bleeding


from the epidural space beneath the bony edge is
observed.
A ap fashioned in this m anner will maxim ize the
vascular supply and, therefore, its viabilit y.

to the craniotomy edge to perm it prim ary closure


after decompression.
Keep the re ected dural ap m oistened with a damp
sponge to minimize shrinkage.

Surgery for Cerebral Contusions of the Front al and Tem poral Lobes

Address the Contusion (Fig. 3.16a, b)

Figure

Procedural Steps

Pearls

Fig. 3.16

(a) Identify the Sylvian ssure. This is best done in relation to


the location of the sphenoid ridge. It may be necessary to drill
the bone of the sphenoid ridge until ush w ith the anterior and
middle fossae to augment the surgical exposure.

The sphenoid ridge separates the anterior

Inspect the cortical surface. Select your site for entry. An area of
obvious contusion or cortical disruption is ideal.

Cauterize the super cial vessels and pia mater at the planned
entry site. Use a no. 11 or no. 15 blade to open the pia. Approach
the hematoma cavity in the subpial plane w ith a combination of
gentle suction and bipolar electrocautery.

temporal lobe from the adjacent frontal lobe


and, in general, serves as a m ore stable landm ark
for identifying the Sylvian ssure than does the
middle cerebral vein.
If the cortical surface appears undisturbed,
consider the use of ultrasound to localize the
most super cial extent of the hem atom a.
A handheld m alleable retractorintroduced
over a saline-m oistened 1- 3 3-cm cot ton pat tie
(to protect the friable tissue along the cavit y
wall)may assist visualization during contusion
resection and hem ostasis.

(b) Upon entry to the hematoma, suction out any liquid clot and
remove solid clot in a piecemeal fashion. Continue evacuation of
hematoma until gliotic brain is visible on all sides.

49

I Cerebral Traum a and Stroke

Anterior Temporal Lobectomy (Fig. 3.17)

50

Figure

Procedural Steps

Fig. 3.17

In the event that the temporal lobe is severely contused, consideration may be
given to an anterior temporal lobectomy. While one may resect up to 5 to 6 cm
of the anterior, nondominant temporal lobecarrying out the resection to the
junction of the Rolandic and Sylvian ssures to demarcate the posterior limit
of resection (as in tumor cases)the posterior limit ultimately w ill depend on
w hat the surgeon feels necessary for the patients survival.

Surgery for Cerebral Contusions of the Front al and Tem poral Lobes

Closing
Hem ostasis is at tain ed w ith in th e h em atom a cavit y u sing a

com binat ion of m ech an ical an d ch em ical tech n iques. Focal


bleeding poin ts are con t rolled w ith bipolar elect rocauter y.
Tem porar y packing w ith gelat in sponge soaked in th rom bin m ay be augm en ted w ith h em ostat ic m at rix sealan t an d
salin e-m oisten ed cot ton p at t ies. Half-st rength hydrogen p eroxide or n orm al salin e-soaked cot ton balls m ay be u sed to
t am pon ade gen eralized oozing as w ell. On ce adequate h em ost asis h as been ach ieved, th e w alls of th e h em atom a cavit y
are lin ed w ith sm all p ieces of a brillar h em ostat ic m aterial.
In th e absen ce of sign i can t sw elling, th e du ra m ay be reap p roxim ated w ith 4-0 braided absorbable or braided nylon
su t u res in th e stan dard w ater-t igh t fash ion . Th e dural closu re can be su p p lem en ted w ith du ral graft m aterial (eith er
au togen ou s or ar t i cial).
If th ere is sign i can t sw elling, th e du ra m ay be left open an d
a du ral patch graft su t u red to th e m argin s of th e n at ive du ra.
Con siderat ion sh ould be given to leaving th e bon e ap out at
th e t im e of closure.
Pilot holes are drilled at regular in ter vals aroun d th e periph er y of th e craniotom y site. Epidural tacking st itches are
placed w ith 4-0 braided nylon sut ures.
Th e bon e ap is reapproxim ated w ith a m in i-plate system .
Th e tem poralis m uscle is reapproxim ated w ith 2-0 braided
absorbable su t u res.
Th e galea an d subcutan eous t issue are reapproxim ated w ith
2-0 braided absorbable sut ures in an inverted, in terrupted
fash ion .
Th e skin is closed eith er w ith staples or w ith 3-0 nylon (in a
vert ical m at t ress or ru n n ing fash ion ).

Bacit racin oin t m en t , w ith a dressing of ch oice, is th en p laced

over th e in cision site.


If th e pat ien t is com atose, a ven t ricu lostom y sh ou ld also be
p laced.

Postoperative Management
Monitoring
It is th e au th ors p ract ice to p lace th e p at ien t in a m on itored

set t ing (e.g., th e in ten sive care u n it) overn igh t in th e p ostop erat ive p eriod to obser ve for seizu re act ivit y or eviden ce of
in t racran ial bleeding or any oth er n eurologic com p licat ion s.
It is also au th ors pract ice to give th ree doses of p rop hylact ic
an t ibiot ics in th e im m ediate postop erat ive p eriod .

Medication
Antiepileptic prophylaxis of choice (phenytoin or levetiracetam )
is m aintained for a total of 7 days.

Radiographic Imaging
Postoperat ive im aging (Fig. 3.18).

Further Management
Skin su t u res or staples are rem oved after 2 w eeks.

b
Fig. 3.18a, b Axial CT images after evacuation of (a) frontal and (b) temporal lobe contusions. In each case, an external ventricular drain has been
placed to facilitate monitoring of intracranial pressure and therapeutic drainage of cerebrospinal uid.

51

I Cerebral Traum a and Stroke

References
1. Bullock MR, Chesnut R, Ghajar J, et al. Surgical m anagem ent
of traum atic parenchym al lesions. Neurosurger y 2006;58(3):
S2546
2. Singou n as EG. Severe h ead inju r y in a p aediat ric pop u lat ion .
J Neu rosu rg Sci 1992;36:201206
3. Gallbraith S, Teasdale G. Pred ict ing th e n eed for op erat ion in th e
pat ien t w ith an occult t raum at ic in t racran ial h em atom a. J Neurosurg 1981;55:7581
4. Gen n arelli T, Spielm an GM, Lang t t T, et al. In u en ce of th e t yp e
of in t racran ial lesion on outcom e from severe h ead inju r y. J Neurosurg 982;56:2632
5. Jallo J, Narayan RK. Gen eral prin cip les of cran iocerebral t rau m a an d t raum at ic hem atom as. In : Sekhar LN, Fessler RG, eds.
Atlas of Neurosurgical Tech n iques. New York: Th iem e; 2006:
895905

52

6. Lobato R, Cord obes F, Rivas J, et al. Ou tcom e from severe h ead


injur y related to th e t ype of in t racran ial lesion. A com puterized
tom ography st udy. J Neurosurg 1983;59:762774
7. Mandera M, Zralek C, Krawczyk I, Zycinski A, Wencel T, Bazowski P.
Surgery or conservative treatm ent in children w ith traum atic intracerebral haem atom a. Childs Nervous System 1999;15(5):267269
8. Miller JD, Bu t ter w or th JF, Gu dem an SK, et al. Fu r th er experien ce in th e m anagem en t of severe h ead inju r y. J Neurosurg
1981;54:289299
9. Nordst rom C, Messeter K, Su n dbarg G, Wah lan der S Severe t rau m at ic brain lesion s in Sw eden. Par t I: Aspect s of m anagem en t in
n on -n eu rosurgical clin ics. Brain Inj 1989;3:247265
10. Solon iu k D, Pit t s LH, Lovely M, Bar tkow ski H. Trau m at ic in t racerebral hem atom as: Tim ing of appearan ce and in dicat ion s for
operat ive rem oval. J Traum a 1986;26:787794
11. Sujit S. Prabh u , Zau n er A, Bu llock MRR. In t racerebral h em atom a
an d cerebral con t u sion . In : Win n HR, ed . You m an s Neu rological
Surger y. Ph iladelph ia: Elsevier; 2010:51595162

Decompressive Craniectomy for


Intracranial Hypertension and Stroke,
Including Bone Flap Storage in
Abdominal Fat Layer
Roberto Rey-Dios and Dom enic P. Esposito

Introduction
The use of a decom pressive craniectom y to treat the sym ptom s of
intracranial hypertension w as rst proposed in the late 19th cen tur y by Sir Victor Horsley.1 Koch er popularized its use in Europe.
Cushing introduced it in the United States in the early 20th
cent ur y as a palliative treatm ent for m ultiple conditions causing intracranial hypertension, including tum ors, hydrocephalus,
an d traum a.2 Th e operation fell in to disfavor as advances in neurosurgery during the rst half of the 20th century transform ed
m ost of the original indications for decom pressive craniectom y
into treatable conditions. In the 1970s, advances in life support
increased the sur vival of patients w ith severe head injuries. This
operation was revisited w ith the goal of treating traum atic brain
injury patients w ith intracranial hypertension not responsive to
m edical treatm ent.3,4 A collection of good results over th e past
t wo decades 57 h as turn ed decom pressive craniectom y surgery
into an accepted option for the m anagem ent of severe traum atic
brain injury w ith refractory intracranial hypertension; new indications are being explored. Several st udies have dem onstrated a
decrease in m ortalit y and im proved outcom es w hen this operation is perform ed in the correct patient population.810

Indications
Th ere is accum ulated eviden ce to suppor t th e use of decom -

pressive cran iectom y for th e follow ing path ologies:


Traum atic brain injury w ith di use or localized cerebral edem a or m ultiple cont usions refractor y to m edical th erapy.10
Large cerebral in farct ion s resu lt ing in severe edem a an d
m ass e ect .11,12
Som e st u dies h ave sh ow n p rom ising resu lts u sing decom pressive cran iectom y for oth er path ologies presen t ing w ith
di use cerebral edem a like an eur ysm al su barach n oid h em orrh age,13 ven ou s th rom bosis,14 or in fect ious en ceph alit is,15
but th e available eviden ce is n ot st rong en ough to allow for
a st an dard in dicat ion .
Tw o p r im ar y t yp es of d ecom p ressive cran ie ctom ies are
p er for m e d :
Fron totem poropariet al (occipit al) decom pressive h em icran iectom y. Th is proced ure is in dicated for t raum at ic lesion s

or edem a con cen t rated in on e h em isph ere w ith m idlin e


sh ift an d risk of u n cal h ern iat ion . Th is t ype of cran iectom y
m ay also be p erform ed in th e set t ing of an isch em ic cerebrovascular even t involving a un ilateral, large vascular territor y (u su ally m id dle cerebral arter y [MCA] or in tern al
carot id ar ter y [ICA])
Bifron tal decom p ressive cran iectom y. Th is p rocedu re is in dicated in cases of di u se, bilateral cerebral edem a or in
th e set t ing bilateral fron tal lesion s w ith associated severe
ed em a.
Decom p ressive cran iectom y m ay be p erform ed early or late 16 :
Early decom pressive cran iectom y is perform ed soon after
th e pat ien t arrives to th e em ergen cy depart m en t . Early
cran iectom y sh ould be con sidered in pat ien t s w ith m ore
th an 5 m m of m idlin e sh ift or if the m idlin e sh ift is out of
propor t ion to th e size of th e ext ra-axial m ass lesion (usu ally h em atom a) to be evacu ated.10
Late decom pressive cran iectom y is u su ally p erform ed
w ith in 48 h ou rs of th e origin al in sult , in th e set t ing of
m ed ically refractor y elevated in t racran ial pressu re (ICP;
de n ed as ICP . 30 m m Hg for greater th an 20 m in utes by
protocol at th e auth ors m edical cen ter). Late decom pressive cran iectom y sh ou ld on ly be con sidered after failu re of
prim ar y t ier th erapy for in t racran ial hyper ten sion .
Later decom pressive cran iectom ylonger th an 48 h ou rs
after th e in it ial in su ltm ay be in dicated for pat ien t s w h o
develop m align an t edem a follow ing isch em ic st roke, delayed expan sion of con t u sion s, or delayed m align an t cerebral edem a an d/or hyperem ic brain syn drom e.

Preprocedure Considerations
Radiographic Imaging
Com pu ted tom ography (CT) is th e m ost com m on im aging
m odalit y u sed to evalu ate poten t ial can didates for a decom pressive cran iectom y. CT im ages n ot on ly dem on st rate acu te
in t racran ial path ology bu t also provide in form at ion con cern ing bony an atom ic lan dm arksuseful for surgical p lan n ing
an d allow for iden t i cat ion of sku ll fract u res th at m igh t
com plicate th e operat ion .

53

I Cerebral Traum a and Stroke

a
Fig. 4.1a, b Axial CT images for t wo patients(a) one with traum atic brain injury and (b) one with a large right MCA strokeselected for
decompressive craniectomy.

CT angiograp hy can be u sefu l to diagn ose m ajor vascu lar oc

clusion s an d vascular injuries associated w ith h ead injuries,


part icularly w h en skull base fract ures are presen t .
Magn et ic reson an ce im agin g (MRI) is u se d m ore sp ar in gly
in t h e con t ext of t rau m a d u e t o t h e ad d e d d ifficu lt y of
organ izin g t h e logist ics for life su p p or t in t h e MRI su it e
an d t h e lon g d u rat ion of t h e st u d y, w h ich a cr it ically ill
p at ie n t m ay n ot t ole rat e. MR d iffu sion -w e igh t e d im ages
are u sefu l for early d et e ct ion of large isch e m ic st rokes.
Early involve m e n t of t h e n e u rosu rge on in su ch cases is
esse n t ial in t h e eve n t t h at lat e r n e u rologic d et e r iorat ion
m igh t p rovid e an in d icat ion for e m e rge n t d e com p ressive
cra n ie ctom y.
Preo perative im aging (Fig. 4.1).

Operative Field Preparation


Th e h air is clipped w ith an elect ric razor. Any foreign bodies

Medication
If the patien t is sh ow ing sign s of im m inent neurologic deterio-

54

ration (dilated nonreactive pupil, hem iparesis, decerebrate or


decorticate post uring), a bolus dose of m annitol (0.5 to 1 g/kg)
can be adm inistered as a tem porizing m easure en route to the
operating room .
Periop erat ive an t im icrobial p rophylaxis sh ou ld be adm in istered w ith in 1 h ou r of skin in cision . Th e auth ors prefer
cefazolin . In th e set t ing of an open skull fract u re an d/or
pen et rat ing brain inju r y, t riple an t ibiot ic coverage (gram posit ive, gram -n egat ive, an d an aerobic organ ism s) is
in it iated.

m ay be rem oved from th e scalp at th is t im e.


Hexach lorop h en e (or sim ilar) soap is u sed to clean se th e skin ,
an d th en 70% alcoh ol is ap plied.
Th e skin in cision s are m arked, an d povidon e iodin e or
ch lorh exidin e m ay be applied as a n al prep.
Th e surgeon also n eeds to m ake a decision at th is t im e about
h ow th e bon e ap w ill be preser ved for fu t u re sku ll recon st ru ct ion . Th ere is n ot en ough eviden ce in th e literat u re to
su p p or t th e preferen t ial u se of su bcu t an eou s or cr yop reservat ion .17,18 In m ost in st it ut ion s, sterile deep -freezing storage
(2 80C) is available. If storage is n ot available, or if th e p at ien t is ant icipated to con t in ue t reat m en t at a di eren t in st it u t ion before th e an t icip ated t im e of recon st ru ct ion , th e
su rgeon sh ou ld p roceed to prep th e abdom en for su bcu t an eous storage. We prefer to store th e bon e ap in th e righ t low er
quadran t of th e abdom en . Many pat ien t s w h o sust ain a t raum at ic brain inju r y w ill even t u ally n eed a gast rostom y t u be,
so th e left side sh ou ld be avoided. Th e righ t u p per qu adran t
sh ou ld be reser ved in th e even t th at th e pat ien t m igh t requ ire
a ven t ricu lop eriton eal (VP) sh u n t in th e fu t u re.
Consideration should be given to perioperative placem ent of an
invasive pressure m onitor, contralateral to the planned surgical
site. W hen feasible, placem ent of an external ventricular drain
(EVD) is preferred. An EVD w ill perm it both continuous assessm ent of ICP to guide therapy and therapeutic drainage of cerebrospinal uid (CSF) for treatm ent of intracranial hypertension.

Decom pressive Craniectom y for Intracranial Hypertension and Stroke

Operative Procedure
Decompressive Hemicraniectomy (Frontotemporoparietal [Occipital]
Craniectomy)
Positioning (Fig. 4.2)

Figure

Procedural Steps

Pearls

Fig. 4.2

The patient is positioned supine on the operating


table. The head is secured w ith a three-point head
holder and turned a minimum of 60 degrees (ideally
90 degrees) to the opposite side of the planned
operation. Depending on the body habitus and
exibility of the neck, a roll under the ipsilateral
shoulder may be needed to achieve the proper
position. Ideally, the parietal eminence should be
near parallel to the oor to avoid posterior sagging
of the brain after the dural opening.

The frontal pin is placed on the midpupillary line contralateral

to the side of the planned craniectomy. The t wo posterior pins


should straddle the m idline, above the transverse sinus. The
posterior pins should not be placed laterally, toward the side of
the craniectomy, to prevent comprom ising the posterior extent
of the craniectomy.
If an ICP monitor has not been placed already, now is the tim e to
do so. Usually, an entry point contralateral to the craniectomy
is chosen. The catheter or wire should be tunneled away from
m idline to avoid interference with the incision.

55

I Cerebral Traum a and Stroke

Skin Incision (Fig. 4.3)

Figure

Procedural Steps

Pearls

Fig. 4.3

For a standard hemicraniectomy, the incision


w ill start at the level of the zygomatic arch, 1 cm
in front the tragus, and extend superiorly and
posteriorly in a reverse question mark fashion. The
incision w ill end anteriorly at the hairline, close to
midline.

In m any patients, the super cial temporal artery (STA) can be

The skin opening technique varies w ith surgeon


preference. The most expedient method that
still minimizes blood loss should be used, since
trauma patients often have already su ered severe
hemorrhage and may be acutely anemic and
hypovolemic. The authors prefer to open the skin
w ith a no. 10 blade and to advance through the
subcutaneous tissue w ith the monopolar. Focal
bleeding points are controlled w ith both monoand bipolar electrocautery. Scalp clips are applied
immediately to the skin edges to assist hemostasis.

56

palpated, and the incision designed to avoid it. Maintaining a


patent STA will increase the viabilit y of the ap. The posterior
portion of the question m ark should be kept uniform in width
with the frontotemporal base of the ap to avoid a narrow,
poorly vascularized distal end of the ap. This is achieved
by allowing the reverse question mark to turn superiorly all
the way to m idline rather than directing it inferiorly into the
territory m ainly supplied by the occipital artery. A narrow or too
caudally directed distal portion of the ap can result in tenuous
perfusion, poor wound healing, or frank skin necrosis.
In cases of traum a, the ap should extend as posteriorly as
possible to include the parietal em inence. In cases of ischem ic
stroke, the decompression area should be tailored to the
m argins of the infarcted area, allowing only the devitalized brain
to bulge through the defect.
Once the whole incision is open and hemostasis has been
achieved, the m onopolar is used to cut the pericranium along
the incision line. The temporalis m uscle and fascia are also cut
following the incision line.

Decom pressive Craniectom y for Intracranial Hypertension and Stroke

Subcutaneous Dissection (Fig. 4.4)

Figure

Procedural Steps

Pearls

Fig. 4.4

The pericranium is carefully separated from the


skull using a Langenbeck type (square) periosteal
elevator. A Hoen type (round) periosteal elevator is
used to dissect the temporalis muscle. At the superior
temporal line, the monopolar is often needed to
dissect the more tenacious muscle insertion.

The pericranium m ust be dissected carefully, without creating

The resultant myocutaneous ap is re ected


anteriorly to expose the bone. Retraction can be
applied by using Fisch hooks or mini-tow el clamps.

tears, since it will be used for the expansive duraplast y. The


temporalis m uscle m ust be dissected caudally until the root of
the zygom a can be easily palpated to allow for access to the
m iddle fossa.
A rolled lap sponge m ust be placed at the base of the ap,
before applying retraction, to prevent kinking of the arterial
supply and hypoperfusion of the ap during the procedure.

57

I Cerebral Traum a and Stroke

Bur Hole Placement (Fig. 4.5)

Figure

Procedural Steps

Pearls

Fig. 4.5

Bur holes are placed in the follow ing locations:


1. Key hole.
2. Above the mastoid posteriorly, high enough to avoid air cells.
3. As low as possible on the squamous portion of the temporal
bone, just above the root of zygoma.
4. Tw o or three bur holes spanning the frontoparietal high
convexity, about 2 cm lateral to midline to avoid bleeding
from veins draining into the sagittal sinus.

Ideally, the craniectomy should extend 12 to

A no. 3 Pen eld is used to strip the dural attachments from the
undersurface of the calvarium at each bur hole site (and betw een
holes, w here feasible). The craniotomy is performed using a
craniotome. At the level of the sphenoid w ing, a small bur can be
used to thin the bone betw een the craniotome cuts above and
below the ridge.

58

15 cm in the anteroposterior dimension and


from the oor of middle fossa to 2 to 3 cm
from midline to avoid injury to the sagit tal
sinus. There is evidence to suggest that smaller
craniectomy defects are associated with worse
outcomes.19 A measuring tape should be used
to con rm the measurem ents before placing the
bur holes.

Decom pressive Craniectom y for Intracranial Hypertension and Stroke

Elevation of the Bone Flap (Fig. 4.6)

Figure

Procedural Steps

Pearls

Fig. 4.6

A periosteal elevator or similar tool is introduced along the


posterior edge of the craniotomy and used to elevate the bone
ap aw ay from the underlying dura. Remaining dural attachments
are severed and gentle leverage applied until the corner of the
sphenoid w ing fractures easily. The explanted bone ap is rinsed
w ith a saline and bacitracin solution. If freezing is planned, the
bone ap can be handed o at this time. If abdominal storage is
planned, the ap is kept in antibiotic solution until the time of
implantation.

The sphenoid ridge should fracture with

m inim al force. If resistance is encountered,


the bone should be thinned further with a bur.
Excessive leverage m ay cause a fracture through
the sphenoid wing with m edial extension and
the potential for severe complications.
Elevation of the bone ap alone should produce
a dem onstrable drop in ICP.

59

I Cerebral Traum a and Stroke

Re nement of the Temporal Craniectomy (Fig. 4.7)

60

Figure

Procedural Steps

Pearls

Fig. 4.7

Once the bone ap is removed and hemostasis is


achieved, the remainder of the squamous portion
of the temporal bone must be removed to allow for
a subtemporal decompression. This portion of the
craniectomy can be performed w ith a Leksell rongeur or
w ith the drill, depending on the surgeons preference.

The squam ous portion of the temporal bone must be


rem oved until ush with the oor of m iddle fossa. If
mastoid air cells are exposed, bone wax should be applied
until completely sealed.

Decom pressive Craniectom y for Intracranial Hypertension and Stroke

Dural Opening (Fig. 4.8)

Figure

Procedural Steps

Pearls

Fig. 4.8

The dura can be opened in several di erent patterns. The


most common is in a U-shape, w ith the base attached to
the temporal edge of the craniotomy defect. Other patterns
include a medially based ap or stellate opening.

This is the key portion of the operation.


When opening the dura, it is important to leave a
generous cu from the bony edge to facilitate the
closure.

61

I Cerebral Traum a and Stroke

Duraplasty (Fig. 4.9)

62

Figure

Procedural Steps

Pearls

Fig. 4.9

Once the dura is open, the surface of the brain is inspected


for subdural hematoma. If present, it should be evacuated.
The duraplasty can be performed w ith autogenous materials
(e.g., pericranium) or synthetic, suturable implants.
Pericranium can be harvested easily from its galeal
attachment by sharp dissection w ith Metzenbaum scissors.
If the pericranium is damaged or contaminated (e.g., open
skull fractures, scalp avulsions, etc.), an arti cial implant
should be considered.

If the ICP is high, the dura should be opened

slowly, 1 or 2 inches at a tim e. While the brain is


decompressing, the pericranial graft can be sutured in
placed as the opening is slowly being m ade.
In the authors experience, a watertight duraplast y,
using an autologous pericranial graft, produces the
best results. We use 4-0 braided nylon suture in
a running fashion for this purpose. The expansive
duraplast y should be m ade as generous as possible.

Decom pressive Craniectom y for Intracranial Hypertension and Stroke

Bone Flap Storage (Fig. 4.10a, b)

Figure

Procedural Steps

Pearls

Fig. 4.10

(a) A linear incision is performed in the previously


designated area of the right low er quadrant. The monopolar
is used to create a pocket of adequate size w ithin Campers
fascia. Good hemostasis must be achieved to prevent
formation of hematomas. (b) The bone ap is introduced
convex side outinto the subcutaneous pocket. The skin
should be closed in at least tw o layers, according to the
surgeons preferences.

This part of the operation can be perform ed by

an assistant surgeon during the cranial closure or


imm ediately after the closure is completed.
The subcutaneous pocket should be of su cient
size that there is not tension on the skin edges when
reapproximation is at tempted. In a particularly sm all
and/or skinny patient, it m ay be necessary to split the
bone ap in half and stack the pieces in the pocket.

63

I Cerebral Traum a and Stroke

Bifrontal Decompressive Craniectomy


Positioning (Fig. 4.11)

64

Figure

Procedural Steps

Fig. 4.11

The patient is positioned supine on the operating table. The head is


secured w ith a three -point head holder, in a slightly exed position.
The pins are placed on the equator of the skull, in a slightly posterior
position in order to allow for access to middle fossa.

Decom pressive Craniectom y for Intracranial Hypertension and Stroke

Incision Planning (Fig. 4.12)

Figure

Procedural Steps

Pearls

Fig. 4.12

A large, bicoronal incision is planned, w ith the limbs


positioned behind the hairline at approximately the level
of the coronal suture, extending bilaterally 1 cm in front
of the tragus and inferiorly to the zygoma.

If the preoperative CT provides evidence of temporal lobe


injury or edem a with threatened uncal herniation, a m ore
posterior incision (up to 3 to 5 cm posterior to the coronal
suture) should be planned to allow for temporal bone
exposure and subtemporal decompression.

65

I Cerebral Traum a and Stroke

Subcutaneous Dissection (Fig. 4.13)

66

Figure

Procedural Steps

Pearls

Fig. 4.13

A skin incision is made along the previously marked line


and clips applied to the skin edges to assist hemostasis.
The incision is carried dow n to the level of pericranium
superiorly and temporalis fascia inferiorly. The
pericranium is opened w ith monopolar cautery1 to 2 cm
posterior to the scalp incision. The temporalis muscle and
fascia, likew ise, are opened in line w ith the scalp incision.
A periosteal elevator is used to carefully separate the
pericranium and anterior belly of the temporalis muscle
from the skull, advancing the myocutaneous ap forw ard.

The dissection should be carried anteriorly to the level of

the supraorbital ridges. Fisch hooks, m ini-towel clamps,


or heavy silk sutures can be used to m aintain the ap
retraction.
Opening the pericranium a few centim eters posterior to
the scalp incision gains a few extra centimeters of graft
material for later use.

Decom pressive Craniectom y for Intracranial Hypertension and Stroke

Craniotomy (Fig. 4.14)

Figure

Procedural Steps

Pearls

Fig. 4.14

Bur holes are placed in the follow ing locations


and in this order:
1. Bilateral keyhole
2. Bilateral temporalin the line of the coronal
plane from the sagittal sinus bur holes
3. One or tw o just above the frontal sinus
4. One on either side of the sagittal sinus;
these bur holes can be placed 1 to 5 cm
behind the coronal suture, depending on the
amount of exposure desired

It is imperative to localize the frontal sinuses on the preoperative

CT and, whenever possible, to avoid them at the tim e of surgery.


If the patient has an extensive, high-reaching frontal sinus system,
intraoperative entry is inevitable. In this case, the surgeon should
anticipate the need for cranialization of the sinuses before closure
and use appropriate antibiotics to cover potential sinus pathogens.
We strongly recomm end perform ing the craniotom e cut bet ween
the t wo m idline bur holes only after all the other cuts have been
made. The dura bet ween the t wo bur holes is stripped from the
undersurface of the calvarium with a no. 3 Pen eld and the cut
made promptly. This m aneuver allows for adequate exposure to
perm it im m ediate control of any bleeding from the sagit tal sinus.

67

I Cerebral Traum a and Stroke

Dural Opening (Fig. 4.15ac)

68

Figure

Procedural Steps

Pearls

Fig. 4.15

(a) The dura is opened in a broad, U-shaped fashion w ith the base oriented
posteriorly. The initial opening is made anteriorly, on either side of the
midline. (b) The anterior portion of the sagittal sinus is ligated using tw o
silk sutures and severed betw een the ligatures. (c) The opening is carried
laterally and once enough exposure is obtained, the falx should be divided
completely. At the temporal corners of the opening, a Y-shape incision can be
performed to release tension and allow the dural ap to fall posteriorly.

The falx m ust be divided in its


entiret y in the anterior portion.
Failure to do so will result in
compression of m idline structures,
as the swollen frontal lobes will
expand again.

Decom pressive Craniectom y for Intracranial Hypertension and Stroke

Duraplasty (Fig. 4.16)

Figure

Procedural Steps

Pearls

Fig. 4.16

The same principles described for the


hemicraniectomy apply to the bifrontal
craniectomy. Whenever possible, autogenous
materials should be used. The pericranium can be
easily harvested from the elevated scalp ap and
usually cut into tw o pieces to allow coverage of the
length of the durotomy. Again, w atertight closure
is recommended.

If the frontal sinuses have been violated, the surgeon m ust


proceed to cranialize and obliterate them . This should be done
after the duraplast y has been completed, to avoid entry of sinus
contents into the CSF spaces. The m ucosa is stripped with a
curet te and the posterior wall of the sinus is rem oved using
rongeurs. The ostia of the sinuses can be obliterated by using
temporalis m uscle or fat. A vascularized pedicle of pericranium
(usually there is enough left after harvesting the duraplast y
graft) is draped over the cranialized sinuses and sutured to the
dural cu .

69

I Cerebral Traum a and Stroke

Closing

Th ere is in su cien t eviden ce to recom m en d a speci c regim en or du rat ion of th erapy.

Per fect h em ost asis sh ou ld be ach ieved on t h e galeal an d

tem p oralis m u scle su r faces to avoid su bgaleal h em atom a accu m u lat ion , w h ich w ou ld d efeat t h e p u r p ose of t h e
op erat ion .
If act ive bleeding is p resen t at th e in terface bet w een th e du ra
an d bon e edge, ep idu ral tack-u p su t u res can be p laced . Th is
is m ostly h elp fu l along th e superior fron topariet al edge (adjacen t to th e m idlin e), w h ere ven ous bleeding can som et im es
be profu se.
A su bgaleal d rain (u su ally a 10-m m Jackson -Prat t [JP]) is left
in p lace.
Th e scalp is closed in a single layer, using 2-0 vert ical m att ress m on o lam en t sut ures.

Postoperative Management
Monitoring
Im m ed iately p ostop, th e blood p ressu re m u st be m on itored

closely an d kept w ith in a t igh t rangeh igh en ough to guaran tee good cerebral p erfu sion pressu re bu t n ot so h igh as to
risk h em orrh age.
Placem en t of an invasive pressu re m on itor is st rongly recom m en ded, if n ot already don e, to p erm it accu rate assessm en t
of ICP in th e postop period.
JP drain ou t pu t sh ou ld be m on itored . Th e drain is u su ally
left in p lace for up to 48 h ou rs. CSF in th e drain is n orm al
an d act u ally ben e cialboth for ICP con t rol an d to preven t
leakage from th e in cision . Focal p oin t s of leakage along th e
in cision lin e sh ou ld be addressed prom ptly w ith sut ure rein forcem en t an d, if persisten t , prom pt con sid erat ion of fur th er
radiograp h ic invest igat ion .
Nu rsing st a m u st be in st ru cted to exercise st rict cran iectom y p recau t ion s, in cluding posit ion ing of th e h ead to preven t
any pressu re on th e defect , avoidan ce of t igh t dressings, an d
rem oval of any equ ipm en t in th e vicin it y th at could injure th e
u np rotected brain .

Medication

Radiographic Imaging
Mobilizat ion of th e pat ien t du ring th e rst 24 h ou rs m u st

Further Management
Th e ICP m on itor can be rem oved if th e values h ave been sta

Adequ ate sedat ion an d an algesia sh ou ld be p rovided du ring

70

th e postoperat ive period, w h ile th e pat ien t rem ain s in t u bated an d at risk for in t racran ial hyp erten sion . Neu rom u scu lar
blockade can be in t roduced for pat ien t s w ith h igh er ICP valu es or severe respirator y com plicat ion s.
Hyperosm olar th erapyw ith m an n itol or hyper ton ic salin e
is app ropriate if th e ICP rem ain s h igh after decom pression
an d rep eat CT iden t i es n o sp ace-occu pying lesion s am en able to surgical th erapy.
Periop erat ive an t im icrobial prop hylaxis is given for 24 h ou rs
(or un t il th e JP drain is rem oved).
If th e pat ien t p resen ted w ith an op en sku ll fract u re, pen et rat ing brain inju r y, or degloving injur y of the scalp, a lon ger cou rse of t riple an t ibiot ic th erapy sh ou ld be con sidered .

be m in im ized to preven t t raum a to th e exposed brain . Th e


au th ors d o n ot perform rou t in e p ostop erat ive im aging for
th e rst 48 h ours u n less a ch ange in n eurologic exam or a
su stain ed in crease in ICP suggests a com plicat ion th at m igh t
be am en able to su rgical in ter ven t ion (e.g., subgaleal h em atom a or blossom ing of con t usion s). If im aging is con sidered
n ecessar y, CT is th e m odalit y of ch oice for th e sam e reason s
described in th e preoperat ive evaluat ion sect ion . MRI can be
usefu l in isch em ic st roke pat ien t s to evaluate for possible exten sion of th e st roke volum e if th e pat ien ts n eurologic st at us
deteriorates fur th er an d th ere is n o CT eviden ce of any of th e
com plicat ion s m en t ion ed above.
Po sto pe rative im aging (Fig. 4.17).

ble an d th e n eurologic st at us of th e pat ien t is st able.


Post t rau m at ic hydrocep h alu s is a w ell-described p h en om en on , an d th e in cid en ce h as been rep or ted to be h igh er in
pat ien t s un dergoing decom pressive cran iectom y.20
Du ring th e early postoperat ive period, pat ien ts experien ce a
dist urbance in CSF dynam ics th at m ay result in the appearance
of extra-axial e usionsm ost often ipsilateral, but som et im es
cont ralateral or in terhem isphericw ith or w ithout an associated increase in ventricular size. This early presentat ion of
extern al hydroceph alu s is often ben ign an d ten ds to resolve
on ce the bone ap is replaced. Th e integrit y of the w oun d in
th ese cases can be protected by tem porar y CSF diversion. In
som e patien ts, resolut ion of th e extra-axial e u sion s after
cran ioplast y is follow ed by the onset of sym ptom atic hydrocephalus, w ith an associated increase in vent ricular size. This
delayed presentat ion can occur w eeks or even m onths after
su rger y. Th ese pat ien ts t ypically com e to m edical at ten t ion
due to an un ant icipated plateau or regression in th eir neurologic recover y and usually require shunting.
Sut ures are usually rem oved 14 days after surgery. Th e incision should be m onitored closely for any leaks, especially in
patients know n to have posttraum atic hydrocephalus. If CSF
continues to leak despite suture reinforcem ent, hydro cephalus
and infection should be ruled out. It is im portant to rem em ber that patients w ith hydrocephalus w ho have an active leak
m igh t not h ave ventricular en largem ent in im aging studies.
W h en ready for m obilizat ion , pat ien t s sh ould be t ted for
a protect ive h elm et to be w orn w h en ou t of bed an d d u ring
t ran sport .
Th e pat ien t sh ou ld be evaluated for recon st ruct ion of th e
cran ial vault approxim ately 4 to 6 w eeks post injur y. Replacem en t of th e bon e ap is addressed in Ch apter 25. Ad dit ion al alloplast ic tech n iques for cran ial recon st ruct ion are
discussed in Ch apter 26.

Decom pressive Craniectom y for Intracranial Hypertension and Stroke

Fig. 4.17a, b Axial CT images for t wo patients who underwent decompressive craniectomies for (a) traumatic brain injury and for (b) a large MCA
stroke. Note that in the case of the MCA stroke, the craniectomy was tailored to encompass the infarcted area only.

Special Considerations

Intraoperative ultrasound can be useful in this context. Postoperative im aging should be obtained as soon as possible.

Malignan t cerebral edem a m ay be encountered upon opening

A severely dam aged scalp an d/or sign i can t soft t issue loss

of the dura. W hen this happens, it m ust be addressed expedien tly to prevent herniation of the brain and shearing against
the dural and bone edge. Earlier in this chapter w e explained
our technique of slow ly opening the dura as the duraplast y
graft is being sut ured in place to allow for gradual expan sion
of the brain. If the surgeon instead has opened the dura com pletely and brain herniation occurs, the follow ing m easures
should be taken :

m ay p resen t a p ar t icu lar ch allenge in th e set t ing of t rau m a.


In su ch sit u at ion s, collaborat ion w ith a p last ics or h ead an d
n eck su rgeon is essen t ial. Art i cial graft s often are u sed as
a tem p orar y m easu re u n t il t issu es h eal su cien tly an d are
clean enough to receive a perm an en t graft , if n eeded.
Th e so-called syn drom e of th e t reph in ed (or sin king scalp
ap syn drom e) in clu des a com bin at ion of n eu rologic sym p tom s th at can be directly related to th e presen ce of a cran iectom y defect an d th at even t ually im prove after cran ioplast y.
Pat ien t s u su ally becom e sym ptom at ic w h en th ey start to sit
u p or am bu late. Most com m on sym ptom s are h eadach e, discom fort in th e region of th e cran ial defect , dizzin ess, seizu res,
an d p sych iat ric alterat ion s. Som e p at ien ts w ill exp erien ce
m ore severe sym ptom s, in clu d ing orth ostat ic veget at ive dysfu n ct ion an d focal cran ial n er ve or m otor de cit s. Sym ptom s
are u su ally t riggered or aggravated by th e u p righ t posit ion .
Sym ptom at ic pat ien t s sh ou ld be evaluated for a cran ial vault
recon st ruct ion as soon as possible.

1. Positioning: Elevate the head of the bed to im prove venous


drainage. Rule out kinking of the endotracheal tube and/ or
neck.
2. Ven t ilat ion : Ch eck th e air w ay pressure. Th e an esth esiologist sh ou ld u se th e ven t ilat ion m ode th at ach ieves th e low est air w ay p ressu res possible.
3. PCO2 : Ch eck th e en d-t idal PCO2 . Hyper ven t ilat ion can be
p erform ed for a brief p eriod of tim e w ith out det rim en t al
e ects, an d it can buy som e t im e.
4. Hyperosm olar th erapy: Man n itol, hyperton ic salin e, an d
loop diu ret ics can be u sed. Investigate th e volu m e st at us of
th e pat ien t an d elect rolytes.
5. CSF drain age: If a ven t ricular cath eter is in place, m ake
su re it is open to drain an d set as low as possible. Con sider
t apping th e ven t ricle th rough th e exposed an terior fron tal
lobe if a ven t riculostom y w as n ot previou sly in serted.
6. Low ering of CMRO2 : Con sid er a bolu s of barbit u rates or
etom idate.
7. Undiagnosed m ass lesion: Bear in m ind that a hem atom a
either extra-axial or intraparenchym alm ay develop as a result
of reperfusion achieved by opening the cranial compartm ent.

References
1. Horsley V. Address in Su rger y: Delivered at th e seven t y-fou r th
an n ual m eet ing of th e brit ish m edical associat ion . Br Med J
1906;2(2382):411423
2. Cu sh ing H. Tech n ical m eth ods of p erform ing cer t ain cran ial op erat ion s. Surg Gyn ecol Obstet 1908;3(6):227246
3. Kjellberg RN, Prieto A Jr. Bifron t al d ecom p ressive cran iotom y for
m assive cerebral edem a. J Neurosurg 1971;34(4):488493

71

I Cerebral Traum a and Stroke


4. Ve n es JL, Collin s W F. Bifron t al d e com p ressive cran ie ct om y in
t h e m an age m e n t of h ead t rau m a . J Ne u rosu rg 1 9 7 5 ;4 2(4 ):
429433
5. Gaab MR, Rit t ierodt M, Loren z M, Heissler HE. Trau m at ic brain
sw elling an d operat ive decom pression : a prospect ive invest igat ion . Act a Neu roch ir Suppl (Wien ) 1990;51:326328
6. Aarabi B, Hesdor er DC, Ah n ES, Aresco C, Scalea TM, Eisen berg HM. Ou tcom e follow ing decom p ressive cran iectom y for
m align ant sw elling du e to severe h ead injur y. J Neurosurg
2006;104(4):469479
7. Morgalla MH, Will BE, Roser F, Tat agiba M. Do long-term resu lt s
ju st ify decom pressive cran iectom y after severe t raum at ic brain
injur y? J Neurosu rg 2008;109:685690
8. Weiner GM, Lacey MR, Mackenzie L, et al. Decom pressive craniectomy for elevated intracranial pressure and its e ect on the cum ulative
ischem ic burden and therapeutic intensity levels after severe traum atic brain injury. Neurosurgery 2010;66(6):11111118
9. Eberle BM, Sch n riger B, In aba K, Gr u en JP, Dem et riades D, Belzberg H. Decom pressive cran iectom y: su rgical con t rol of t rau m at ic in t racranial hyper ten sion m ay im prove outcom e. Injur y
2010;41(7):934938
10. Bu llock MR, Ch esn u t R, Gh ajar J, et al. Gu idelin es for th e Su rgical
Man agem en t of Traum at ic Brain Inju r y Auth or Group. Neurosurger y 2006;58(3):S262
11. Kakar V, Nagaria J, Kirkp at rick JP. Th e cu rren t st at u s of d ecom pressive cran iectom y. Br J Neurosurg 2009;23(2):147157
12. Vah edi K, Hofm eijer J, Ju et tler E, et al. Early decom pressive su rger y in m align an t in farct ion of th e m iddle cerebral ar ter y: a
pooled an alysis of th ree ran dom ised con t rolled t rials. Lan cet
Neurol 2007;6(3):215222

72

13. Sch irm er CM, Hoit DA, Malek AM. Decom p ressive h em icran iectom y for th e t reat m en t of in t ract able int racranial hyperten sion after an eur ysm al subarach n oid h em orrh age. St roke
2007;38(3):987992
14. Ste n i R, Lat ron ico N, Corn ali C, Rasu lo F, Bollat i A. Em ergen t
decom pressive cran iectom y in p at ien t s w ith xed dilated p u p ils
du e to cerebral ven ou s an d du ral sin u s th rom bosis: rep or t of
th ree cases. Neu rosu rger y 1999;45(3):626629
15. Adam o MA, Desh aies EM. Em ergen cy decom pressive cran iectom y for fulm in at ing infect ious en ceph alit is. J Neu rosurg
2008;108(1):174176
16. Coloh an AR, Gh ost in e S, Esp osito D. Exploring th e lim it s of su rvivabilit y: rat ion al in dicat ion s for decom p ressive cran iectom y
an d resect ion of cerebral con t u sion s in adu lt s. Clin Neu rosu rg
2005;52:1923
17. Flan n er y T, McCon n ell RS. Cran iop last y: w hy th row th e bon e ap
out? Br J Neurosurg 2001;15(6):518520
18. In am asu J, Ku ram ae T, Nakat su kasa M. Does di eren ce in th e
storage m eth od of bon e ap s after d ecom p ressive cran iectom y
a ect th e in ciden ce of su rgical site in fect ion after cran iop last y?
Com parison bet w een su bcu t an eou s p ocket an d cr yopreser vat ion . J Traum a 2010;68(1):183187; discussion 187
19. Jiang JY, Xu W, Li W P, et al. E cacy of st an dard t rau m a cran iectom y for refractor y in t racran ial hyper ten sion w ith severe
t raum at ic brain injur y: a m ult icenter, prospect ive, ran dom ized
cont rolled st udy. J Neurot rau m a 2005;22(6):623628
20. Ch oi I, Park HK, Ch ang JC, Ch o SJ, Ch oi SK, Byu n BJ. Clin ical
factors for th e develop m en t of p ost t rau m at ic hydrocep h alus after decom pressive cran iectom y. J Korean Neurosurg Soc
2008;43(5):227231

Surgery for Cerebellar Stroke and


Suboccipital Trauma
Faiz U. Ahm ad and Ross Bullock

Introduction
Acu te cerebellar p ath ologyin th e form of h em orrh age, sw elling, an d/or in farct ion rep resen ts on e of th e m ost urgent an d
t reach erou s of n eurosurgical em ergen cies. Pat ien ts presen t ing
w ith th ese con dit ion s can deteriorate rapidly an d irreversibly.
Posterior fossa h em atom as an d in farct s m ay com p ress th e low er brain stem respirator y an d cardiovascu lar cen ters, t riggering
respirator y arrest an d cardiac in st abilit y.
Em ergen t surgical in ter ven t ion is usually life-saving.14
Tim ely in ter ven t ion len ds it self to a bet ter overall progn osis in
su ch p at ien t s becau se com a often resu lt s from hydrocep h alu s
(u sually reversible) an d brain stem com pression (rath er th an
d est ru ct ion ).510 Also, th e fact th at th e cerebral h em isph eres
rem ain relat ively u n a ected allow s m any of th ese pat ien t s to
retain th eir prem orbid person alit ies an d h igh er-order cogn it ive
fu n ct ion d esp ite presen t ing in com a before su rger y.

Indications
Spontaneous Cerebellar
Hemorrhage
Several factors m u st be con sidered before deciding to op erate:
Size of h em atom a: Surgical in ter ven t ion gen erally is in dicated for lesion s of greater th an 3 to 4 cm to im prove clin ical
con dit ion an d preven t secon dar y deteriorat ion du e to cerebellar sw elling an d h ern iat ion .9,11
Neu rologic st at u s: Th e p resen ce of sign s an d sym ptom s att ribut able to hydroceph alus (agitat ion , con fusion , leth argy),
brain stem com pression (sixth or seven th n er ve palsy, h orizon t al gaze paresis, hem iparesis), or com a sh ould prom pt
em ergen t su rgical in ter ven t ion .
Tim e sin ce ict u s: Pat ien t s presen t ing w ith in 6 to 48 h ou rs of
h em orrh age often experien ce n eu rologic deteriorat ion due to
a com bin at ion of sw elling an d re-h em orrh age. By con t rast ,
th ose presen t ing 5 to 7 days after th e in it ial bleed t ypically
im p rove or rem ain st able.
Issu es t angen t ial to th e p rim ar y path ology: Age, com orbidit ies, social sit u at ion , an d advan ce direct ives also m ust be
taken in to accoun t . A n u rsing h om econ n ed, 80-year-old
pat ien t w ith dem en t ia an d m ult iple m edical com orbidit ies,
presen t ing in com a, m ay n ot an appropriate can didate for
su rgical m an agem en t .1114

Cerebellar Infarction
Th e in dicat ion s for decom pressive surger y are broadly th e

sam e as th ose for h em orrh age. How ever, th e clin ical cou rse
ten ds to evolve m ore slow ly.15,16 Resect ion of th e in farcted
cerebellum itself is seldom h elpful.
Cerebellar h em isph ere in farct ion (due to dist al posterior
in ferior cerebellar arter y [PICA] occlusion ) cau sing brain stem
com pression sh ould be di eren t iatedby com puted tom ography (CT) an d/or m agn et ic reson an ce im aging (MRI)from
brain stem dest ruct ion due to proxim al isch em ia, as th e lat ter
w ill n ot im prove w ith surger y.

Trauma
Pat ien ts p resen t ing w ith posterior fossa epidu ral h em atom a

(EDH) or acu te subdural h em atom a (SDH) w h o are aw ake an d


m eet all of th e follow ing radiograp h ic criteria can be m an aged con ser vat ively, un der close super vision : clot volum e
less th an 10 m L, h em atom a th ickn ess less th an 15 m m , an d
m idlin e sh ift less th an 5 m m .17
Conversely, pat ien ts w h o presen t w ith a depressed level of
con sciousn ess, focal n eurologic de cit s, an d/or om in ou s
n dings on CT scan (hydrocep h alu s, obliterated p erim esen cep h alic cistern s, an d/or a disp laced fou rth ven t ricle) are
can didates for early surgical in ter ven t ion .1,3,6,18,19
Th e in dicat ion s for operat ive in ter ven t ion in th e set t ing of
t raum at ic in t racerebellar h em atom as are sim ilar to th ose for
spon t an eou s h em orrh age (see above).

Preprocedure Considerations
Radiographic Imaging
Non con t rast CT p rovides ad equ ate in it ial im aging in th e set

t ing of t raum a or h em orrh age.


MRIin p art icu lar, di u sion -w eigh ted im aging (DW I)m ay
be a usefu l adjun ct in th e set t ing of st roke to di eren t iate
brain stem from cerebellar h em isph ere isch em ia.
If th e in it ial CT scan reveals eviden ce of su barach n oid h em orrh age an d/or blood in th e fou r th ven t ricle, preoperat ive vascu lar im aging (angiogram or CT angiogram ) sh ould st rongly
be con sidered to ru le out an un derlying an eu r ysm or arterioven ou s m alform at ion . Th e p resen ce of an u n derlying vascu lar
lesion m ay dictate a ch ange in operat ive plan an d/or p reop erat ive en dovascu lar in ter ven t ion .

73

I Cerebral Traum a and Stroke


A pat ien t w ith a kn ow n p osterior fossa h em atom a (t rau m at ic

A st at bolus dose of m an n itol (0.51 g/kg in t raven ous pig-

or spon t an eous) w h o is deteriorat ing rapidly sh ould be t aken


to th e op erat ing room directly, w ith ou t a rep eat CT scan . Th e
t im e requ ired to com plete an addit ion al diagn ost ic st u dy m ay
n ot be w or th th e diagn ost ic yield in th is set t ing.
Preo perative im aging (Fig. 5.1).

gyback [IVPB]) m ay be given if clin ical deteriorat ion occurs.


Oth er w ise, a bolu s is adm in istered prior to skin in cision in
th e operat ing room .
Th ere is n o role for preoperat ive an t iepilept ics un less th ere is
con curren t supraten torial h em orrh age.
Prophylact ic an t im icrobial prophylaxis (th e auth ors prefer
cefuroxim e) to cover gram -posit ive organ ism s is given per
h osp it al p rotocol.

Ventriculostomy
Th e propen sit y of posterior fossa m ass lesions to cause

obst ruct ive hydroceph alu s m ean s th at a presurgical ven t ricu lostom y is alm ost alw ays m an dator y before decom pression .
Failure to do so m ay result in m assive hern iat ion of th e posterior fossa con ten t s in to th e decom pression , cau sing death on
th e operat ing table. Th e ven t riculostom y sh ould be in serted
ver y rap idly to avoid delay in th e deteriorat ing pat ien t , an d
m ay be don e as a p ar t of th e decom pression (see below ).
Occasion ally, in m oribu n d pat ien t s, or in th ose w ith sm aller
posterior fossa h em orrh agic lesion s, a ven t riculostom y m ay
be placed, an d th e pat ien t obser ved an d re-scan n ed in 3 to
4 h ours to determ in e if de n it ive su rger y is in dicated (e.g., if
clin ical im provem en t or en largem en t of h em atom a occurs).
Many au th ors advocate carefu l t it rat ion of th e h eigh t of th e
drain (e.g., st art ing at 30 cm w ater an d th en low ering it by
5 cm w ater decrem en t s ever y h our un t il 10 cm w ater is
reached) in order to avoid upw ard t ran sten torial h ern iat ion .
Th is m ay be m ore im por tan t in th e set t ing of n eoplast ic posterior fossa m ass lesion s, w h ere edem a an d a m ore prot racted
clin ical cou rse m ake th is com plicat ion m uch m ore com m on .

Positioning and Operative Field


Preparation
To m ain t ain adequate h ead

Medication
Th e use of sedat ive-hypn ot ic agen t s sh ould be avoided. Such
m edicat ion s m ay con fou n d th e clin ical exam in at ion an d p recipit ate respirator y depression .

74

exion an d rot at ion , a th reepin ion h ead h older is essen t ial. Th e cross bar sh ou ld be
padded to preven t pressure injur y w ere slippage of th e pin s
to occur (e.g., w h ere th e bridge of th e n ose or foreh ead w ould
con t act th at cross bar).
For evacu at ion of a p red om in an t ly u n ilateral h em atom a,
t h e lateral p ark ben ch p osit ion w it h t h e h ead t u r n ed to
t h e con t ralateral sid e an d exed is su it able. For su bd u ral
or ext rad u ral h em atom as exten d in g bilaterally, an d for
u n ilateral cerebellar in farct ion s (w h ere exten sive foram en
m agn u m d ecom p ression is n eed ed), t h e p ron e p osit ion is
ch osen . For t rau m a cases, w e at tem pt to red u ce/m in im ize
cer vical exion d u r in g p osit ion ing if t h e cer vical sp in e h as
n ot been cleared . Th e cer vical collar is rep laced after t h e
p roced u re.
Eith er an iodin e-based prep arat ion or ch lorh exidin e/alcoh olbased solut ion is u sed for skin preparat ion , taking care th at
th e solut ion does n ot en ter th e eyes, especially in pron e
posit ion . We use a t ran sparen t adh esive dressing lm over
th e eyes to protect th e corn ea.
Th e in cision is m arked an d in lt rated w ith 1% lidocain e w ith
ep in ep h rin e 1:100,000.

Surgery for Cerebellar Stroke and Suboccipit al Traum a

Fig. 5.1ae Axial CT images demonstrating


an (a) epidural hematoma, (b) intracerebellar
hematoma, and (c) left cerebellar infarction with
m ass e ect on the fourth ventricle. (d) MRI DWI
sequence dem onstrating restricted di usion in
the region of the infarction depicted in (c). DWI
m ay distinguish the cerebellar stroke shown in
from one that extends proximally to the adjacent
brainstem (e). This distinction is important as
the lat ter is unlikely to improve with surgery.

75

I Cerebral Traum a and Stroke

Operative Procedure
Positioning (Fig. 5.2a, b)

76

Figure

Procedural Steps

Pearls

Fig. 5.2

Choice of the (a) prone or (b) lateral park bench


position is dictated by the location of the clot,
anticipated extent of exposure, and urgency of the
situation (see above).

Make sure to protect the eyes, face, and cervical spine (if not
cleared). Ensure that an arm ored endotracheal tube is used
and secured well (by suture or tape and ties) to the external
face and head holder.

Surgery for Cerebellar Stroke and Suboccipit al Traum a

Skin Incision (Fig. 5.3)

Figure

Procedural Steps

Pearls

Fig. 5.3

The skin incision is alw ays marked prior to skin preparation to avoid confusion after
draping. If positioned prone, a midline incision is planned from the inion to the
spinous process of C2. It can be extended later, if needed. A paramedian incision is
used for unilateral intraparenchymal hematomas.

Mark the m idline and the

The entry point for a ventriculostomy (if not placed preoperatively) should be
planned and marked, using anatomic landmarks: 5 cm above the inion and 3 cm
lateral to midline.

position of transverse sinus


(extrapolate from a line
connecting the zygom a
to the inion) prior to skin
incision.

A no. 10 blade is used to incise the skin along the previously marked line. The initial
incision is carried dow n to the level of deep dermis.

77

I Cerebral Traum a and Stroke

Subcutaneous Dissection (Fig. 5.4a, b)

78

Figure

Procedural Steps

Pearls

Fig. 5.4

(a) If using a midline approach, monopolar electrocautery is used to


incise the subcutaneous fat and then deepen the incision in the avascular
plane of ligamentum nuchae. The fascia should be cut sharply w ith a
knife, instead of cautery, to avoid shrinkage. Self-retaining posterior
fossa retractors assist retraction of the skin edges at this level. (b) If
using a paramedian approach, muscle is divided in line w ith the skin
incision, using monopolar electrocautery. The occipital branch of the
external carotid artery (betw een the third and fourth layers of posterior
cervical muscles) should be identi ed, coagulated w ith bipolar cautery,
and divided sharply. Hemostasis is attained w ith monopolar or bipolar
electrocautery.

Monopolar electrocautery should not


be used when dissecting the tissue
laterally at the level of foram en m agnum
and C1. Careful sharp dissection with
Met zenbaum scissors (after thinning out
the tissue by spreading) is recom mended
to avoid injury to the vertebral artery at
this level.

Surgery for Cerebellar Stroke and Suboccipit al Traum a

Bony Exposure (Fig. 5.5)

Figure

Procedural Steps

Pearls

Fig. 5.5

The bony exposure should extend from the inion to the foramen
magnum. A w ide exposure is needed for cerebellar infarcts,
extending laterally to a centimeter from the mastoid process.
This essentially means incorporating the w hole of the w ide
bony exposure into the craniotomy. A smaller exposure (either
unilateral or bilateral depending upon the pathology) is needed for
hematomas. Additional exposure can be obtained if necessary based
on the CT scan ndings.

Care should be taken to avoid stripping the


muscles o the spinous process and lam ina of
C2 as this is a m ajor insertion point for m any
of the stabilizing m uscles of the neck.

The C1 posterior arch is alw ays exposed (20 mm on each side) but
need not be resected. Deep cerebellar retractors spread the skin and
dissected muscles at this level.

79

I Cerebral Traum a and Stroke

Bur Hole Placement (Fig. 5.6a, b)

80

Figure

Procedural Steps

Pearls

Fig. 5.6

(a) Bur holes are placed at the level of the transverse sinus (approximately
1 cm below the inion), to either side of midline. We typically use a perforator
drill; alternately, a matchstick or acorn bur may be employed. A second set of
bur holes can be made at the lateral edge of the craniotomy if the dura is very
stuck to the bone, but typically only tw o are required. (b) For a paramedian
approach, one bur hole is placed in the midline position and one at the lateral
edge of the planned opening.

Protect the drill from slipping


into the foram en m agnum region
during initial stages of the drilling.

Surgery for Cerebellar Stroke and Suboccipit al Traum a

Craniectomy (Fig. 5.7)

Figure

Procedural Steps

Pearls

Fig. 5.7

An 8-mm acorn bur is used to thin the thick bone buttresses


over the transverse sinuses and cerebellar convexities.
When a thin shell of bone remains, a combination of Leksell
rongeur and Kerrison punches may be used to complete the
craniectomy.

The size of the craniectomy depends on the


underlying pathology. Typically, infarction requires
a larger exposure than hem atom a.

81

I Cerebral Traum a and Stroke

Epidural Hematoma Evacuation (Fig. 5.8)

Figure

Procedural Steps

Pearls

Fig. 5.8

In the case of an epidural hematoma, clot is immediately visible upon bony


removal. Hematoma is evacuated by gentle suction. Focal bleeding points
along the dural surface are identi ed and coagulated. Gelatin sponge pow der
(or bone w ax, if pow der is not e ective) is applied to the bone edges.

Rapid, partial decompression of the

Clot removal over the sinus may produce heavy bleeding from a sinus tear.
Small amounts of clot stuck to the sinuses should be left intact.
There is no need to open the dura if the brain appears slack after evacuation
of the epidural hematoma. How ever, if the dura is tense, subdural
exploration is indicated to look for any additional clots (subdural or
intracerebellar hematoma).

82

brain can be achieved by suctioning


visible clot through the bur holes,
prior to completion of the bony
opening. However, care must be
taken to avoid suctioning in the
direction of the venous sinuses.

Surgery for Cerebellar Stroke and Suboccipit al Traum a

Dural Opening and Subdural Hematoma Evacuation (Fig. 5.9)

Figure

Procedural Steps

Pearls

Fig. 5.9

The dura is opened in a Y-shaped fashion to gain adequate


access to the posterior fossa contents. The superior limbs of
the Y should commence just inferior to the transverse sinus.
Either clot or cerebellum w ill usually bulge out from the dural
opening at this stage. Complete the dural opening expediently
w hile protecting the brain w ith a piece of nonadherent
bandage or a cotton pattie to avoid incarceration betw een the
dural edges. The inferior aspect of the opening (the stem of
the Y) should extend to the foramen magnum. The dural edges
may be held open w ith 4-0 braided nylon sutures.

The ventriculostomy should be opened to drain at a

height of 10 to 15 cm water (zeroed to ear level) at


this stage.
Be prepared for tears of the transverse sinus in
trauma cases (ligating clip system , pressure, head
up position).
A persistent circular sinus (or venous lakes within
the dural leaves) can be a problem in children
and occasionally m ay be encountered in adults.
Coagulation with bipolar electrocautery and/or the
use of ligating vascular clips m ay be necessary.

83

I Cerebral Traum a and Stroke

Intracerebellar Hematoma Evacuation (Fig. 5.10)

84

Figure

Procedural Steps

Pearls

Fig. 5.10

In case of an intracerebellar hematoma, a 2- to 3-cm corticectomy is


made over the site of clot presentation w ith a bipolar and microscissors/
no. 11 blade. White matter is gently suctioned in the direction of the clot
until the hematoma cavity is accessed. A brain cannula (e.g., Dandy) can be
passed into the clot to assist in localization.

Ultrasound can be useful for sm aller

The clot is gently suctioned out using no. 9 or no. 12 suction tips. Discrete
bleeding points are identi ed and coagulated. Self-retaining brain
retractors assist the exposure during hemostasis. Fukushima (teardrop side
port) suction tips (e.g., no. 7) may be useful during the hemostasis stage.

Surgical loupes and a headlight are

The brain w ill usually be slack after clot removal. If not, cerebrospinal uid
drainage from the cisterna magna should be attempted prior to resection
of edematous cerebellum.

Always keep in m ind the location of

and/or deeply located hem atom as,


or if the hem atom a is not found
at the anticipated site after the
corticectomy.

useful adjuncts at this point.

the fourth ventricle while suctioning


the depths of the hem atom a cavit y.

Surgery for Cerebellar Stroke and Suboccipit al Traum a

Decompression of Infarcted Brain (Fig. 5.11)

Figure

Procedural Steps

Pearls

Fig. 5.11

In the case of surgery for infarction, w ide decompression is the primary


objective. The posterior rim of the foramen magnum should alw ays be
opened. Resection of infarcted cerebellum is required only if closure is
di cult. Release of cerebrospinal uid from the cisterna magna is more
useful for infarcts than for hematoma.

In som e cases, severe cerebellar swelling


due to autonom ic dysregulation can
occur.

85

I Cerebral Traum a and Stroke

Hemostasis (Fig. 5.12)

86

Figure

Procedural Steps

Fig. 5.12

Hemostasis is attained w ithin the resection cavity w ith pinpoint


bipolar coagulation and again con rmed by Valsalva maneuver. The
w alls of the cavity then are lined w ith an absorbable hemostatic
agent.

Surgery for Cerebellar Stroke and Suboccipit al Traum a

Dural Closure (Fig. 5.13)

Figure

Procedural Steps

Pearls

Fig. 5.13

Once an adequate decompression is achieved, the native dura


is not reapproximated. Duraplasty may be performed w ith local
pericranium, cadaveric dura, or synthetic materials. Dural substitutes
may be used as an onlay or incorporated w ith the native dural edges
using a 4-0 braided nylon suture.

Duraplast y, in the set ting of cerebellar

Epidural tacking stitches are not necessary except in the setting of


epidural hematoma.

If epidural tacking stitches are placed, care

infarction, is m andatory to accom m odate


anticipated swelling.

must be taken (in particular, along the


superior edge) to avoid the venous sinuses.

87

I Cerebral Traum a and Stroke

Closing

of use. Altern ately, 3-0 nylon or polypropylen e in terrupted


st itch es m ay be u sed for skin closu re.

Th e cran iectom y defect is n ot closed. Replacem en t of bon e

or m esh recon st ruct ion of th e calvarium w ould defeat th e


purpose of th e procedure. Pat ien ts seldom require delayed
cran ioplast y for th is in dicat ion .
After ach ieving h em ostasis an d irrigat ing th e w ou n d w ith
an t ibiot ic solu t ion , th e n eck m u scles are ap proxim ated
loosely w ith 2-0 braided absorbable in terru pted sut u res.
The need for a subgaleal drain is assessed on a case-by-case basis.
Th e fascia is closed t igh tly w ith th e sam e sut ure.
Su bcu t an eou s t issu es are ap p roxim ated w ith 3-0 braided ab sorbable su t u res.
Th e auth ors prefer to approxim ate th e skin w ith st aples due
to th eir in er t n ess, m in im al risk for t issu e n ecrosis, an d sp eed

Postoperative Management
Ventriculostomy
Ven t ricu lostom y is m an dator y to p reem pt recu rren ce of

obst ruct ive hydroceph alus (secon dar y to h em orrh age or


sw elling) in th e early postoperat ive period .
Th e drain is m ain tain ed in th e open posit ion , at a h eigh t of
10 cm H2 O. If drain age is m in im al (, 50 m L) in 24 h ou rs, it is
closed for 24 h ou rs an d th en rem oved, provided a repeat CT
scan sh ow s n orm al ven t ricu lar size.

d
Fig. 5.14ad (a) Axial CT image demonstrating resolution of hydrocephalus following evacuation of a posterior fossa
epidural hem atoma. (b) Axial CT soft tissue and (c) bone windows dem onstrating a tailored approach for evacuation
of an intracerebellar hematoma. (d) Axial CT bone window demonstrating the bony margins of a wide suboccipital
craniectomy for decompression in the set ting of ischemic stroke.

88

Monitoring
Th e pat ien t is obser ved in a m on itored set t ing (in ten sive care

u n it), at least overn igh t .


No sedat ion is given if th e p at ien t is ext u bated.

Medication
Prophylact ic an t ibiot ics are con t in ued for 24 h ours, regardless of th e p resen ce of ven t ricu lostom y.

Radiographic Imaging
A n on con t rast CT scan is obt ain ed in th e early postopera-

t ive period to assess th e st at us of th e h em orrh age, decom p ression , an d ven t ricular size. Th e early postoperat ive st udy
also allow s screen ing for th e develop m en t of a delayed epidural or in t racerebral h em orrh age at a dist an t , supraten torial
locat ion w h ich is n ot un com m on .
Po sto perative im aging (Fig 5.14).

Further Management
Th e drain (if presen t) is rem oved over th e n ext 24 to 48 h ours.
Skin su t u res or st aples are rem oved after 1 to 2 w eeks.

References
1. Hayash i T, Kam eyam a M, Im aizu m i S, Kam ii H, On u m a T. Acu te
epidural h em atom a of the posterior fossacases of acute clin ical
deteriorat ion . Am J Em erg Med 2007;25:989995
2. Elliot t J, Sm it h M. Th e acu t e m an age m e n t of in t race reb ral
h e m or rh age: a clin ical review . An est h An alg 2010;110:1419
1427
3. Karasu A, Saban ci PA, Izgi N, Im er M, Sen cer A, Can sever T,
Can bolat A. Trau m at ic epid u ral h em atom as of th e p osterior
cran ial fossa. Surg Neurol 2008;69:247251
4. Koc RK, Pasaoglu A, Men ku A, Oktem S, Meral M. Ext radu ral
h em atom a of th e posterior cran ial fossa. Neu rosurg Rev
1998;21:5257

Surgery for Cerebellar Stroke and Suboccipit al Traum a


5. Ciu rea AV, Nu tean u L, Sim ion escu N, Georgescu S. Posterior fossa
ext radu ral h em atom as in ch ild ren : rep or t of n in e cases. Ch ilds
Ner v Sys 1993;9:224228
6. Berker M, Cat altepe O, Ozcan OE. Trau m at ic epid u ral h aem atom a
of th e posterior fossa in ch ildh ood: 16 n ew cases an d a review of
th e literat u re. Br J Neu rsu rg 2003;17:226229
7. Bozbuga M, Izgi N, Polat G, Gu rel I. Posterior fossa ep idu ral
h em atom as: obser vat ion s on a series of 73 cases. Neurosu rg Rev
1999;22:3440
8. Moh an t y A, Kollu ri VR, Su bbakrish n a DK, Sat ish S, Mou li BA,
Das BS. Prognosis of ext radural h aem atom as in ch ildren . Pediat r
Neurosurg 1995;23:5763
9. Don au er E, Loew F, Fau ber t C, Alesch F, Sch aan M. Progn ost ic factors in th e t reat m en t of cerebellar h aem orrh age. Act a Neuroch ir
(Wien ) 1994;131:5966
10. Mah ajan RK, Sh arm a BS, Kh osla VK, Tew ari MK, Math uriya
SN, Path ak A, Kak VK. Posterior fossa ext radural h aem atom a
experien ce of n in eteen cases. An n Acad Med Singap ore
1993;22:410413
11. Auer LM, Auer T, Sayam a I. In dicat ion s for surgical t reat m en t of
cerebellar h aem orrh age and in farct ion . Act a Neuroch ir (Wien )
1986;79:7479
12. Ogungbo BI. Posterior fossa decom pression an d clot evacuat ion
for fou r th ven t ricle h em orrh age after an eu r ysm al ru pt u re: case
report . Neurosurger y 2002;50:11661167
13. Kirollos RW, Tyagi AK, Ross SA, van Hille PT, Marks PV. Man agem en t of spon t an eous cerebellar h em atom as: a prospect ive t reatm en t protocol. Neurosurger y 2001;49:13781386
14. Math ew P, Teasdale G, Ban n an A, Oluoch - Olunya D. Neurosu rgical
m an agem en t of cerebellar h aem atom a an d in farct . J Neurol
Neurosurg Psych iat r y 1995;59:287292
15. Tan eda M, Ozaki K, Wakayam a A, Yagi K, Kan eda H, Irin o T. Cerebellar in farct ion w ith obst r uct ive hydroceph alus. J Neurosurg
1982;57:8391
16. Kh an M, Polyzoidis KS, Adegbite AB, McQueen JD. Massive
cerebellar infarct ion : con ser vat ive m an agem en t . St roke 1983;
14:745751
17. Wong CW. Th e CT criteria for con ser vat ive t reat m en tbu t
un der close clin ical obser vat ion of posterior fossa epidural
h aem atom as. Act a Neurochir (Wien ) 1994;126:124127
18. Bor-Seng-Sh u E, Aguiar PH, de Alm eida Lem e RJ, Man del M,
An drade AF, Marin o R, Jr. Epidural h em atom as of th e posterior
cran ial fossa. Neu rosurg Focus 2004;16:ECP1
19. dAvella D, Ser vadei F, Scerrat i M, et al. Trau m at ic in t racerebellar
h em orrh age: clin icoradiological an alysis of 81 pat ien t s. Neurosurger y 2002;50:1625

89

Elevation of Depressed
Skull Fractures
Anand Veeravagu, Bow en Jiang, and Odet te A. Harris

Introduction

Preprocedure Considerations

Depressed cran ial sku ll fract u res often resu lt from h igh en ergy,
blun t , t rau m at ic im pact s. Most depressed fract ures are located
in th e fron topariet al region . Alth ough clin ical p resen tat ion is
variable, ap p roxim ately 25% of p at ien ts w ith dep ressed fract ures presen t w ith loss of con sciousn ess an d clin ical sequelae
of in t racran ial h em orrh age.1
A depressed cran ial fract ure m ay be ch aracterized fu rth er as
open or closed, based on th e in tegrit y of th e overlying scalp .
Closed fract u res, w h erein th e scalp is in tact , m ay be t reated
n on su rgically if th e depth of th e dep ressed segm en t is less th an
th e m easu red w idth of th e calvarial bon e adjacen t to th e fract ure. Open fract ures com m un icate w ith th e extern al environ m en t an d, as su ch , are presu m ed con tam in ated. Su rgical in terven t ion is often requ ired in th ese cases for debridem en t , rep air
of dural lacerat ion s, clean sing of bon e fragm en ts, evacu at ion of
u n derlying h em atom a, an d elevat ion of th e depressed fract u re.

Radiographic Imaging
Com puted tom ography (CT) is th e st an dard im aging m odalit y

u sed to assess calvarial in tegrit y an d associated in t racran ial


injur y in th e acu te set t ing. CT ven ogram (CTV) m ay be u t ilized to assess sin u s inju r y.
Magn et ic reson an ce im aging (MRI)/angiograp hy (MRA) m ay
be used to diagn ose suspected vascular injur y (e.g., to a dural
ven ou s sin u s).
An teroposterior an d lateral skull radiograph s are used rarely to delin eate bony injur y an d/or th e presen ce of m issile
fragm en t s.
Preo perative im aging (Fig. 6.1).

Medication
Op en fract u res sh ou ld be t reated con sisten t w ith oth er op en

Indications

Prese n ce of an op en , d ep ressed fract u re in an in fan t or

90

ch ild .
Dep ression of t h e fract u re segm en t greater t h an 5 m m
below t h e in n er t able of t h e adjacen t calvar ial bon e in an
ad u lt .
Presence of gross contam ination, signi cant ext ra- or int raaxial h em atom a, an d/or pn eum oceph alus suggest ive of a dural tear.
Neu rologic p rogression in th e set t ing of a closed fract u re m ay
be due to an associated expan ding h em atom a or com pressive
e ect of th e depressed bon e fragm en t . In th is case, elevat ion
of th e fract ure is in dicated.
Depressed fract u res crossing du ral ven ou s sin u ses d eser ve
sp ecial con siderat ion . W h ile com pression of a du ral ven ou s
sin u s m ay in du ce elevated in t racran ial p ressu re an d h eigh ten
th e risk of ven ous th rom bosis, th e risk of h em orrh age w ith
fract u re m obilizat ion m ay also be sign i can t . Th erefore, it is
reason able to obser ve a n eurologically st able pat ien t w ith a
closed fract u re overlying a du ral ven ous sin u s. Likew ise, scalp
debridem en t alon e (w ith out fract ure elevat ion ) is an opt ion
for a n eu rologically stable p at ien t w ith an op en fract u re overlying a paten t sin us. A n eu rologically un st able pat ien t , h ow ever, sh ou ld u n dergo elevat ion u rgen tly.

lacerat ion s. Th is in cludes adm in ist rat ion of tet an u s toxoid


an d broad-sp ect ru m an t im icrobial p rophylaxis.
If elevated intracranial pressure is suspected, additional m anagem ent, in accordance w ith traum atic brain injury (TBI)
guidelines, is recom m en ded. This m ay include hyperosm olar
therapy.
An t iepilept ic drug (AED) prophyla xis is appropriate for th e
p reven t ion of early seizu res in th e set t ing of TBI, w ith in t racran ial path ology iden t i ed on CT im aging.

Operative Field Preparation


Lim ited clip ping of local h air is reason able for a closed, com -

p ressed fract ure. A w ider approach m ay be n ecessar y in th e


set t ing of an op en , com pou n d fract u re w ith an t icip ated or
kn ow n in t racran ial inju r y.
St an dard sterile su rgical tech n iqu e is used to prepare th e op erat ive site.
In cision s are m arked an d in lt rated w ith 1% lid ocain e w ith
1:100,000 epin eph rin e.
Prophylact ic an t ibiot ics are adm in istered.
Availabilit y of blood produ cts sh ou ld be dictated by th e t yp e
of injur y an d plan n ed surgical in ter ven t ion . Rapid an d sign i can t blood loss is p ossible, for exam ple, in th e set t ing of a
su sp ected du ral ven ou s sin u s inju r y.

Elevation of Depressed Skull Fractures

Fig. 6.1a, b Axial CT (a) brain and (b) bone windows dem onstrating a focal comminuted and depressed left frontal skull fracture with associated
extra-axial blood and parenchymal contusion.

91

I Cerebral Traum a and Stroke

Operative Procedure
Positioning (Fig. 6.2)

92

Figure

Procedural Steps

Pearls

Fig. 6.2

Patient position is dictated by location of injury and planned surgical


procedure. In the event of a standard frontotemporoparietal
craniotomy, the patient may be positioned supine, w ith the head turned
to the contralateral side. An ipsilateral shoulder roll may be placed and
the head of the bed elevated slightly. A horseshoe -shaped headrest
should be used. 3

A slightly elevated position m ay improve


the surgeons view of the injury, but m ay
also increase the risk of air em bolism.
Head exion should be minimized to
avoid obstruction of venous out ow and
increased airway resistance.

Elevation of Depressed Skull Fractures

Skin Incision (Fig. 6.3a, b)

Figure

Procedural Steps

Pearls

Fig. 6.3

Super cial debridement may be necessary at the planned incision site for open fractures.
A (a) linear, (a) inverted horseshoe, or (b) lazy-S incision may be selected, based on the
actual fracture location and the presence of a scalp disruption. (b) Scalp lacerations should
be excised as an ellipse and incorporated into the incision if possible. A bicoronal incision is
preferred for access to depressed fractures in the forehead area.

When feasible, the


incision should be
planned posterior to
the hairline.

93

I Cerebral Traum a and Stroke

Subcutaneous Dissection (Fig. 6.4)

Figure

Procedural Steps

Pearls

Fig. 6.4

Bipolar electrocautery is used for hemostasis. The scalp ap can be separated from
the pericranium using a periosteal elevator. The plane betw een pericranium and
galea may be developed w ith sharp dissection.

Where palpable and/or

The temporalis muscle may be exposed and the fascia incised for dissection using
monopolar cautery. Well-preserved muscle can be separated from the underlying
bone using sharp dissection. The muscle should be re ected inferiorly and secured
w ith suture or hook-based retraction.

For closed fractures, the underlying skull is inspected and loose fragments
removed. Contused pericranium in an open fracture is incised, w ith the
corresponding clean pericranium elevated to allow for inspection of the bone.

94

visible bony depression is


present, the temporalis
should be dissected away
from the underlying bone
with a periosteal elevator.
Avoid the use of m onopolar
electrocautery in these areas.
Any impacted fragm ents
that m ay be com pressing or
lacerating dura are not yet
rem oved at this stage.

Elevation of Depressed Skull Fractures

Craniectomy (Fig. 6.5ac)

Figure

Procedural Steps

Pearls

Fig. 6.5

(a) A standard, high-speed neurosurgical drill is used to create several points of


trephination in the normal bone lateral to the rim of the depressed bone. (b) In the
setting of an open fracture, a larger craniectomy that incorporates the traumatic
fracture line may be planned. (c) Leksell rongeurs (or a matchstick bur) can be used to
complete a circumferential craniectomy, maintaining a margin of normal bone around
the area of depression. Free bone fragments are carefully removed and discarded.

Bone edges are waxed.


Salvageable bony
fragm ents should be
soaked in antibiotic
solution before being
reassembled.

95

I Cerebral Traum a and Stroke

Depressed Fracture Elevation and Exploration of Dural Tears 4 (Fig. 6.6)

Figure

Procedural Steps

Pearls

Fig. 6.6

The depressed bone is elevated w ith a no. 1 Pen eld. Epidural hematoma, if
present, is evacuated. Bleeding dural vessels are cauterized. Any area of dural
penetration should be explored. This may require extension of the dural defect
to permit adequate visualization of the subdural space and cortex. If the dural
tear cannot be approximated primarily, interposition of a pericranial graft may
be necessary.

Autograft m ay be preferable

Holes are drilled circumferentially at the periphery of the craniectomy defect.


Epidural tacking stitches are placed w ith 4-0 braided nylon sutures.

96

to allograft for dural repair in


the set ting of an open fracture
given presumed contam ination
of the wound and increased risk
of infection.
Ping pong-t ype depressed
skull fractures in the pediatric
population can be elevated
with gentle aspiration using a
breast m ilk extractor.

Elevation of Depressed Skull Fractures

Venous Sinus Repair (Fig. 6.7a, b)

Figure

Procedural Steps

Pearls

Fig. 6.7

If injury to the superior sagittal sinus is identi ed, management is dictated by


anatomic considerations.

Depressed fractures with

(a) If initial mechanical maneuvers to achieve hemostasis fail, the anterior one third of the sinus can be ligated w ithout serious adverse e ects. (b) How ever,
injury involving the posterior tw o -thirds requires repair w ith a galeal or
pericranial patch.

potential venous sinus


involvem ent m ay require
additional preoperative im aging
to assess sinus patency and injury.
Management of venous sinus
injury is discussed in Chapter 10.

97

I Cerebral Traum a and Stroke

Calvarial Reconstruction (Fig. 6.8)

Figure

Procedural Steps

Pearls

Fig. 6.8

If explanted bone fragments


are not excessively comminuted
or contaminated, they may be
replaced using a mini-plate and
screw xation system.

Salvageable fragm ents m ay be reassem bled on the back table prior to

If the bone fragments are not


salvageable, titanium mesh
may be used to bridge the
defect.

98

reimplantation, so as to achieve reasonable cosm esis. Special at tention (and possibly


the participation of a plastic surgeon) m ay be required in areas of high visibilit y, such
as the orbital rim and forehead.
Methyl m ethacrylate should be avoided in children but can be used as a
reconstructive adjunct for adultseither to augm ent the reimplanted bony construct
or to provide contour if m esh m ust be used to cover larger defects.
Absorbable bone plates and screws are recom m ended for pediatric patients.
A custom cranioplast y implant is an option for an adult patient with a large cranial
defect. However, this does require a second surgical procedure, as well as use of a
protective helm et during the interval bet ween injury and receipt of the implant.5

Closing
Th e w oun d is irrigated w ith copious am ou n ts of an t ibiot ic

solu t ion .
Depen ding on t ype of t rau m at ic inju r y, sterile drain age t u bing m ay be im p lan ted an d secu red.
Tem poralis m uscle an d fascia are reapproxim ated w ith
2-0 braided nylon sut ures.
Th e galea is closed w ith inverted, in terrupted 3-0 braided
absorbable su t u res.
Th e skin is closed eith er w ith st aples or 3-0 nylon vert ical
m at t ress st itch es.
A sterile dressing is applied an d accom pan ied by a com pressive h ead w rap , if n ecessar y.

Postoperative Management

Radiographic Imaging
Patients w ith contam inated, open depressed fractures m an -

Depressed fract ure over a venous sinus poses a unique situ-

Post t raum at ic an d postoperat ive m an agem en t are perform ed

aged surgically should be follow ed w ith CT im aging over the 2


to 3 m onth s after initial debridem ent. Clin ical signs/sym ptom s
of infection, as w ell as w ound com plications and seizures, m ay
prom pt unscheduled CT investigation. Intravenous contrast
infusion is indicated if a diagnosis of infection is contem plated.
Po sto perative im aging (Fig. 6.9).

Special Considerations

Further Management
in accordan ce w ith p ublish ed TBI gu idelin es.
Skin su t u res or st ap les m ay be rem oved in 7 to 10 days,
dep en ding on t ype of injur y an d w ou n d closu re.
Prophylact ic an t ibiot ics are given for 5 to 7 days to lessen th e
risk of cen t ral n er vou s system in fect ion . Th e au th ors p refer
in t raven ou s cefazolin or piperacillin -t azobact am . How ever,
th ere is in su cien t eviden ce to support a speci c agen t or
durat ion of th erapy in th is set t ing.
An t iconvulsan t s are often given to reduce risk of seizures,
alth ough th e su pp or t ing eviden ce is equ ivocal.

Elevation of Depressed Skull Fractures

ation. A preoperative angiogram w ith venous ow phase, CT


ven ogram , or MRA is recom m en ded. The decision to operate is
based on the neurologic stat us of the patient, the location of sin us involvem ent, and the degree of venous ow com prom ise.
A n eu rologically st able pat ien t w ith a closed, depressed fract ure over a ven ous sin u s can be obser ved. A pat ien t w ith an
open , depressed fract ure over a paten t ven ous sin us should
u n dergo skin debridem en t w ith out elevat ion of th e dep ressed bon e segm en t . How ever, if th e pat ien t is n eurologically un st able, urgen t elevat ion m ay be required.
In the case of sinus throm bosis, the anterior one-third of the
superior sagit tal sinus usually can be ligated w ithout consequence. However, injury to the posterior t w o-thirds of the sinus
requires either prim ary repair or interposition grafting (w ith a
galeal or pericranial patch). Alternatively, a piece of m uscle or
gelatin sponge can be sutured over the sinus as a bolster.
If the native bone cannot be replaced, either titanium cranioplast y or a polyetheretherketone (PEEK) im plant m ay be considered.

Fig. 6.9a, b Axial CT (a) brain and (b) bone windows demonstrating elevation and repair of the depressed skull fracture depicted in Fig. 6.1.
An external ventricular drain has been placed to facilitate monitoring of intracranial pressure and therapeutic drainage of cerebrospinal uid.

99

I Cerebral Traum a and Stroke

References
1. Qu resh i N, Harsh G. Sku ll fract u re. Availab le on lin e at: h t t p ://
em e d icin e.m e d scap e.com /ar t icle /248108- ove r view
2. Bullock MR, Chesnut R, Ghajar J, et al. Surgical m anagem ent of depressed cranial fract ures. Neurosurger y 2006;58(3 Suppl):S5660

100

3. Con n olly ES. Fu n dam en t als of Op erat ive Tech n iqu es in Neu rosurger y, 2n d ed. New York: Th iem e Medical Publish ers; 2010
4. Sekh ar LN, Fessler RG. Atlas of Neu rosu rgical Tech n iqu es: Brain .
New York: Th iem e Medical Publish ers; 2006
5. March er S, An dres RH, Fath i AR, Fan din o J. Prim ar y recon st ru ct ion of open depressed skull fract ures w ith t it aniu m m esh . J Cran iofac Surg 2008;19(2):490495

Invasive Neuromonitoring Techniques


Mathieu Laroche, Michael C. Huang, and Geof rey T. Manley

Introduction
Invasive neurom onitoring assists the diagnosis and treatm ent of
patients presenting w ithor at risk forintracranial hypertension,
de ned as intracranial pressure (ICP) greater than 20 m m Hg.
A variety of intracranial pathologies such as traum atic brain injury,
subarachnoid hem orrhage, intracerebral hem orrhage, and ischem ic stroke (associated w ith m alignant edem a) m ay contribute to
an altered level of consciousness and, therefore, an unreliable neurologic exam . Further decline in neurologic status m ay be di cult
to detect based on serial clinical evaluation alone. Invasive neurom onitoring can point to signs of deterioration and trigger appropriate interventions. Although ICP m onitoring is m ost com m on,
additional advanced m odalities for the m onitoring of brain tissue
oxygen tension, m icrodialysis, cerebral blood ow, and jugular
venous saturation can help the practitioner achieve a m ore com prehensive understanding of pathologic cerebral physiology and,
in turn, provide individualized treatm ent w ith targeted therapies.

Monitoring of Brain Tissue


Oxygen Tension, Jugular Venous
Saturation, and/or Cerebral
Blood Flow 3
An cillar y m on itoring of cerebral physiology m ay facilitate

Microdialysis 4
An cillar y m on itoring of cerebral m et abolic param eters m ay

Indications
Monitoring of ICP by
External Ventricular Drain or
Intraparenchymal Pressure Probe 1
Diagn osis an d t reat m en t of in t racran ial hyper ten sion
An extern al ven t ricu lar drain (EVD) is con sidered th e gold

stan dard for ICP m easu rem en t . Placem en t of an EVD allow s


both for diagn ost ic m on itoring of ICP an d th erapeut ic
drain age of cerebrospin al uid (CSF).
An in t rap aren chym al p ressu re m on itor ( beropt ic or m icro
st rain gauge device) allow s for m on itoring of ICP alon e.
Th e in t raparen chym al probe m ay be coupled w ith oth er
n eurom on itoring m odalit ies in a m ult ip or t bolt app arat us
or used in isolat ion .
As per publish ed guidelin es, in dicat ion s for ICP m on itoring in
th e set t ing of severe t raum at ic brain injur y (TBI) 2
Glasgow Com a Scale (GCS) score 8 after resuscitation, in
com bination w ith an abnorm al head com puted tom ography
(CT; hem atom a, contusions, swelling, herniation, com pressed
basal cisterns) (Level II recom m endation)
GCS 8 after resuscitat ion , w ith a n orm al h ead CT, an d
associated w ith t w o or m ore of th e follow ing on adm ission
(Level III recom m en dat ion ):
Age . 40 years
Un ilateral or bilateral m otor post uring
Systolic blood pressure , 90 m m Hg

cerebral perfusion pressu re (CPP) m an agem en t in severe TBI


w ith loss of au toregulat ion (Level III recom m en dat ion ).
Th e brain t issue oxygen ten sion probe usu ally is placed in th e
less injured cerebral h em isph ere for m ore con sisten t m easu rem en t an d early detect ion of secon dar y brain inju r y.

facilitate CPP an d brain -sp eci c m an agem en t in severe TBI


(Level III recom m en dat ion ).
Placem en t of th e m icrodialysis cath eter is dictated by th e
speci c p ath ology:
In th e righ t fron tal lobe of p at ien t s w ith di u se brain inju r y.
In th e pericon t u sion al t issu e (p en u m bra) in pat ien t s w ith
a focal m ass lesion ; a secon d p robe m ay be placed in
un injured or n orm al t issue for com p arison .
In th e region of th e brain at risk of vasosp asm follow ing
severe su barach n oid h em orrh age.4

Preprocedure Considerations
Radiographic Imaging
Non con t rast h ead CT sh ou ld be review ed for:
Size of th e ven t ricular system
In t raven t ricu lar h em orrh age
Mass e ect or focal lesion
Sku ll fract u res
Distan ce from th e bon e to th e fron tal h orn (for EVD
placem en t)

Coagulation Parameters
In tern at ion al n orm alized rat io (INR), p ar t ial th rom boplast in

t im e (PTT), an d platelets sh ould be in n orm al range.


In t h e coagu lop at h ic p at ien t , con sid er t ran sfu sion of p latelet s, fresh frozen p lasm a (FFP), an d /or p rot h rom bin com p lex
con cen t rateas ap p rop r iatebefore t h e p roced u re.

101

I Cerebral Traum a and Stroke

Availablity of All Necessary


Equipment
Placem en t can be perform ed eith er in th e operat ing room or
at th e bedside (m ost com m on ly).

Medication
Lidocain e 1%w ith epin ep h rin e 1:100,000 for local an esth esia
Midazolam or prop ofol for sedat ion
Fen t anyl for an algesia

Elevate th e h ead of th e bed ap p roxim ately 30 degrees.


Clip h air overlying th e fron tal quadran t using an elect ric razor.
Iden t ify im port an t an atom ic lan dm arks:
Midlin e
Nasion
Mid-p u p illar y lin e
Extern al auditor y can al
Coron al sut ure (by palpat ion )
Iden t ify th e app roxim ate locat ion of Koch ers p oin t by on e of

Operative Field Preparation for


Intracranial Neuromonitoring

Posit ion th e h ead in th e n eu t ral posit ion (a rigid C-collar,

bean bag, or xat ion w ith t ape are e ect ive w ays to ach ieve
th is at th e bedside).

th e follow ing st rategies:


11 cm posterior to th e n asion an d 3 cm lateral to m idlin e
1 cm an terior coron al sut ure an d 3 cm lateral to m idlin e
In tersect ion of th e m idpu pillar y lin e w ith a p erp en dicu lar lin e exten ding from th e m idpoin t of an im agin ar y lin e
con n ect ing th e extern al can th us to th e t ragus
In lt rate th e skin at th e p lan n ed in cision site w ith 1% lidocain e w ith epin eph rin e 1:100,000.
Prepare th e skin w ith alcoh ol before applicat ion of proviodin e iodin e or ch orh exidin e.
Anato m ic landm arks fo r placem e nt o f EVD (Fig. 7.1).

a
Fig. 7.1ac Multiple measurement strategies have been proposed to determine the optim al entry point for insertion of an EVD (or comparable
invasive monitor): (a) 11 cm posterior to the nasion and 3 cm lateral to midline, (continued)

102

Invasive Neurom onitoring Techniques

c
Fig. 7.1ac (continued) (b) 1 cm anterior to coronal suture and 3 cm lateral to midline, and (c) intersection of the midpupillary line with a
perpendicular line extending from the midpoint of an imaginary line connecting the external canthus to the tragus.

103

I Cerebral Traum a and Stroke

Operative Procedure
Placement of Intracranial Monitors
Positioning (Fig. 7.2)

Figure

Procedural Steps

Pearls

Fig. 7.2

The head is maintained in the neutral position w ith


the head of bed at 30 degrees.

The operator stands behind the patient.


A C-collar or bean bag is useful to m aintain the head in the

104

neutral position.
EKG electrodes can be placed on the nasion and tragus for easier
palpation of the landm arks after draping.

Invasive Neurom onitoring Techniques

Skin Incision (Fig. 7.3)

Figure

Procedural Steps

Pearls

Fig. 7.3

A small stab incision is made at the planned entry


site and extended through the scalp to the level of
bone.

For EVD: at Kochers point.


For brain tissue oxygen: 1 to 2 cm behind Kochers point.
For cerebral blood ow : 1 to 2 cm in front of Kochers point.
If advanced neurom onitoring probes are too close to the EVD,
or each other, they m ay not provide accurate and reliable
inform ation.

105

I Cerebral Traum a and Stroke

Tw ist Drill Craniostomy (Fig. 7.4)

Figure

Procedural Steps

Pearls

Fig. 7.4

Using the tw ist drill,


a small craniostomy is
performed, follow ed
by copious irrigation to
remove blood and bone
debris.

An assistant is helpful to stabilize the head during drilling to m aintain neutral positioning.

106

As a general rule, each cannulation system com es equipped with a proprietary drill bit. For
an EVD, a 5.3-m m drill bit is provided. If available, a drill safet y stop should be used.
It is important to perform the craniostomy absolutely perpendicular to the plane of the
skull. The trajectory m ay be assisted by aim ing at the ipsilateral inner canthus in the coronal
plane and just anterior to the tragus in the sagit tal plane or with the use of a tripod device.
The operator is able to feel a change in the resistance as the drill travels through the outer
cortex (hard), diploe (soft), and inner cortex (hard). The operator should slow down as
more resistance is felt while the drill penetrates into the inner cortex to avoid plunging
into the brain tissue. After rem oving the t wist drill, the dura can be palpated using a spinal
needle or a small blunt instrum ent.

Invasive Neurom onitoring Techniques

Variation for Bolt-type Monitors (Fig. 7.5)

Figure

Procedural Steps

Pearls

Fig. 7.5

If a bolt-based system is being used, the bolt


should be screw ed into the craniostomy site to
nger tightness.

The dura then is punctured by passage of the central st ylet. The


beroptic pressure monitor or EVD catheter is threaded through
the central opening in the bolt to the desired depth. The cu is
tightened and the locking sheath pulled over top to secure the
system .

107

I Cerebral Traum a and Stroke

Opening of Dura and Leptomeninges (Fig. 7.6)

Figure

Procedural Steps

Pearls

Fig. 7.6

The dura is punctured using a 18-gauge spinal


needle or a 14-gauge needle.

A loss of resistance will be felt when the dura is perforated using

The pia is perforated using the spinal needle or a


no. 11 blade.

108

the needle. Multiple punctures m ight be necessary to open the


dura completely.
For brain tissue oxygen m onitors: The dura m ust be opened
completely beneath the craniostomy to avoid dam aging
the electrode tip. To achieve a bet ter result, a no. 11 blade
is used to open the dura in a cruciate m anner, under direct
visualization. A slight y larger skin incision m ay be necessary.
A good pial opening is essential to m inim ize the risk of subdural
placem ent of neurom onitors.

Invasive Neurom onitoring Techniques

Variation for External Ventricular Drain (Fig. 7.7)

Figure

Procedural Steps

Pearls

Fig. 7.7

The ventricular catheterw ith styletis inserted


slow ly to a maximal depth of 6 cm from the
outer table of the bone. When the frontal horn is
cannulated, a slight increase in resistance, follow ed
by a loss of resistance (a pop), is classically felt.
The stylet then is removed. There should be clear
CSF drainage from the ventricular catheter.

The ipsilateral frontal horn should be punctured at a depth of

3 to 5 cm from the inner table of the bone with the catheter


oriented perpendicular to the bone and targeted at the inner
canthus of the ipsilateral eye in the coronal plane and just in
front of the tragus in the sagit tal plane.5,6
If the ventricle is not cannulated after three at tempts, the
ventricular catheter should be left in place and its position
veri ed with a head CT.
EVD placement is m ore di cult in patients with sm all ventricles.
In this situation, adjuncts such as a tripod (a sm all device
that ensures that the catheter is perpendicular to bone),7
neuronavigation, and ultrasound m ay be considered to assist
accurate catheter positioning.

109

I Cerebral Traum a and Stroke

Tunneling and Securing the Cathether (Fig. 7.8a, b)

110

Figure

Procedural Steps

Pearls

Fig. 7.8

(a) Using a trocar, the ventricular catheter is tunneled


about 5 cm from the incision.

Secure the Luer lock connection with a 2-0 silk tie.

(b) After removing the trocar, a Luer lock and cap are
applied. The EVD is secured to the skin at multiple
points w ith 3-0 nylon stitches.

A gentle loop of the external portion of the catheter perm its


stay sutures at 3, 6, 9, and 12 oclock. Failure to secure the EVD
adequately to the patient may leave the system vulnerable to
unintended, traumatic explantation.

Invasive Neurom onitoring Techniques

Variations for Monitor Placement (Fig. 7.9)

111

I Cerebral Traum a and Stroke

Figure

Procedural Steps

Pearls

Fig. 7.9

The beroptic ICP probe is zeroed w ith respect to air.

To zero the probe, follow the individual m anufacturers


instructions.

Intraparenchymal Monitor
The probe then is introduced into the central
opening of the bolt apparatus and advanced into
the brain parenchymadeep enough to obtain a
reliable ICP measurement (no more than 2.5 cm).
The pressure probe then is secured to the bolt
system or tunneled and secured to the skin
depending on the system.

Visualization of the ICP waveform during insertion can assist

Variation for Brain Tissue Oxygen Monitor


After ensuring that the dura and the pia are
opened, the inner sleeve is inserted into the bolt.
The brain tissue oxygen probe, in turn, is inserted
through the inner sleeve into its predetermined
port. The inner sleeve then is secured to the bolt by
a screw.

There should be no resistance when the inner sleeve and the

Variation for Cerebral Blood Flow Monitor


After connecting to the monitor, the cerebral
blood ow probe is inserted into the w hite matter
(2 to 2.5 cm deep to the dura, into the centrum
semiovale). The probe is secured to a bolt or
tunneled and secured to the skin.
Variation for Microdialysis Cathether
The microdialysis probe is inserted into the
parenchyma to a depth of about 2 cm, depending
on the region of interest. It is secured to the skin
after tunneling, or it can be secured through a bolt
system. 8

112

in the placem ent. If no waveform or an unexpectedly high


pressure is observed, rem ove the probe temporarily, reassess
the patency of the dural opening, and consider irrigation with a
sm all am ount of sterile saline.
The ICP m onitor can be tested after insertion with brief bilateral
m anual compression of the jugular veins (Queckenstedt
m aneuver). This m aneuver reduces venous out ow and,
thereby, increases ICP.

brain tissue oxygen probe are inserted if the dura is widely open
and the pia has been pierced. Any signi cant resistance during
placem ent of the inner sleeve indicates a need for wider dural
opening. Resistance during probe placem ent could m ean that
the probe is m igrating in the epidural space or sliding over the
brain. An FiO2 challenge (rapid increase in inspired oxygen to
100%) should be used to verify that the probe is functioning.

Invasive Neurom onitoring Techniques

Placement of Jugular Venous Saturation (SjVO2 ) Monitor


Positioning (Fig. 7.10)

Figure

Procedural Steps

Pearls

Fig. 7.10

The patient is positioned in a slight Trendelenburg


position to distend the jugular vein. The entire neck
and the upper thorax are prepped and draped.

Retrograde catheterization of the internal jugular vein is


accomplished using the sam e Seldinger technique as for the
placem ent of central venous catheters.

113

I Cerebral Traum a and Stroke

Skin Incision and Insertion (Fig. 7.11)

114

Figure

Procedural Steps

Pearls

Fig. 7.11

The puncture site is medial to the


sternocleidomastoid muscle, about 3 cm lateral
and 2 cm above the medial border of the clavicle.
After the internal jugular vein is cannulated,
the Seldinger technique is used to advance the
introducer sheath. The medial and distal port of the
beroptic catheter are ushed w ith a heparinized
solution and the catheter is advanced to a depth of
16 to 18 cm.

The needle m ust be advanced from the insertion point toward

the external auditory m eatus under constant aspiration with a


30-degree angle in the sagit tal plane. When the internal jugular
vein is cannulated, there will be a blush of dark blood and a loss
of resistance.
The guidewire should not be introduced m ore than the
intended length of the beroptic catheter (16 to 18 cm ).
An ultrasound device can be helpful in identi cation and
cannulation of the vessels.

Invasive Neurom onitoring Techniques

Veri cation of Position (Fig. 7.12)

Figure

Procedural Steps

Pearls

Fig. 7.12

Anteroposterior (AP) and


lateral skull X-rays are obtained
to verify position. In this
representative lateral X-ray, the
tip of the catheter is denoted
by the arrow.

The tip of the beroptic catheter should be high in the jugular bulb to m axim ize the
likelihood of m easuring the venous blood draining from the brain and to m inim ize
contam ination from extracranial blood. X-ray veri cation is recom m ended to ensure
that the tip of the catheter is just m edial to the base of the m astoid bone in the AP
plane and at the lower portion of C1 in the lateral plane. The position of the catheter
can also be veri ed with a head CT, where it should be seen in the jugular foram en at
the base of the skull.

115

I Cerebral Traum a and Stroke

Closing
Th e in cision site is irrigated. Th e skin in cision is closed w ith

3.0 nylon sut ures.


A sterile t ran sp aren t dressing is placed over th e in cision site
(or arou n d th e bolt apparat us).
Calibrat ion
EVD: after cath eter placem en t , th e drain h eigh t is selected
(in cm H2 O). Th e drain age system is set w ith th e zero poin t
level to th e top of th e pat ien ts ear. Th is correspon ds to th e
ap proxim ate level of th e foram en of Mon roth e m idp oin t
of th e vent ricular system . Th e pressure w aveform m ay be
record ed by at t ach m en t to an extern al st rain gauge or by
in ser t ion of a beropt ic pressure probe or m icro st rain
gauge d evice in to th e EVD lu m en (an d con n ect ion to a
stan d-alon e m on itor box).
Parenchym al ICP m onitor: the beroptic pressure probe
is at tached to a stand-alone m onitor box and zeroed w ith
respect to air prior to insertion into the seated bolt apparatus.
Brain tissue oxygen m o nito r: Calibrat ion is ach ieved
th rough th e use of a sm artcard.
Cerebral blood f ow m onitor: To ensure that the probe is op tim ally placed, the K value on the m onitor should be between
4.8 and 5.6 and the probe position assistant (PPA) below 2. The
K value varies depending on the conductivity of the tissue.
The K value of w hite m atter is between 4.8 and 5.9. PPA indicates the artifact created by the pulsation of the brain tissue (if
the probe is close to a vessel). A value of 0 indicates no artifact.
Jugular ve no us saturatio n m o nito r: On ce correct probe
posit ion h as been veri ed, ligh t in ten sit y calibrat ion of th e
oxim et r y system can be p erform ed. A blood sam p le from
th e t ip of th e cath eter is also sen t for an alysis to con rm
th e value on th e oxim et r y system . Frequen t recalibrat ion
is requ ired an d sh ou ld be prom pted by any su dden ch ange
in th e jugu lar ven ous sat urat ion p rior to any alterat ion of
m edical m an agem en t .

Radiographic Imaging
It is com m on pract ice to p erform a p ost-procedu re n on con

Further Management
Advan ces in th e elds of n eu roin ten sive care an d m u lt im odal

Postoperative Management
Monitoring
Patients for w hom invasive neurom onitoring is indicated generally w ill be housed in the intensive care unit setting. The m ajorit y w ill be intubated. Intensive adjunctive m onitoring w ith
a com bination of frequent neurologic checks, an arterial line, a
central venous catheter, telem etry, pulse oxim etry, and, in som e
cases, end-tidal CO2 capnography is routine in this population.

Medication
Sedat ion w ith prop ofol or dexm edetom id in e is preferred

116

because th e sh or t-act ing n at ure of th ese agen ts perm it s


serial assessm en t of n eu rologic st at u s.
A p rophylact ic dose of an t ibiot ics (cefazolin , or clin dam ycin
in th e set t ing of allergy to pen icillin ) sh ou ld be adm in istered
w ith in th e h our prior to skin in cision for m on itor placem en t .

t rast h ead CT in order to verify th e posit ion of th e probe(s)


an d to exclu d e iat rogen ic h em orrh age.
Most invasive in t racran ial m on itors, w ith th e except ion of
th e extern al ven t ricular drain , are n ot MRI-com pat ible. For
fu rth er in form at ion , refer to th e m an u fact u rer gu idelin es for
th e speci c device.
Po stpro ce dure CT im aging (Fig. 7.13).

n eu rom on itoring h ave sign i can tly ch anged th e m an agem en t


of severe t rau m at ic brain injur y (TBI) in th e last t w o decades.
Sin ce 1995, th e Brain Traum a Foun dat ion h as publish ed
m an agem en t gu idelin es for th e t reat m en t an d p reven t ion of
in t racran ial hyp erten sion (ICP . 20 m m Hg) an d th e m ain ten an ce of adequ ate CPP (50 to 70 m m Hg) in order to m in im ize
secon dar y inju ries. Th e u se of advan ced n eu rom on itoring
m odalit ies su ch as th e brain t issu e oxygen , cerebral blood
ow, an d m icrodialysis probes sh ou ld be con sidered in cases
w h ere cerebral autoregulat ion is com prom ised. W h en used
ap prop riately, th ese addit ion al m on itors m ay p rovide a m ore
com preh en sive un derst an ding of th e altered physiology an d
en able in dividu alized, t argeted th erapy.
Cerebral tissue oxyge n (PbtO2 ) is m easured by a sm all,
polarograph ic, Clarke-t ype in t raparen chym al probe th at
records th e part ial pressure of brain t issue oxygen ten sion .
It is u su ally in serted in n on inju red w h ite m at ter, aw ay from
any con t u sion , to perm it an est im ate of global cerebral
physiology an d ser ve as an early detect ion system for secon dar y brain injur y. Accurate, real-t im e m easurem en ts can
be obtain ed 1 to 2 h ours after insert ion . Th e frequen cy an d
durat ion of cerebral desat u rat ion episodesde n ed as PbtO2
less th an 15 m m Hgcorrelate w ith ou tcom e. Alth ough th ere
seem s to be a t ren d tow ard bet ter ou tcom e w ith PbtO2 targeted th erapy to preven t an d agressively t reat episodes
of subth resh old PbtO2 , it is u n clear w h eth er a h igh er PbtO2
o ers any ben e cial e ect for th e pat ien t .3,911 Mon itoring
of PbtO2 also h igh ligh t s th e in terd ep en den ce of brain t issu e
oxygen ten sion an d p u lm on ar y fu n ct ion . Before at t ribu t ing
a low PbtO2 to a reduct ion in cerebral blood ow, it is n ecessar y to exclud e any ext racran ial con dit ion s th at cou ld n egat ively im pact blood oxygen at ion , such as lung con t u sion s,
acu te resp irator y dist ress syn drom e, p n eu m on ia, atelect asis,
or an em ia. Adjun ct ive diagn ost ic m odalit iesarterial blood
gas (ABG), com p lete blood cou n t (CBC), ch est X-ray, an d FiO2
ch allengesm ay h elp to elucidate th e un derlying cause of an
obser ved desat u rat ion . Moreover, th e posit ion of th e probe
sh ou ld be assessed before in it iat ing m ore aggressive t reatm en t s. Im p roper p robe p osit ion ing in th e ep idu ral sp ace, in a
su lcu s, in th e cortex, or adjacen t to con t u sed brain can cau se
erron eou s read ings.
Jugular veno us saturatio n m o nito r (SjVO2 ): Ret rograde
can n ulat ion of th e dist al por t ion of th e in tern al jugular vein
perm it s a global m easurem en t of th e oxygen deliver y to
th e brain . Norm al SjVO2 ranges bet w een 55 an d 70%. A low

Invasive Neurom onitoring Techniques

Fig. 7.13ae Normal appearance of the indwelling blood ow and cerebral tissue oxygen probes, as well as the EVD catheter, at the level of the
left frontal lobe (a, bone window; b, brain window). From anterior to posterior: cerebral blood ow, EVD, and cerebral tissue oxygen. (c, e) Optimal
positioning of the EVD catheter in the right anterior horn, near the foramen of Monro, and (d) the cerebral brain tissue oxygen probe in the white
mat ter of the right frontal lobe.

sat u rat ion (, 50%) h as been correlated w ith isch em ia an d


w orse ou tcom e after severe TBI, w h ereas a h igh valu e (. 80%)
m ay correlate eith er w ith hyp erem ia (w h ere in creased ow
redu ces th e sat u rat ion di eren ce) or w ith brain death (w h ere
im p aired m etabolism an d t issue death redu ce th e sat urat ion
di eren ce). Th e obser ved value is sen sit ive to th e posit ion of
th e cath eter. Con t am in at ion by ext racerebral ven ous blood,
for exam p le, w ill lead to a low er valu e.12,13 As w ith brain t issu e oxygen m on itoring, p oten t ial system ic cau ses (hypoxia,
hypoten sion , hypocarbia, an em ia) m ust be ruled out w h en a
low valu e is obser ved. Alth ough m u ch con t roversy exists regarding th e opt im al sid e for p lacem en t of th e SjVO2 probe, it
is t yp ically in ser ted on th e righ t side becau se th e righ t t ran sverse sin u s is th e m ost frequ en tly th e dom in an t site for th e
ven ou s drain age of th e brain . Th e jugu lar ven ou s sat u rat ion
m on itor, w h en u sed in com bin at ion w ith th e PbtO2 probe,
p rovides both a global (SjVO2 ) an d a focal (PbtO2 ) assessm en t
of brain t issue oxygen at ion . Th is com bin at ion allow s for
th e dist in ct ion bet w een hyperem ia an d h ardw are failure if
a valu e seem s to be ou t of range. Moreover, th e t an dem u se
of SjVO2 an d PbtO2 m ay facilitate m odi cat ion of th erapy to
opt im ize CPP in th e set t ing of im paired autoregulat ion . Th e

p ract it ion er sh ould be aw are th at th e m easurem en t of SjVO2


is ext rem ely labor in ten sive because of th e frequ en t n eed to
assess th e p osit ion of th e p robe an d to com pare blood sam ples obtain ed from th e t ip of th e cath eth er to th e valu es ob t ain ed by oxim et r y.
Cerebral blo o d f ow (CBF) m o nitoring: An in t rap aren chym al p robe m easu res th e local blood ow u sing a th erm al
di usion tech n ique. Th e probe is in serted in th e w h ite m at ter (n orm al CBF 2035 m L/100 g/m in ). A valu e of less th en
9 m L/100 g/m in in dicates a degree of isch em ia th at w ill lead
to irreversible cellular dam age. It is im port an t to n ote th at th e
m easu red valu e re ects th e st at u s of on ly th e sm all, sph erical volu m e of brain t issue (27 m m 3 ) aroun d th e cath eter
t ip an d th at th e m easurem en t is ext rem ely probe posit ion depen den t .1416 Proxim it y of th e probe to inju red t issu e w ill
produ ce a low er CBF valu e as com pared w ith th at m easured
by a probe position ed w ith in n orm al-appearing cor tex.
Micro dialysis: A m icrodialysis p robe allow s for th e st u dy of
th e brain t issue ch em ist r y th rough m easurem en t s of cerebral m et abolism . Glucose, pyruvate, an d lact ate are m arkers
of en ergy m et abolism . Glutam ate an d glycerol are m arkers
for n eu ron al inju r y. Th e rat io of lact ate to pyruvate correlates

117

I Cerebral Traum a and Stroke


w ith th e severit y of clin ical sym ptom s an d outcom e after
brain injur y. Microdialysis h as been used in th e set t ing of severe TBI an d su barach n oid h em orrh age to p redict isch em ia
an d vasosp asm .4 Th e use of m icrodialysis is labor in ten sive
an d n ecessitates a h igh ly t rain ed team . Resu lts w ill d i er depen ding on w h eth er th e probe is posit ion ed w ith in n orm al
or con t used t issue.17

Special Considerations
ICP rem ain s th e corn erston e of invasive brain m on itoring. Advan ced n eu rom on itoring tech n iqu es p rovide an op port u n it y
for bet ter u n derstan ding of cerebral path ophysiology; h ow ever,
e ect ive u se of th is tech n ology requ ires an u n d erst an ding of
h ow to both properly p lace th e p robe an d in terpret th e dat a.
Dat a derived from th ese m odalit ies are ext rem ely depen den t
on th e posit ion of each probe. Th erefore, veri cat ion of probe
posit ion is essen t ial prior in it iat ing sign i can t ch anges in clin ical m an agem en t . Fu rth erm ore, pat ien t s requiring su ch m on itoring t yp ically are com p lex an d m ay p resen t w ith a variet y of
cerebral path ophysiologic abn orm alit ies. Th e pract it ion er m ust
possess a deep an d clear un derst an ding of cerebral physiology
an d m et abolism in order to u se th e in form at ion e ect ively in
th e pat ien t-speci c t reat m en t of TBI. In sum m ar y, w h ile th ere
does exist a role for th e use of advan ced n eu rom on itoring tech n iques, th e resu lt s m ust be in terp reted an d ap plied crit ically.

References
1. Brat ton SL, Ch est n u t RM, Gh ajar J, et al. Gu idelin es for th e
m an agem en t of severe t rau m at ic brain injur y. VII. In t racran ial
pressure m on itoring tech n ology. J Neu rot raum a 2007;24 Suppl
1:S4554
2. Brat ton SL, Ch est n u t RM, Gh ajar J, et al. Gu idelin es for th e m an agem en t of severe t raum at ic brain injur y. VI. Indicat ion s for in t racranial pressu re m on itoring. J Neurot raum a 2007;24 Suppl
1:S3744
3. Brat ton SL, Ch est n u t RM, Gh ajar J, et al. Gu idelin es for th e m an agem en t of severe t raum at ic brain inju r y. X. Brain oxygen m on itoring an d th resh old s. J Neu rot rau m a 2007;24 Su p pl 1:S6570

118

4. Bellan der BM, Can t ais E, En blad P, et al. Con sen su s m eet ing
on m icrodialysis in neu roin ten sive care. In ten sive Care Med
2004;30(12):21662169
5. OLear y ST, Kole MK, Hoover DA, Hysell SE, Th om as A, Sh a rey
CI. E cacy of th e Gh ajar Guide revisited: a prospect ive st udy.
J Neu rosurg 2000;92(5):801803
6. Tom a AK, Cam p S, Watkin s LD, Grieve J, Kitch en ND. Extern al
ven t ricu lar drain in ser t ion accu racy: is th ere a n eed for ch ange
in pract ice? Neurosurger y 2009;65(6):11971200; discussion
12001191
7. Gh ajar JB. A gu ide for ven t ricu lar cath eter p lacem en t . Tech n ical
n ote. J Neurosu rg 1985;63(6):985986
8. Poca MA, Sah u qu illo J, Vilalt a A, d e los Rios J, Robles A, Exp osito
L. Percut an eous im plan t at ion of cerebral m icrodialysis cath eters
by t w ist-drill cran iostom y in n eurocrit ical pat ien t s: descript ion
of th e tech n ique an d resu lt s of a feasibilit y st udy in 97 pat ien t s.
J Neu rot raum a 2006;23(10):15101517
9. Narot am PK, Morrison JF, Nath oo N. Brain t issu e oxygen m on itoring in t rau m at ic brain inju r y an d m ajor t rau m a: ou tcom e
an alysis of a brain t issue oxygen -directed th erapy. J Neurosurg
2009;111(4):672682
10. Rose JC, Neill TA, Hem p h ill JC, 3rd. Con t in u ou s m on itoring of th e
m icrocircu lat ion in n eurocrit ical care: an update on brain t issue
oxygen at ion . Cu rr Op in Crit Care 2006;12(2):97102
11. Spiot t a AM, St iefel MF, Gracias VH, et al. Brain t issu e oxygen directed m an agem en t an d ou tcom e in pat ien t s w ith severe t rau m at ic brain injur y. J Neurosurg 2010;113(3):571580
12. Fan din o J, Stocker R. Cath eterizat ion of th e in tern al jugu lar vein
for jugular bulb oxygen sat urat ion m on itoring after brain injur y.
J In ten Care Med 1999;14:270290
13. Bh at ia A, Gu pt a AK. Neu rom on itoring in th e in ten sive care u n it .
II. Cerebral oxygen at ion m on itoring and m icrodialysis. In ten sive
Care Med 2007;33(8):13221328
14. Jaeger M, Soeh le M, Sch u h m an n MU, Win kler D, Meixen sberger J. Correlat ion of con t in u ously m onitored region al cerebral
blood ow an d brain t issue oxygen . Act a Neuroch ir (Wien )
2005;147(1):5156; discussion 56
15. Bh at ia A, Gu pt a AK. Neu rom on itoring in th e in ten sive care u n it . I.
In t racran ial pressure an d cerebral blood ow m on itoring. In ten sive Care Med 2007;33(7):12631271
16. Vajkoczy P, Roth H, Horn P, et al. Con t in u ou s m on itoring of
region al cerebral blood ow : experim en t al an d clin ical validat ion of a n ovel th erm al di usion m icroprobe. J Neurosurg
2000;93(2):265274
17. Engst rom M, Polito A, Rein st ru p P, et al. In t racerebral m icrodialysis in severe brain t raum a: th e im por t an ce of catheter locat ion .
J Neu rosu rg 2005;102(3):460469

Surgical Debridement of
Penetrating Injuries
Roland A. Torres and P.B. Rak sin

Introduction

Indications

Alth ough open h ead inju ries are com m on ly referred to as


penet rat ing, n ot all su ch inju ries are alike. Th e term penet rat ing
inju r y tech n ically describes th e sit uat ion in w h ich a project ile
en ters th e sku ll bu t does n ot exit . A perforat ing injur y occurs
w h en th e project ile passes en t irely th ough th e h ead, leaving
both an en t ran ce an d an exit w oun d. Th is dist in ct ion h as
progn ost ic im plicat ion s. In a series of project ile-related h ead
inju ries du ring th e Iran -Iraq War, p at ien ts t reated for perforating w ou n d s h ad a poorer post su rgical outcom e (50% greater
m orbidit y an d m ort alit y) th an th ose t reated for p en et rat ing
w ou n ds.1
Pen et rat ing h ead inju ries m ay resu lt from in ten t ion al or
un in ten t ion al even ts, in clud ing sh oot ings, st abbings, blast in ju ries, an d m otor veh icle or occup at ion al acciden t s (e.g., n ails).
Stab w ou n ds are ch aracterized by a sm aller im pact area an d
low er velocit y th an m issile w oun ds. For th e p urp oses of th is
chapter, w e lim it ou r discussion to m issile w oun ds.
Historically, th e m an agem en t of civilian m issile inju ries h as
been in form ed by an d evolved in con cer t w ith m ilit ar y pract ice. Sin ce World War II, m ilitar y n eurosurgeon s h ave un iform ly
advocated th orough debridem en t an d w ater t igh t du ral closu re
to preven t cerebrosp in al u id (CSF) leak an d p ossible in fect ion .
During th e Viet n am War era, cran iectom y or cran iotom y w as
accom pan ied by aggressive d ebridem en t of th e in -driven bon e,
project ile fragm en t s, an d associated debris. Th e pursuit of
debris in to areas of poten t ially viable brain t issue w as believed
to be respon sible for addit ion al n eu rologic de cit s an d im pairm en t .2,3 Part ially in respon se to th is n ding an d as th e result
of experien ce glean ed from m ult iple m ilitar y con icts over th e
past 40 years, a n ew m an agem en t paradigm h as em erged. In it ial t reatm en t of project ile w oun ds of th e brain is n ow design ed
to p reser ve th e m axim u m cerebral t issu e an d fu n ct ion eith er by
lim it ing th e w ou n d debridem en t p erform ed th rough a cran iectom y or by care of scalp w ou n ds on ly.46 Branvold et al fou n d n o
relat ion sh ip bet w een th e presen ce of ret ain ed fragm en ts an d
th e developm en t of eith er a seizure disorder or an in fect ion of
th e cen t ral n er vous system .7 Fin dings such as th is on e support
th e grow ing con sen su s th at rout in e reoperat ion for rem oval of
retain ed fragm en ts is u n n ecessar y. Th e n et result of th is st rategy h as been im p roved ou tcom es w ith sign i can tly d ecreased
m orbidit y an d m ort alit y.

The totalit y of the obser ved injury re ects a com bination of

forces: (1) direct crush injur y in icted by the projectile along


its path; (2) cavitation produced by the centrifugal e ects of the
projectile on the parenchym a; and (3) stretch injury resulting
from th e shock wave generated by the projectile in transit.
Each m ust be factored into the decision-m aking process.
Tw o fun dam en tal decision s drive m an agem en t: (1) w h eth er
or n ot to operate an d, if so, (2) th e exten t of th e in ter ven t ion
to be un der taken .
Th e decision of w hether or not to operate is dict ated both by
clin ical st at us an d th e obser ved radiograph ic path ology.
Su pp ort ive, expect an t (n on operat ive) m an agem en t m ay be
ap p rop riate for a pat ien t p resen t ing w ith a Glasgow Com a
Scale (GCS) score
5 an d bilateral xed, dilated pupils
post-resuscit at ion .
If such a patient presents w ith a potentially reversible m ass
lesion and is deem ed otherw ise m edically viable, consideration m ay be given to em ergent operative intervention.
If n o ext ra-axial m ass lesion is presen t , con siderat ion m ay
be given to a t rial of hyperosm olar th erapy (20% m an n itol bolus 1 g/kg); if a sign i can t im provem en t in m otor
exam an d/or pu pillar y respon se is n oted , th e p at ien t m ay
be con sidered a poten t ial can didate for surger y.
Hem odyn am ic in st abilit y an d/or p rofou n d coagu lopathy
m ay in u en ce th e d ecision to forego op erat ive in ter ven t ion .
Certain om inous radiographic ndings portend a poor prognosis: anteroposterior or bilateral hem ispheric throughand-through trajector y; or trajectory through the brainstem ,
hypothalam us, posterior fossa, and/or venous sinuses. These
factors should be taken into account w hen determ ining candidacy for operative inter vention.
On th e oth er h an d, a p at ien t p resen t ing w ith a GCS score of
14 or 15 an d m in im al radiograph ic injur y m ay require on ly
local w oun d care an d close obser vat ion .
Clin ical exam an d radiograph ic feat u res gu ide th e extent of
operat ive intervent ion.5,8
Lim ited su rger y m ay be app ropriate for a pat ien t presen ting w ith a sm all en t ran ce w oun d, coupled w ith m in im ally
depressed bon e fragm en t s an d lit tle or n o m ass e ect an d/
or h em atom a on h ead com puted tom ography (CT). Su ch a
pat ien t m ay ben e t from super cial debridem en t .9

119

I Cerebral Traum a and Stroke

Craniotom y/craniectom y w ith targeted, lim ited debridem ent

Non con t rast CT p rovides th e m ost com preh en sive sou rce

m ay be appropriate for a patient presenting w ith lim ited m ass


e ect, som e in-driven bone fragm ents, som e projectile fragm ents, and m ild to m oderate cerebral edem a. Only the easily
accessible bone and projectile fragm ents should be retrieved.
Aggressive adjacent brain debridem ent should be avoided.
These patients do very well w ith a com bination of copious
intraoperative antibiotic irrigation, form al dural closure, good
scalp closure, and periprocedural broad-spectrum antibiotics.
Craniotom y/craniectom y w ith m ore extensive debridem ent
is appropriate in the presence of signi cant m ass e ect.
Space-occupying lesions should be evacuated. Debridem ent
of necrotic brain tissue, along w ith safely accessible bone and
m issile fragm ents, is recom m ended.5,10,11 Deep-seated bone
and m issile fragm entsespecially in eloquent areasshould
not be retrieved because this has been show n to correlate
w ith worse outcom es. When the projectiles trajectory traverses an air sinus, operative intervention is recom m ended to
achieve water-tight closure of the dam aged dura.1,9 This m ay
decrease the risk of CSF stula and abscess form ation.1,12
No eviden ce-based recom m en dat ion s address th e t im ing of
in ter ven t ion . Here, pragm at ism ap plies.
If a sign i can t space-occu pying lesion is p resen t , em ergen t
su rgical in ter ven t ion is w arran ted for relief of m ass e ect
as a life-saving m easu rew ith th e recogn it ion th at it m ay
n ot ch ange ou tcom e.
If n dings suggest ing m ass e ect are less com p elling, it
w ou ld be reason able to m on itor in t racran ial pressu re (ICP)
an d m an age expect an tly.
If th e goal is sim ple w ou n d care, it w ou ld follow th at exp edien t in ter ven t ion m ay dim in ish th e risk of in fect ion an d
CSF com p licat ion s.9,10

of an atom ic in form at ion . CT w ill reveal th e presen ce of


h em atom a an d foreign bodiesboth bony an d m et allicas
w ell as in form at ion regard ing th e likely m issile t rajector y.
Th e CT sh ould be st udied for poten t ial violat ion of vascular
st ru ct u res.
If direct vascu lar inju r y is su spected , em ergen cy vascu lar
im aging m ay be approp riate.
Im aging n dings arou sing su spicion m ay in clu de: orbitofacial or pterion al locat ion ; t rajector y th rough a ven ous sin us
or th e Sylvian ssure; th e presen ce of fragm en t s crossing
dural com par t m en t s; or th e presen ce of a large h em atom a
proxim ate to a n am ed vessel.
Form al cerebral angiograp hy n ot on ly perm it s d iagn ost ic
assessm en t bu t also o ers th e poten t ial for in ter ven t ion .
In recogn it ion of expedien cy, CT angiograp hy m ay be
an oth er opt ion in th is set t ing.9
A single n egat ive st u dy does n ot d e n it ively ru le ou t inju r y.
Th e developm en t of un explain ed subarach n oid h em orrh age or h em atom a in th e days follow ing th e in it ial inju r y
m ay p rovide an in dicat ion for delayed or rep eat im aging.
Magn et ic reson an ce im agin g (MRI) is ge n e rally con t rain d icate d in t h e set t in g of a p e n et rat in g in ju r y w it h m et allic fore ign b od y. How eve r, it sh ou ld b e n ot e d t h at m ost
civilian am m u n it ion p ar t icu larly p istol am m u n it ion is
act u ally n on fe r rom agn et ic an d , h yp ot h et ically, sh ou ld n ot
p re clu d e MRI evalu at ion . Cau t ion m u st b e exe rcise d w it h
sh ot gu n w ou n d s as m any sh ot gu n sh ells n ow d elive r st e el
sh ot (d u e to Environ m e n t al Prote ct ion Age n cy legislat ion
regard in g lead p ollu t ion ). MRI m ay p lay a role in t h e d iagn ost ic evalu at ion of p e n et rat in g in ju r ies from w ood e n or
n on m agn et ic obje ct s. Ke e p in m in d t h at MRI is n ot p ract ical in t h e acu te set t in g, give n t h e t im e n e cessar y to p e rfor m t h e st u d y as w ell as p ote n t ial r isks associat e d w it h
t ran sp or t in g a cr it ically ill p at ie n t to an ofte n re m ote
area of t h e h osp it al.
Pre o pe rative im aging (Fig. 8.1).

Preprocedure Considerations
General
At ten d to th e ABCs of resu scitat ion (air w ay, breath ing,

circulat ion ).
Con t rol brisk bleeding from th e scalp an d associated w oun ds
w ith h em ost at s or tem porar y st aple closure, as w ell as a pressu re dressing. Large, isolated scalp w ou n d s m ay lead to fat al
blood loss.
Docu m en t en t ran ce an d exit (if p resen t) w ou n ds, as w ell as
th e presen ce of pow der burn s, CSF leak, an d brain h ern iat ion .
Early invasive ICP m on itoring is an opt ion w h en un able to
follow a serial n eurologic exam , w h en th e n eed to evacu ate
an obser ved m ass lesion is u n cert ain , an d/or w h en im aging
suggest s in creased in t racran ial p ressu re.9 Brain t issu e oxygen
m on itoring m ay be con sidered as w ell.

Radiographic Imaging
Anteroposterior and lateral skull X-rays m ay provide general inform ation regarding the presence of radiopaque foreign bodies
as well as entrance and exit sites. The ease w ith w hich m ultiplanar CT can be obtained in m ost settings has largely obviated the
need for this diagnostic m odalit y.

120

Medication
An t im icrobial prophylaxis is adm in istered. Broad-spect rum

coverage, perh aps skew ed tow ard skin ora, is appropriate in


th e set t ing of gross con t am in at ion of th e w ou n d.
An t iepilept ic drug prophyla xis is in it iated.
A loading dose of m an n itol 20% (1 g/kg) m ay be given .
A t ype an d cross-m atch sh ou ld be perform ed. Coagulopathy often develops in th e set t ing of pen et rat ing injur y due
to in creased t issue th rom boplast in act ivit y. En sure availabilit y of a range of blood p rodu cts (red blood cells, fresh
frozen plasm a, an d p latelets), as w ell as adju n ct ive agen ts
(aprot in in , desm opressin , recom bin an t factor VII, t ran exam ic
acid, vit am in K, an d p roth rom bin com p lex con cen t rates) th at
m igh t becom e n ecessar y p erioperat ively.

Operative Field Preparation


If vascu lar inju r y is su sp ected, en su re th at app rop riate
su p p lies (m icroscop e, an eu r ysm clip s, m icrosu rgical in st ru m en t s, blood produ cts) are available prior to skin in cision .

8 Surgical Debridem ent of Penetrating Injuries

Fig. 8.1ac Axial CT (a) brain and (b) bone windows demonstrating
a comminuted bilateral frontal bone fracture, associated with a
large left frontal intraparenchymal hematoma, in-driven bone,
and pneum ocephalus. (c) Three-dimensional reconstructed image
demonstrates the full extent of the bony injury; note that the missile is
actually lodged in the extracranial space, just posterior and lateral to the
depressed fracture.

Con t rol bleeding from scalp an d associated w oun ds. Tem -

Th e surgical site is prepared w ith alcoh ol, follow ed by a

p orar y st aple or su t ure closure m ay be n ecessar y to perm it


p reparat ion of th e eld.
Foreign bod ies prot ruding from th e h ead are left in place d uring prep arat ion of th e su rgical site.
A w ide area of scalp is sh aved to ensure iden t i cat ion of
en t ran ce an d exit sites, to clear su p er cial scalp d ebris, an d
to allow for a large cran ial open ing.

p ovidon e-iodin e or ch lorh exidin e solu t ion in th e usu al sterile


fash ion . Avoid th e lat ter if exp osed brain is presen t . A dilu ted
p ovidon e-iodin e solut ion m ay be u sed for th e preparat ion of
large con t am in ated w ou n ds.
Th e in cision is m arked an d in lt rated w it h 1% lid ocain e
w it h 1:100,000 ep in ep h r in e. Avoid areas of exp osed brain
t issu e.

121

I Cerebral Traum a and Stroke

Operative Procedure
Positioning (Fig. 8.2)

Figure

Procedural Steps

Pearls

Fig. 8.2

The patient position w ill be dictated by the localization of the


pathology. A donut or horseshoe head holder is used to expedite the
procedure.

If the cervical spine has not been cleared,

If a unilateral procedure is planned, the patient is positioned supine,


w ith the head turned contralateral to the side of the approach. A
shoulder roll is placed longitudinally beneath the ipsilateral shoulder.
If a bilateral procedure is planned, the patients head is positioned in a
neutral, upright position.
The back of the bed is raised slightly.

122

the cervical collar should be m aintained


and the patient rotated in-line to expose
the side of the approach.

8 Surgical Debridem ent of Penetrating Injuries

Incision Planning (Fig. 8.3)

Figure

Procedural Steps

Pearls

Fig. 8.3

A reverse question marktype incision is traced on the scalp for a


unilateral approach. A bicoronal incisionpositioned posterior to
the hairlineis marked for a bilateral procedure.

Avoid incorporating the entrance/exit

A no. 10 blade is used to incise the skin along the previously


marked line. The incision is carried dow n to the level of pericranium
superiorly and temporalis fascia inferiorly. Scalp clips are applied to
the skin edges to facilitate hemostasis.

wound into the incision, given the high


likelihood of devitalized local soft tissue. By
the sam e token, be sensitive to the position
of the wound(s) with respect to the planned
incision and scalp blood supply.

123

I Cerebral Traum a and Stroke

Subcutaneous Dissection (Fig. 8.4)

124

Figure

Procedural Steps

Pearls

Fig. 8.4

The pericranium is opened w ith monopolar electrocautery,


in-line w ith the scalp incision. The temporalis fascia and muscle
are also opened w ith monopolar electrocautery. The resultant
myocutaneous ap is re ected forw ard until the keyhole and
root of zygoma are visible. The ap is secured w ith the surgeons
retraction system of choice.

Dissection of soft tissue away from areas of

known bony defect (i.e., entrance and exit


sites) should be accomplished with a periosteal
elevator rather than electrocautery.
In the set ting of a bicoronal approach, the
pericranium may be elevated in a separate
layer to provide vascularized grafting material
later in the procedure.

8 Surgical Debridem ent of Penetrating Injuries

Bur Hole Placement (Fig. 8.5)

Figure

Procedural Steps

Pearls

Fig. 8.5

For a unilateral approach, bur holes are placed at the key hole,
just above the root of zygoma, over the parietal eminence,
and at a point that is just anterior to coronal suture and 1 cm
lateral to midline.

If substantial bony injury is present, it

For a bilateral approach, bur holes are placed bilaterally at


the keyhole ; just above the root of zygoma; at the junction of
superior temporal line and coronal suture ; and at one or tw o
points straddling the midline, anterior to coronal suture.

Bone w ax is applied to the bony edges. A no. 3 Pen eld is used


to strip the dural attachments from the undersurface of the
calvarium betw een each set of holes.

m ay be feasible to rem ove portions of


the involved calvarium without the use of
power tools. In such cases, bur holes should
be positioned to facilitate creation of a
bone ap that allows access to adequate
surface area to perm it control of vascular
structures, judicious debridem ent, and
dural closure.
Take particular care when adequate access
requires crossing the m idline. If the path
is not readily cleared, rem em ber that bur
holes are cheap relative to a sinus injury.

125

I Cerebral Traum a and Stroke

Craniotomy (Fig. 8.6)

Figure

Procedural Steps

Pearls

Fig. 8.6

The craniotome is used to create a path that circumnavigates the


previously placed bur holes.The resulting bone ap is carefully elevated
aw ay from the underlying dura and set aside in antibiotic solution.

Direct visualization of the dural

For a bilateral approach, it may be easier to create tw o separate unilateral


aps, temporarily leaving a strip of bone along the midline. Craniotome
cuts then can be made across the midline and the bony isthmus removed.
Venous sinus bleeding is controlled w ith a combination of gentle pressure
and hemostatic agents.
Epidural hematoma, if present, may be evacuated at this time.

126

surface during elevation of the bone


ap is key, as the craniotomy site likely
includes an area of known bony and
dural defect.
If direct injury to the sinus is
suspected, it may be necessary to
proceed with repair and/or ligation
(anterior one-third only). Preoperative
imaging should prompt appropriate
forethought and preparation.

8 Surgical Debridem ent of Penetrating Injuries

Dural Opening (Fig. 8.7)

Figure

Procedural Steps

Fig. 8.7

By de nition, the dura is already open. In certain cases, it may be appropriate simply to enlarge the existing
dural opening to permit the necessary exposure for local debridement.
If a need for broad exposure is anticipated, a cruciate or reverse C-shaped dural opening should be considered.
In the setting of a bicoronal approach, trap-door dural aps can be re ected tow ard the midline sagittal sinus.

127

I Cerebral Traum a and Stroke

Approach to Parenchymal Injury (Fig. 8.8a, b)

128

8 Surgical Debridem ent of Penetrating Injuries

Figure

Procedural Steps

Pearls

Fig. 8.8

Subdural hematoma, if present, should be evacuated w ith


a combination of gentle suction and saline irrigation.
(a) Inspect the cortical surface. Address obvious points
of arterial or venous bleeding. There is likely obvious
cortical disruption. This should be the portal of entry
for debridement. Associated large intraparenchymal
hematoma should be approached w ith a combination of
gentle suction and bipolar electrocautery. Upon entry to
the hematoma cavity, suction out any liquid clot. Remove
solid clot in a piecemeal fashion. (b) If no signi cant
hematoma is present, super cial, necrotic brain tissue
should be debrided w ith gentle suction and irrigation.
Readily accessible missile and bone fragments should be
retrieved. Continue until gliotic brain is visible on all sides.
Hemostasis should be achieved w ith a combination of
bipolar electrocautery and hemostatic agents.

Principles of debridem ent for penetrating injuries

encom pass techniques previously discussed for


evacuation of subdural hem atom a (Chapter 1)
and cerebral contusions (Chapter 3). Managem ent
of venous sinus injury is discussed in Chapter 10.
Techniques for frontal sinus reconstruction are
discussed in Chapter 27. Please refer to these sections
for m ore detailed nuances of m anagem ent.
A hand-held m alleable retractor, introduced over a
saline-m oistened 1 3 3 cm cot ton pat tie m ay assist
visualization.
No at tempt should be made to follow m issile trajectory
to deep subcortical structures.
Always maintain awareness of position relative to the
lateral ventricles. Avoid entry to the ventricle, if feasible.

129

I Cerebral Traum a and Stroke

Duraplasty (Fig. 8.9)

Figure

Procedural Steps

Pearls

Fig. 8.9

Once debridement of devitalized brain tissue is complete, assess


the extent of the dural defect.

It is important to determ ine the relationship

For a unilateral approach, a piece of pericranium may be harvested


to bridge the defect. The graft is incorporated circumferentially
w ith 4-0 braided nylon sutures.
For a bicoronal approach, the previously harvested vascularized
pericranial graft may be apped over the exenterated frontal sinus
and secured w ith 4-0 braided nylon suture, augmented by brin glue.

130

of the defect to adjacent air sinuses.


If no viable pericranium is available,
temporalis fascia, fascia lata, or synthetic dural
substitute may be prepared for this purpose.

8 Surgical Debridem ent of Penetrating Injuries

Closing
Th e surgical site is irrigated w ith an t ibiot ic solu t ion .
Th e decision of w h eth er to replace th e bon e ap at th e con -

clusion of th e procedure is based both on th e degree of brain


sw elling p resen t an d w h eth er th e bon e ap can be salvaged .
In som e cases, th e bon e ap is too com m in u ted or too grossly
con t am in ated to perm it re-im plan t at ion .
Th e soft t issue elem en t s (m uscle an d scalp) m ust be in spected at sites of en t r y an d exit . Sh arp local debridem en t back to
viable t issu e m ay be n ecessar y. Irrigate w ith cop iou s am ou n t s
of an t ibiot ic solut ion prior to single-layer reapproxim at ion
w ith 3-0 nylon in terrupted st itch es. Th e part icipat ion of a
p last ic surger y colleagu e m ay be ap prop riate if exten sive soft
t issue injur y is presen t an d ch allenges to ach ieving su cien t
su rface area coverage are an t icipated .
A Jackson -Prat t drain is laid in th e subgaleal space prior to
closure.
Th e tem poralis m uscle an d fascia are re-approxim ated w ith
0 braided absorbable sut ures.
Th e galea an d su bcut an eou s t issue are reapproxim ated w ith
2-0 braided absorbable sut ures.
Th e skin is closed w ith st aples. A run n ing-locking 3-0 nylon
st itch m ay assist h em ostasis if coagu lop athy is presen t or bolster th e closu re if su bst an t ial sw elling is p resen t .

Medication
Th e opt im al prophylact ic an t im icrobial regim en an d durat ion

Im m ediate p ostop erat ive CT allow s for assessm en t of residu al

Postoperative Management
Monitoring

t ing follow ing operat ive in ter ven t ion .


Th e use of invasive n eurologic m on itors (in t raparen chym al
or in t raven t ricu lar) is appropriate for pat ien ts in w h om
serial n eu rologic exam is n ot feasible an d/or w h ose GCS
rem ain s 8.
Th e out put of subgaleal an d/or su bdural drainsif presen t
sh ou ld be m on itored . Drain rem oval m ay be con sidered w h en

of th erapy rem ain a m at ter of debate. Th ere is th e suggest ion


th at broad-spect ru m coverage sh ould probably con t in ue for
a p eriod th at is som ew h at longer th an stan dard prop hylaxis
for a clean , elect ive p rocedu re. Th e au th ors con t in u e broadsp ect ru m coverage for 3 to 5 days p ost-inju r y.9
An t iepilept ic drug prophylaxis is con t in ued for a tot al of
7 days post-injur y.

Radiographic Imaging

Pat ien t s sh ou ld be m on itored in th e in ten sive care u n it set-

out put s becom e m in im al an d/or serial im aging dem on st rates


resolu t ion of th e t argeted collect ion .
Mon itor for clin ical eviden ce of CSF otorrh ea or rh in orrh ea.

or n ew h em atom a, exten t of foreign body debridem en t , an d


edem a pat tern . On ce st abilit y of any evolving h em atom a h as
been establish ed, CT im aging sh ould be repeated on ly for sign i can t ch anges in n eu rologic st at u s.
Th e persisten ce or delayed developm en t of pn eum oceph alus
beyond th e im m ediate postoperat ive periodin th e absen ce
of an overt CSF leaksh ould prom pt a search for an occult
p oin t of egress.
Th e presen ce of n ew su barach n oid h em orrh age or h em atom a
in th e area of a n am ed vessel sh ou ld prom pt vascu lar im aging. Likew ise, repeat vascular im aging at an in ter val of several
days is appropriate for any pat ien t w h o un der w en t such im aging at p resen tat ion w ith a n egat ive resu lton th e basis of
su sp iciou s CT n d ings.
Po sto perative im aging (Fig. 8.10).

Further Management
Invasive n eu rom on itoring devices are rem oved w h en n eu ro

logic st at u s dictates.
Skin su t u res or staples are rem oved at an in ter val of 10 to
14 days.

c
a
b
Fig. 8.10ac Axial CT (a) brain and (b) bone windows demonstrating evacuation of the frontal hematoma and accessible foreign body fragment s.
A bony defect remains. (c) CT obtained approximately 3 months later (at the tim e of cranioplast y) demonstrates expected frontal encephalomalacia.

131

I Cerebral Traum a and Stroke

Special Considerations
CSF leak
The inciden ce of CSF leak follow ing m issile injury approached

132

28%in one large series.13


Th is com p licat ion resu lts from direct violat ion of th e
duraby project ile or bony fragm en t salong w ith failure
to seal th e defect by n orm al t issu e h ealing p rocesses.
CSF drain age occu rs along th e p ath of least resist an ce
from en t ran ce or exit w ou n ds or from th e ear or n ose in
th e set t ing of air sin us violat ion .
Th e m ost feared com p licat ion of CSF leak is in fect ion
m en ingit is an d /or abscess.1,12,14
Ever y e ort sh ou ld be m ade to at t ain a w ater-t igh t closu re
of th e du ra at th e t im e of in it ial su rgical debridem en t .1,9
Prim ar y su t ure closure m ay be feasible. Som et im es, augm en t at ion w ith a p ericran ial graft or syn th et ic m aterial is
n ecessar y. In oth er cases, th e leak occu rs along th e sku ll
base, w h ere closure is n ot n ecessarily feasible. A m ult ilayer w ou n d closu re w ill bolster th e repair.
CSF leak m ay be a d elayed p h en om en on . In it ial brain sw elling m ay t am p on ade a site of poten t ial egress. Th e leak m ay
on ly becom e eviden t as sw elling subsides several days after
th e injur y.
If a CSF leak develop s, in it ial m an agem en t m ay con sist of
tem porar y diversion via ven t ricu lostom y or lum bar drain
(if n ot con t rain dicated). Th e h ead of th e bed sh ou ld be elevated . Many leaks w ill resolve sp on tan eou sly w ith con servat ive m easu res. If th e leak is refractor y to CSF diversion ,
su rgical repair is recom m en ded.9
If th e p oin t of egress is n ot obviou s by im aging, a CT sin u s
m et rizam ide st u dy m ay assist localizat ion . Low -dose in t rath ecal uorescein (less th an or equ al to 50 m g) m ay provide
an adju n ct at th e t im e of en doscopic exp lorat ion .
In fect iou s com plicat ion s
Th e rate of in fect ion follow ing pen et rat ing brain inju r y is
low er in th e civilian th an m ilitar y popu lat ion an d appears
to var y directly w ith th e u se of broad-sp ect ru m an t ibiot ics
in th e early m an agem en t of th ese pat ien ts.9
Risk factors for in fect ion in clu de CSF leak, w ou n d deh iscen ce, violat ion of an air sin us, t ran sven t ricular t rajector y,
an d/or inju r y crossing m idlin e.15 Ret ain ed m issile an d bon e
fragm en ts dem on st rate a less con clu sive relat ion sh ip to th e
developm en t of in fect ion .
Most in fect ion s occu r relat ively early in th e post-inju r y
period. In on e st udy, 55% occurred w ith in 3 w eeks an d 90%
w ith 6 w eeks; rarely, a delay in on set of several years m ay
be obser ved.16
Th ere exist s great variabilit y in pract ice arou n d th e issu e
of an t im icrobial prophylaxis in th e set t ing of pen et rat ing
inju r y. Th e cu rren t Pen et rat ing Brain Inju r y guidelin es
m ake th e argu m en t th at if exten sive Class I an d Class II
dat a suppor t th e use of prophylaxis in th e set t ing of clean
procedures, it w ould be reason able to provide broader coverage of longer du rat ion in th e set t ing of a kn ow n open ,
con tam in ated w oun d. How ever, n o dat a con clusively su p port a speci c regim en or durat ion .9
Staphylococcus is isolated m ost com m only; however, a w ide
range of gram -negative and anaerobic organism s have also

been im plicated as causative agentsbolstering the argum ent


for broad-spectrum coverage at the outset. Once an infectious
process has been identi ed, antibiotic therapy m ust be tailored to culture and susceptibilit y data. Surgical debridem ent
m ay be indicated in the setting of brain abscess or em pyem a.
Please see Chapter 20 for further discussion regarding the surgical m anagem ent of intracranial infection.

References
1. Aarabi B. Cau ses of in fect ion s in pen et rat ing h ead w ou n d s in th e
Iran -Iraq War. Neurosurger y 1989;25:923926
2. Am irjam sh idi A. Min im al debrid em en t or sim p le w ou n d closu re
as th e on ly su rgical t reat m en t in w ar vict im s w ith low -velocit y
pen et rat ing h ead inju ries. In dicat ion s an d m an agem en t p rotocol based upon m ore th an 8 years follow up of 99 cases from
Iran -Iraq con ict . Surg Neurol 2003;60:105111
3. Tah a JM, Haddad FS, Brow n JA. In t racran ial in fect ion after m issile injuries to th e brain : repor t of 30 cases from th e Lebanese
con ict . Neurosurger y 1991;29:864868
4. Ch au dh ri KA, Ch ou dh u r y AR, al Mou t aer y KR, et al. Pen et rating cran iocerebral sh rap n el inju ries during Operat ion Desert
Storm : early resu lt s of a con ser vat ive su rgical t reat m en t . Act a
Neuroch ir (Wien ) 1994;126:120123
5. Esp osito DP, Walker JB. Con tem p orar y m an agem en t of p en et rating brain injur y. Neurosurg Q 2009;19(4):249254
6. Mu en ch E, Horn P, Bau h u f C, et al. E ect s of hyp er volem ia an d
hyperten sion on region al cerebral blood ow, in t racran ial pressure, an d brain t issue oxygen at ion after subarach n oid h em orrhage. Crit ical Care Med 2007;35:18441851
7. Bran dvold B, Levi L, Fein sod M, et al. Pen et rat ing cran iocerebral
injuries in th e Israeli involvem en t in the Leban ese con ict . J Neurosurg 1990;72:1521
8. George ED, Diet ze JB. Pat ien t select ion : determ in ing th e n eed
for and t ype of su rger y. In : Bizh an A, ed. Missile Woun ds of th e
Head an d Neck. Neurosurgical Topics Volum e I. New York: AANS;
1999:127134
9. Aarabi B, Alden TD, Ch est n u t RM, et al. Gu idelin es for th e
m an agem en t of pen et rat ing brain injur y. J Traum a 2001;
51(supplem en t):S186
10. Helling TS, McNabn ey W K, W h it t aker CK, et al. Th e role of early
surgical in ter ven t ion in civilian gun sh ot w oun ds to th e h ead.
J Traum a 1992;32:398400
11. Hu bsch m an n O, Sh ap iro K, Bad en M, et al. Cran iocerebral gu n sh ot injuries in civilian pract ice: progn ost ic criteria an d surgical
m an agem en t experien ce w ith 82 cases. J Traum a 1979;19:612
12. Gon u l E, Baysefer A, Kah ram an S. Cau ses of in fect ion s an d m an agem en t resu lt s in p en et rat ing cran iocerebral inju ries. Neu rosurg Rev 1997;20:177181
13. Aren dall RE, Mein ow sky AM. Air sin u s w ou n d s: an an alysis of
163 con secut ive cases in curred in the Korean War, 1950-1952.
Neurosu rger y 1983;13:377380
14. Meirow sky AM, Caven ess W F, Dillon JD, et al. Cerebrospin al u id
st ulas com plicat ing m issile w oun ds of th e brain . J Neurosurg
1981;54:4448
15. Aarabi B, Tagh ipou r M, Alibaii E, Kam garp ou r A. Cen t ral n er vou s
system in fect ion s after m ilit ar y m issile h ead w oun ds. Neu rosurger y 1998;42:500509
16. Tah a JM, Saba MI, Brow n JA. Missile inju ries to th e brain t reated by sim ple w oun d closure: result s of a protocol during th e
Lebanese con ict . Neurosurger y 1991;29:380383

Management of Traumatic
Neurovascular Injuries
Boyd F. Richards and Mark R. Harrigan

Sp eci c segm en t s of th e carot id an d ver tebral ar teries are

Introduction
All t rau m at ic cerebrovascu lar inju r ies (TCVI) involve eit h er
p ar t ial or com p lete d isr u pt ion of t h e vessel w all. Trau m at ic
ar ter ial cerebrovascu lar inju r ies con st it u te a con t in u ou s
sp ect r u m of d isease, ran gin g from m in im al d isr u pt ion of
t h e in t im a to occlu sion or t ran sect ion of t h e ar ter y. TCVI can
also lead to t h e for m at ion of ar ter ioven ou s st u las an d an eu r ysm s. Th ese inju r ies can be classi ed accord in g to locat ion (ext racran ial or in t racran ial) an d by m ech an ism (blu n t
or p en et rat in g).
Th is ch ap t e r is d ivid e d in t o fou r cat e gor ies b ase d on locat ion an d m e ch an ism . Th e a u t h ors p rese n t a lgor it h m s b ase d
on ou r p refe r re d t reat m e n t st rat e gy for m ost ca ses at ou r
in st it u t ion .

Indications
Extracranial Blunt Injury
TCVI occu rs in abou t 1%of all blu n t t rau m a pat ien t s.1 Carot id

inju r y occurs in 0.1 to 1.55% of blun t t raum a pat ien t s. Vertebral injur y occurs in 0.2 to 0.77% of t raum a pat ien t s.
Motor veh icle collision s accou n t for 41 to 70%of cases.2 Oth er
m ech an ism s of inju r y in clu de assau lt , p ed est rian versu s veh icle, an d h anging.
Th e inju r y m ay result from a direct vascular blow, ext rem e
hyperexten sion /rotat ion , or lacerat ion by bony fragm en ts.
In depen den t risk factors for carot id ar ter y inju r y in clu d e:
closed h ead inju r y (w ith Glasgow Com a Scale [GCS] score
6), pet rou s bon e fract u re, d i u se axon al inju r y, an d
LeFor t II or III fract u re.
Cer vical spin e injur yC1, 2, or 3 fract u re; t ran sverse foram en fract u re; or su blu xat ion is an in dep en d en t risk factor
for vertebral ar ter y inju r y.
Th e m ost com m on ly used classi cat ion system divides TCVI
in to ve t yp es (Table 9.1).3,4
Ar t er ia l dissect ion (t ype I a n d II in ju r ies)
Results from rapid decelerat ion of th e body w ith subsequen t st retch ing of th e involved vessel.
Tw o m ech an ism s h ave been proposed (Figs. 9.1 an d 9.2):
(1) in t ram ural h em atom a form at ion bet w een layers of
th e arter y w all; an d (2) an in t im al tear leading to exposed
su ben d oth elial collagen , in it iat ing p latelet aggregat ion an d
leading to th rom bus form at ion .

m ore vu ln erable to dissect ion th an oth ers:


Carot id : th e dist al cer vical in tern al carot id ar ter y (ICA),
w h ere th e ICA is st retch ed over th e lateral m asses of th e
cer vical spin e, is at risk. Injur y t ypically result s from hyperexten sion an d rotat ion to th e con t ralateral side.
Ver tebral: th e V2 an d V3 segm en t s, as th e vessel t ravels
th rough th e t ran sverse foram in a of C6 to C2 an d arou n d
th e lateral m ass of C1, are at risk. V2 segm en t injuries
t yp ically h ave an associated cer vical spin e injur y, w h ereas inju r y to V3 or V4 segm en t s m ay occu r in isolat ion .
Tr a u m a t ic a n eu r ysm (t ype III in ju r ies)
Th is results from disrupt ion of th e in tern al elast ic lam in a,
w h ich w eakens th e vessel w all an d leads to expan sion of
th e adven t it ia.
Th e term pseudoaneurysm im plies a com plete disrupt ion
of all layers. How ever, dissect ing an eur ysm s m ay con t ain
a com p lete ar ter y w all. So, th e term t raum at ic aneurysm is
m ore app ropriate.
Traum at ic an eu r ysm s of th e carot id arter y t ypically occu r
in th e m id- or u pp er cer vical ICA an d accoun t for 15 to 44%
of TCVIs. A port ion (7.6%) of carot id injuries th at in it ially
con sist on ly of lum in al irregu larit y later develop in to t rau m at ic an eu r ysm s.5
Traum at ic an eur ysm accoun t s for on ly 4.8%of vertebral arter y TCVIs.
Un like spon tan eous dissect ing an eur ysm s, t raum at ic an eu r ysm s ten d to persist an d often en large over t im e.6
Occlu sion (t ype IV in ju r ies)
Traum at ic vascular occlu sion m ay occur at th e t im e of th e
inju r y or m ay arise in a delayed fash ion as th e resu lt of
th rom bu s form at ion at th e site of an arterial dissect ion .

Table 9.1 Classi cation of blunt traumatic cerebrovascular injury


Type

Description

Lum inal irregularit y or dissection; , 25% stenosis

II

Raised intim al ap or dissection; . 25% stenosis

III

Traum atic aneurysm

IV

Complete occlusion

Transection and/or development of arteriovenous stula

Source: Bi WL, Moore EE, O ner PJ, et al. Blunt carotid arterial injuries:
implications of a new grading scale. J Trauma 1999;47(5):845853; Bi
WL, Moore EE, Elliot t JP, et al. The devastating potential of blunt vertebral
arterial injuries. Ann Surg 2000;231(5):672681.

133

I Cerebral Traum a and Stroke


Carot id ar ter y inju r y d u e to p en et rat in g n eck t rau m a re -

Physical Findings
Physical ndings of penetrating, extracranial cerebrovascular
injury
Act ive bleeding
Hem atom a
Th rill or bruit
Absen ce of carot id pulse
Neu rologic de cit

Fig 9.1 Type I traumatic cerebrovascular injury. A mid-cervical internal


carotid artery intramural hematoma (arrow) causing , 25% reduction in
luminal diameter.

Occlu sion is m u ch less com m on th an ar terial dissect ion .


Pat ien t s m ay p resen t w it h sym ptom s of isch em ic st roke

or rem ain asym ptom at ic if good collateral circu lat ion


exist s.
Ar t er ioven ou s f st u la s (t ype V in ju r ies)
Presen t w ith t inn it us, cer vical radiculopathy, h eart failure,
h em orrh age, steal, in t racran ial ven ou s hyp erten sion , or
em bolic st roke.
Type I traum atic ce rebrovascular injury (Fig. 9.1).
Type II traum atic ce rebrovascular injury (Fig. 9.2).

Intracranial Blunt Injury


Dat a regarding th e overall in ciden ce of blun t in t racran ial

Extracranial Penetrating Injury


Pen et rat ing n eck t rau m a is accom pan ied by vascu lar inju r y

134

in 20% of pat ien t s.7


Seven t y- ve p ercen t of th ese vascu lar inju ries are att ribu t able to st abbing. Gu n sh ot w ou n ds accou n t for th e
rem ain d er.8
Th e ven ous system is m ore com m on ly a ected bu t less likely
to requ ire t reat m en t .

su lt s in vessel occlu sion in 36% of cases an d t rau m at ic


an eu r ysm for m at ion in 33% of cases.9 As com p ared w it h
blu n t ext racran ial carot id inju r y, t h e rate of isch em ic st roke
w it h a p en et rat in g inju r y is low er, bu t t h e m or t alit y rate is
h igh er.10
Pen et rat ing ext racran ial inju ries can be classi ed by t yp e:
Ar t er ia l la cer a t ion
Dissect ion
Occlu sion
An eu r ysm
Ar t er ioven ou s f st u la . Fist u las m ay be eit h er carot id -caver n ou s (d iscu ssed in t h e blu n t in t racran ial inju r y sect ion )
or ver tebral-ven ou s in n at u re. Th e lat ter m ay p resen t as
t in n it u s, cer vical rad icu lop at hy, h ear t failu re, h em orrh age, steal, in t racran ial ven ou s hyp er ten sion , or em bolic
st roke. Slow - ow st u las m ay be follow ed exp ect an t ly
w it h ser ial angiograp hy ever y 12 m on t h s in asym ptom at ic an d ot h er w ise clin ically st able p at ien t s. High - ow
st u las m ay cau se brain stem or sp in al cord sym ptom s
d u e to p ressu re from ar ter ializat ion of t h e cer vical ven ou s
p lexu s. Poster ior circu lat ion isch em ia m ay resu lt from d iversion of ow .
Physical exam in at ion is th e m ost im p or tan t part of th e diagn ost ic evaluat ion for pen et rat ing cer vical vascular injur y
(see box below ).
If physical sign s of vascu lar inju r y are p resen t , th ere is a
90% ch ance of a m ajor arterial or ven ou s injur y.11
In th e absen ce of p hysical sign s, th e risk of m ajor vascu lar
inju r y falls to 0.9%.11

TCVIs is lacking. Su ch inju ries are su bst an t ially less com m on


th an blun t ext racran ial injuries.
GCS score , 8 an d th e p resen ce of facial fract u res are in depen den t risk factors for blun t in t racran ial arterial injur y.12
Blun t in t racran ial injuries m ay be classi ed by t ype:
Dissect ion
May be associated w ith t rivial t rau m a or blu n t inju r y in
closed h ead t raum a, as w ell as pen et rat ing injur y.
Th e m ost com m on a ected sites are th e su praclin oid ICA
an d th e in t radu ral p or t ion of th e ver tebral arter y.
In t racran ial dissect ion m ay be associated w ith u n derlying vascu lar abn orm alit y of th e cerebral ar teries, in clu d ing broelast ic th icken ing an d congen it al de cien cy
w ith disrupt ion of th e in tern al elast ic lam in a. Associated
con dit ion s th at m ay predispose on e to dissect ion in th e

Managem ent of Traum atic Neurovascular Injuries

Fig. 9.2a, b Type II traumatic cerebrovascular injury, t wo examples: (a) focal dissection, likely an intimal ap, with thrombus (arrow) and (b) di use
injury, likely an intramural hem atoma (arrows).

set t ing of blu n t inju r y in clu de brom u scu lar hyp erp lasia, cyst ic m edial degen erat ion , Marfan syn drom e, h om ocyst in u ria, an d syph ilis.
Pat ien t s m ay p resen t w ith u n ilateral h eadach e,
cran ial n er ve palsy (from m ech an ical com pression or
n eurap raxia from th e expan ded ar ter y or t ran sien t im p airm en t of blood su pply), Horn ers syn drom e, an d/or
focal cerebral isch em ia.
An eu r ysm
Trau m at ic an eu r ysm s accou n t for , 1%of all in t racran ial
an eu r ysm s in adu lt s, bu t com prise abou t on e-th ird of
p ediat ric an eu r ysm s.13
An eur ysm s in th is set t ing result from rapid decelerat ion ,
w h ich cau ses sudden brain m ovem en t an d arterial w all
injur y from stat ion ar y st ru ct ures su ch as th e skull base
or falx cerebri.
Pe r icallosal bran ch (an t e r ior com m u n icat in g ar te r y
[ACA]) an e u r ysm s, resu lt in g from collision b et w e e n
t h e ar t e r y an d t h e e dge of t h e falx, are m ost com m on .
Basilar arter y an d pet rocavern ou s segm en t an eu r ysm s
often are associated w ith skull base fract ures.

Ar t er ioven ou s f st u la
Ar terioven ous st ulasarising from eith er th e carot id

or ver tebral circulat ion are presen t in 4% of all pat ien t s


w ith blu n t TCVI.14
Th e m ost com m on in t racran ial t raum at ic st ula is a direct carot id-cavern ous st ula (CCF).
Seven t y- ve p ercen t of direct CCFs occu r secon dar y to
t raum a.
Most are associated w ith facial or sku ll base fract u res.
Iat rogen ic injur ydue to tran ssph en oidal surger y, skull
base surger y, or percutaneous lesioning of the trigem in al ganglion also accoun ts for a signi can t n u m ber of
t raum at ic st ulas.
Pat ien t s t yp ically p resen t w ith cavern ou s sin u s syn drom e (see box on n ext page).
In d icat ion s for u rgen t t reat m en t in clu de:
In creased in t racran ial p ressu re or th e p resen ce of cerebral cort ical ven ous hyperten sion
Progressive visual de cit
In creased in t raocu lar p ressu re
Worsen ing proptosis

135

I Cerebral Traum a and Stroke


Traum atic Caverno us Fistula
Traum atic cavernous stula symptom s and physical ndings
Pain fu l exop h th alm ia
Pulsat ing conjun ct ival hyperem ia
Oph th alm op legia
Vascu lar m urm u r
Elevated in t raocu lar pressu re
Loss of vision (du e to ven ou s congest ion )

Intracranial Penetrating Injury


Pen et rat ing in t racran ial inju r y m ay resu lt in dissect ion , oc-

clusion , t raum at ic an eur ysm , or ar terioven ous st ula. All


h ave been discu ssed p reviously. How ever, th e form at ion of
t raum at ic in t racran ial an eur ysm s secon dar y to pen et rat ing
inju r y w arran t s fur th er con siderat ion .
Trau m at ic in t racran ial an eu r ysm s can result from direct in ju r y by m issile, bu llet , or bon e fragm en t s. An eu r ysm s are
presen t in :
2.7% of pat ien ts w ith m issile inju ries to th e h ead.16
12% of pat ien t s w ith st ab w oun ds to th e h ead.17
An eu r ysm s m ay ap pear as soon as 2 h ou rs after th e inju r y
an d are m ost com m on ly fou n d along bran ch es of th e m iddle

cerebral ar ter y (MCA) (as opposed to in t racran ial an eur ysm s


due to blun t t raum a, w h ich are m ost often iden t i ed on
bran ch es of th e ACA).
Factors th at sh ould raise suspicion for a t raum at ic an eur ysm
in clude:
Missile or bon e fragm en ts close to th e sku ll base
Large h em atom a at th e m issile en t ran ce w ou n d
Th ough an eur ysm s occurring secon dar y to t rau m a are believed to carr y a h igh risk of rupt ure, on e st udy foun d th at
19.4% of th ese lesion s h ealed spon t an eously an d sh ran k or
disappeared altogether on subsequen t angiogram s.18

Preprocedure Considerations
Radiographic Imaging
Extracranial Blunt Injury
A screening com puted tom ography angiogram (CTA) or m agnetic resonance angiogram (MRA) should be perform ed for any
patient w ith risk factors for TCVI and/or any unexplained neurologic de cit (Fig. 9.3). In the setting of TCVI, CTA m ay reveal:
Eccen t ric vessel lum en com bin ed w ith m ural th icken ing
Sten osis

Fig. 9.3ad Patterns of injury in blunt, extracranial traumatic cerebrovascular injury. Common t ypes of injury include: (a) intimal tear,
(b) intimal tear with associated thrombosis, (c) dissecting aneurysm formation due to disruption of the internal elastic lamina and bulging of the
adventitia, and (d) intramural hematoma.

136

9
Occlu sion
Dissect ing an eu r ysm
Mu ral th icken ing

MRI an d MRA are u sefu l in cases of a w ooden foreign body

Cerebral angiography is in dicated w h en n ecessar y for claricat ion of th e diagn osis or w h en en dovascu lar t reat m en t is
p lan n ed . In th e set t ing of TCVI, angiograp hy m ay reveal:
Eccen t ric, sm ooth , or t apered sten osis
In t im al ap an d associated false lu m en
Tapered sten osis proxim al to a dissect ing an eur ysm (st ring
an d p earl sign )
Flam e-sh ap ed occlu sion
Dissect ing an eu r ysm
In t ralu m in al th rom bu s

Extracranial Penetrating Injury


CTA or MRA is th e rst-lin e im aging m odalit y at our in stit ution .
Angiograp hy is reser ved for cases in w h ich t h e CTA re

Extracranial Blunt Injury (Fig. 9.4)


Th e corn erston es of m an agem en t for ext racran ial blun t

Intracranial Blunt Injury


Dissect ion
All pat ien t s suspected of h aving an in t racran ial dissect ion

Intracranial Penetrating Injury


A screen ing CTA or MRA (un less con t rain dicated) sh ould be

p erform ed for any pat ien t presen t ing w ith p en et rat ing h ead
inju r y.
Met allic foreign bodies m ay com p rom ise CT im ages secon dar y to scat ter art ifact . Th ey m ay also ren der an MRA im p ossible. In th is case, an angiogram m ay be n ecessar y p rior to
rem oval of th e foreign object .

injur y, as it is di cult to visualize w ooden m aterial on a CT.


Repeat , delayed angiography sh ould be perform ed 3 to
6 m on th s later for pat ien t s in w h om an arterioven ous st u la
is suspected.

Management

su lt s are equ ivocal or w h en en d ovascu lar t reat m en t is


an t icip ated .
Angiography is also in dicated if th ere is a retain ed m et allic
foreign object th at m igh t obscu re in terp retat ion of CTA or
MRA du e to art ifact .

sh ou ld u n d ergo a CTA or MRA as a rst-lin e im aging m odalit y. How ever, if a dissect ion is st rongly suspected, con ven t ion al angiography rem ain s th e gold st an dard.
An eu r ysm
CTA is th e recom m en ded screen ing m odalit y. How ever,
t raum at ic an eur ysm s are often located dist ally an d can be
dangerous even w h en , 3 m m . Th ese t w o feat ures ren der
CTA less reliable.
Angiography is recom m en ded for all pat ien t s in w h om a
t raum at ic an eur ysm is suspected.
Ar t er ioven ou s f st u la
Angiography is th e gold st an dard to im age ar terioven ous
st u las.
An early- lling vein m ay be a path ogn om on ic sign .
Assess for access to th e lesion by looking at th e direct ion
of ow w ith in each of th e ven ou s st ruct ures.
For CCFs, assess th e presen ce of th e superior op h th alm ic
vein as a possible access p oin t for t reat m en t .
CTA an d MRA are st at ic st u dies. Early ven ou s lling often
is n ot visu alized as th e t im ing of th e con t rast bolu s m ay
a ect t im ing of th e lling of th e vein s.

Managem ent of Traum atic Neurovascular Injuries

TCVI are an t ith rom bot ic th erapy (to m in im ize th rom boem bolic com plicat ion s), follow -up im aging, an d select ive use of
en dovascu lar tech n iqu es.
Medica l m a n a gem en t
Anticoagulation w ith intravenous heparin, followed by warfarin, has been com m on practice. However, hem orrhagic
com plication rates range from 8 to 16%19 and a signi cant proportion (3036%) of patients w ith this type of injury are not
candidates for system ic anticoagulation due to concom itant
injuries.
An t iplatelet th erapy o ers a m ore favorable risk pro le an d
m ay be equ ivalen t to or su p erior to an t icoagu lat ion w ith
respect to n eu rologic outcom es.20 Th e au th ors p refer single
agen t an t iplatelet th erapy in th e form of aspirin 325 m g
per day.
Repeat n on invasive im aging, preferably CTA, sh ou ld be
u n der t aken in 6 m on th s.
En dova scu la r m a n a gem en t
Dissect ion
Dissect ion s requ ire t reat m en t (u su ally sten t ing) if th ere
are n ew n eu rologic de cits or oth er sym ptom s desp ite
an t iplatelet th erapy.
Sten t ing requires dual an t iplatelet th erapy for a period of
app roxim ately 1 m on th ; th is m ay p rove p roblem at ic for
p olyt rau m a pat ien ts.
Trau m at ic an eur ysm
En dovascular t reat m en t is in dicated if th e pat ien t is
sym ptom at ic despite an t ip latelet th erapy or if th e
an eu r ysm is fou n d to en large sign i can tly on follow -u p
im aging. Follow -u p im aging sh ould be perform ed after
6 m on th s (see Fig. 9.5).
A covered sten t m ay be appropriate if th e t raum at ic
an eu r ysm occu rs in a port ion of th e vessel devoid of
im port an t bran ch es.
Coil em bolizat ion of t raum at ic an eur ysm s sh ould be
avoided w h en ever possible as th e w all of th e an eu r ysm
m aybe eith er ext rem ely fragile or con sist en t irely of
th rom bo- brous t issue. Coils w ith in t raum at ic an eu r ysm s m ay be pron e to m igrate th rough th e w all of th e
an eu r ysm .
Occlu sion
Vessel occlu sion sh ou ld b e ap p roach e d in a sim ilar
m an n e r to acu t e isch e m ic st roke. Sym p tom at ic ar t e r ial
occlu sion s sh ou ld u n d e rgo re can alizat ion w h e n feasible an d ap p rop r iate. Pat ie n t s w it h asym p tom at ic occlu sion s m ay d o w ell w it h con se r vat ive m an age m e n t
(se e Fig. 9.6).

137

I Cerebral Traum a and Stroke


Su spected blu n t
ext racran ial TCVI
CTA

Eviden ce of
vascular inju r y

Dissect ion

Traum at ic
An eu r ysm

An t ip latelet
Agen t

An t ip latelet
Agen t

No evid en ce of
vascu lar inju r y
Un explain ed
n eu rologic
deficit or
h igh susp icion

Occlu sion

Asym ptom at ic

Sym ptom at ic
DSA

Neu rologic
obser vat ion an d
repeat CTA in 6
m on th s
New
n eu rologic
deficit

If stable
con t in u e
an t iplatelet
agen t

Neu rologic
obser vat ion an d
repeat CTA in 6
m on th s
If en larging
or n ew
n eu rologic
deficit

If resolved,
d/c
an t iplatelet
agen t

Con sider
en dovascu lar
t reat m en t

DSA

If un ch anged,
con t in u e
an t iplatelet agen t

An t ip latelet
Agen t

If resolved, d/c
ant ip latelet agen t

New Trau m at ic
An eu r ysm

Neurologic
obser vat ion an d
repeat CTA in 6
m on th s

<8 h ou rs
At tem pt
en d ovascu lar
recan alizat ion

>8 h ou rs
CT
Perfusion
At tem pt
recan alizat ion if CT
Perfusion sh ow s
reversible isch em ia
Su p p ort ive care
n o reversible
isch em ia

Fig. 9.4 Algorithm for the management of blunt, extracranial traumatic cerebrovascular injury. DSA, digital subtraction angiography; CTA,
CT angiography; d/c, discontinue.

Reperfu sion tech n iques, in cluding m ech an ical th rom -

bectom y an d at tem pted recan alizat ion , sh ould be


con sidered if th e t im e from sym ptom on set is less th an
8 h ou rs an d n on invasive im aging m odalit ies (such as CT
perfusion or MR perfusion ) suggest a reversible isch em ic
pen um bra. Reperfusion tech n iques in such cases m ay in clude em ergen t sten t placem en t or th rom bectom y.
Sten t ing in th e acute set t ing requires loading w ith t w o
an t iplatelet agen t s (e.g., aspirin an d clopidogrel) at least
3 h ours prior to th e procedure. An altern at ive w ould
be to t reat th e pat ien t w ith an in t raven ous GPIIB/IIIA
in h ibitorto perm it sten t ing im m ediatelyan d p roceed
w ith an t iplatelet agen t loading later. Th e use of th ese
agen ts in any pat ien t w ith polyt rau m a sh ou ld be con sid ered carefu lly becau se of bleeding risks an d th e p oten t ial
n eed for oth er invasive in ter ven t ion s.

Extracranial Penetrating Injury


(Fig. 9.7)
Th e ch oice of an open surgical or en dovascular approach for
th e m an agem en t of pen et rat ing n eck inju ries is based on th e
locat ion of th e inju r y (see Fig. 9.8). Th e surgical approach for
pen et rat ing vascular injuries w ill be described in m ore det ail
(see Operat ive Procedure, p. 145).

138

A few elem ents of m anagem ent are com m on to all such injuries:
Asser t ive m an u al com pression sh ould be used to con t rol
bleeding in it ially.
Th e air w ay m ust be secured, preferably by en dot rach eal
in t ubat ion . If en dot rach eal in t u bat ion is n ot feasible,
cricothyrotom y is th e n ext best opt ion for air w ay con t rol.
Nasot rach eal in t u bat ion sh ou ld be avoided w h en p ossible
because of th e possibilit y of cran ial or n asoph ar yngeal
inju r y due to th e p en et rat ing injur y.
En dova scu la r Tr ea t m en t
En dovascular t reat m en t m ay be preferable for pat ien t s
w ith Zon e I an d III injuries due to th e di cult y of surgical access to th ese areas (see Fig. 9.9).
Covered sten t placem en t m ay be e ect ive for carot id lacerat ion s, p rovided th e lesion can be crossed .
En dovascular ar terial occlu sion m ay be in dicated. Select ive occlusion of extern al carot id bran ch es is u su ally
st raigh tfor w ard . In som e sit u at ion s, occlu sion of th e in tern al carot id or vertebral arter y m ay be n ecessar y to
con t rol bleeding. Angiograph ic assessm en t of collateral
circulat ion to th e a ected brain territor y can h elp determ in e th e risk of resultan t cerebral isch em ia. Sacri ce
of an ar ter y sh ou ld in clu de occlusion of th e vessel both
proxim al an d dist al to th e inju r y, if possible, to m in im ize
th e ch an ce of ret rograde bleeding th rough th e distal segm en t of th e a ected arter y.

Managem ent of Traum atic Neurovascular Injuries

Fig. 9.5a, b Traumatic dissecting aneurysm (type III traumatic cerebrovascular injury). Patient with an asymptomatic cervical ICA dissecting
aneurysm identi ed on screening CTA. Because signi cant enlargement was noted on follow-up surveillance imaging, it was treated with a covered
stent. Angiograms (a) pre- and (b) post-stenting.

Fig. 9.6 Arterial occlusion (type IV traumatic cerebrovascular


injury). Patient with asymptomatic complete occlusion of the ICA
secondary to blunt trauma. The patient was managed conservatively
and did not experience neurologic problems at tributable to the
occlusion.

139

140

>

<

I Cerebral Traum a and Stroke

Managem ent of Traum atic Neurovascular Injuries

Fig. 9.8 Zones of the neck. Anatomic zones of the neck. Zone I: clavicle to the cricoid cartilage. Zone II: cricoid cartilage to the angle of the
mandible. Zone III: angle of the mandible to the base of skull.

Fig. 9.9a, b Arterial dissection due to penetrating neck trauma. Patient with a knife wound to the distal cervical ICA (Zone III). The injury was
initially controlled by placement of a Foley balloon catheter in the wound to stop the bleeding. Angiography showed complete transection of the
vessel (a, arrow). The patient was treated with endovascular sacri ce of the ICA (b).

141

I Cerebral Traum a and Stroke

Intracranial Blunt Injury (Fig. 9.10)


Injury t ype dictates the m anagem ent of blunt intracranial TCVIs.
Dissect ion
Hem orrh agic an d sym ptom at ic ow -lim it ing dissect ion s

can be t reated w ith en dovascular occlusion an d/or sten t ing.


Clin ically silen t in t racran ial dissect ion s sh ou ld be m on itored w ith su r veillan ce im aging ever y 6 m on th s to assess
for th e delayed develop m en t of dissect ing an eur ysm s.
An eu r ysm
Conservative m anagem ent (i.e., no intervention) is associated
w ith a m ortalit y rate as high as 50%.14 Therefore, all traum atic
intracranial aneurysm s should be treated w hen possible.
Open su rgical clip p ing w ith evacu at ion of associated h em atom a often involves sacri ce of th e paren t vessel.
Coil em bolizat ion of t raum at ic an eur ysm s m ay be perform ed in a sim ilar m an n er to th e t reat m en t of sp on tan eous
an eu r ysm s; h ow ever, th e form er often involves sacri ce of
th e paren t vessel.
Ar t er ioven ou s f st u la
Open su rgical p acking of th e cavern ou s sin u s is an opt ion
for p at ien t s w h o requ ire cran iotom y for oth er reason s related to th e t raum a.

En dovascular t reat m en t depen ds on th e ow st ate of th e


st u la. A fou r-vessel cerebral angiogram (to assess collateral
circulat ion ) an d balloon test occlusion are pruden t in case
th erapeut ic occlusion of th e a ected carot id arter y becom es n ecessar y.
Low - ow t rau m at ic st u las m ay be t reated w ith coil or
liquid em bolic em bolizat ion .
High - ow lesion s m ay requ ire a covered sten t p lu s coiling an d liquid em bolic em bolizat ion , or carot id occlu sion . A pitfall of u sing coil em bolizat ion alon e to t reat
h igh - ow st u las is th at th e coils m ay m igrate arou n d
th e cavern ous sin us, resu lt ing in recu rren ce of th e st ula
(Fig. 9.11).

Intracranial Penetrating Injury


(Fig. 9.12)
Conven t ion al t reat m en t of in t racran ial an eur ysm s due to
pen et rat ing t raum a is by cran iotom y an d clipping or t rap ping. En dovascu lar t reat m en t is an opt ion , th ough global experien ce, to date, is lim ited.

Su spected Blu n t
In t racran ial TCVI

CTA eviden ce of
vascu lar inju r y?

Yes

Dissect ion w ith


h em orrh age

Dissect ion

DSA to assess
collateral
circu lat ion

An t iplatelet
agen t

Poor collateral
circu lat ion
an t iplatelet
agen t
Good collateral
circu lat ion
en dovascular
vessel sacrifice

Repeat CTA in 6
m on th s

New t raum at ic
an eur ysm
If resolved, D/C
an t iplatelet
agen t

No

Trau m at ic
an eur ysm
Treat m en t w ith
en dovascular
or su rgical
in ter ven t ion

Un explain ed
n eu ro deficit?

Occlu sion

Asym ptom at ic

An t ip latelet
Agen t

Repeat CTA in 6
m on th s

If yes, DSA

Sym ptom at ic

< 8 h ou rs,
at tem pt
en dovascu lar
recan alizat ion

If n o, n o furth er
w orku p

> 8 h ou rs,
at tem pt
recan alizat ion
if CTA or MRP
sh ow s pen u m bra

If u n ch anged,
con t in ue
an t ip latelet
agen t
Fig. 9.10 Algorithm for the management of blunt intracranial cerebrovascular injury. MRP, magnetic resonance perfusion.

142

Managem ent of Traum atic Neurovascular Injuries

b
Fig. 9.11a, b Intracranial blunt injury, dissection. (a) Patient with an intradural vertebral artery dissection (arrow) due to blunt trauma. The
dissection caused a cerebellar hemorrhage. (b) The lesion was treated with endovascular occlusion.

Su sp ected pen et rat ing


in t racran ial TCVI
CTA eviden ce of
vascu lar inju r y?

Yes

Dissect ion w ith


h em orrh age
DSA to assess
collateral
circu lat ion
Poor collateral
circu lat ion -an t iplatelet
agen t
Good collateral
circu lat ion -en d ovascular
vessel sacrifice

Dissect ion

An t iplatelet
agen t
Repeat CTA in 6
m on th s

No

Trau m at ic
an eur ysm
Treat m en t
w ith
en d ovascu lar
or su rgical
in ter ven t ion

Fist u la

Con sider
t reat m en t
(en dovascular
or su rgical)

Un explain ed
n eu ro deficit?
If n o, n o fur th er
w orku p
If yes, DSA

New t rau m at ic
an eu r ysm
If resolved, D/C
an t iplatelet
agen t
If u n ch anged,
con t in u e
an t iplatelet agen t

Fig. 9.12 Algorithm for the management of penetrating intracranial cerebrovascular injury.

143

I Cerebral Traum a and Stroke


Rem oval of foreign bodies sh ould be deferred un t il radio-

If th e foreign body app ears to be proxim ate to or p rovid-

graph ic evalu at ion h as been com pleted.


In pat ien t s w ith n o eviden ce of in t racran ial h em orrh age or
cerebrovascular injur y, th e pen et rat ing object can be rem oved u n der gen eral an esth esia.

ing tam pon ade for a poten t ial vascular inju r y, th e foreign
body sh ould be rem oved in th e operat ing room un der
direct vision .
Pen et rat ing in t racran ial inju r y (Fig. 9.13).

b
Fig. 9.13a, b Penetrating intracranial injury. (a) Patient with a knife wound to the left temporal area. (b) The blade penetrated the squamous
portion of the temporal bone. The tip was buried in the petrous bone (arrow), adjacent to the carotid canal and temporomandibular joint. Once it
was established by imaging that the injury did not involve any arterial structures, the patient underwent craniotomy and rem oval of the knife blade.

144

Managem ent of Traum atic Neurovascular Injuries

Operative Procedure
Surgical Management of Extracranial Penetrating Arterial
Injuries Zone II
Positioning (Fig. 9.14a, b)

Figure

Procedural Steps

Pearls

Fig. 9.14

(a) Place a roll betw een the shoulder blades to extend the
patients neck, and rotate the patients head aw ay from the
side of injury. (b) Prep and drape the entire neck, upper chest,
and low er face.

Rem ove the cervical collar if the patient is wearing


one.

145

I Cerebral Traum a and Stroke

Incision (Fig. 9.15)

146

Figure

Procedural Steps

Pearls

Fig. 9.15

Make a longitudinal incision along the anterior border of the


sternocleidomastoid muscle (SCM).

Err on m aking the incision too long rather than too


short; it may extend from the ear lobe to the sternal
notch if necessary.

Managem ent of Traum atic Neurovascular Injuries

Initial Dissection (Fig. 9.16)

Figure

Procedural Steps

Fig. 9.16

Use monopolar cautery to divide the platysma muscle. Mobilize and retract the sternocleidomastoid muscle
laterally. Ligate and divide the transverse facial vein.

147

I Cerebral Traum a and Stroke

Carotid Artery Dissection (Fig. 9.17)

148

Figure

Procedural Steps

Pearls

Fig. 9.17

Use both blunt and sharp


dissection to expose the carotid
sheath.

Avoid the area of injury by working around the hem atom a. All veins (including
the internal jugular vein) m ay be ligated and divided if necessary. If both internal
jugular veins are involved, one should be preserved. Use judicious and selective
compression of bleeding arterial branches and veins as they are encountered.

Managem ent of Traum atic Neurovascular Injuries

Proximal and Distal Control (Fig. 9.18)

Figure

Procedural Steps

Pearls

Fig. 9.18

Once the ICA distal to the injury and the CCA or ICA
proximal to the injury have been exposed, place
either a clamp or an aneurysm clip on the artery in
each location.

Large perm anent aneurysm clips are usually su cient for the
ICA, and a Fogart y clamp is usually necessary for the com m on
carotid artery. Large aneurysm clips m ay also be used for
temporary occlusion of external carotid artery (ECA) branches.

149

I Cerebral Traum a and Stroke

Repair of Arterial Injury (Fig. 9.19a, b)

Figure

Procedural Steps

Pearls

Fig. 9.19

(a) Repair the arterial injury primarily, w hen possible, w ith a running 6-0
nonabsorbable polypropylene mono lament stitch.

Ligation and sacri ce of the ICA

(b) When primary repair is not possible, place a tubular polytetra uoroethylene
(PTFE) interposition graft and secure w ith simple interrupted 6-0 polypropylene
mono lament sutures.
Remove the arterial clamps in the follow ing order: ECA, CCA, and ICA.

150

should be avoided; repair of the


artery versus ligation results in
an 8% versus 50% ischem ia stroke
rate.10

Closing
Leave a drain in place. Close the wound w ith absorbable braided
stitches in the platysm a m uscle and staples or stitches in the skin.

Postoperative Management
Monitoring
All pat ien ts w ith cerebrovascular injuries sh ould be m on i-

tored in a n eurologic in ten sive care un it during th e acute


p h ase, w ith frequen t n eu rologic exam in at ion s, vit al sign
m on itoring, an d daily laborator y st u dies.
Blood pressu re m on itoring w ith an arterial lin e is p referable
for p at ien t s w ith labile blood p ressu re or for th ose requ iring
con t in uous m edicat ion in fusion s for blood pressure con t rol.
Main ten an ce of systolic blood pressu re bet w een 90 an d
180 m m Hg is adequ ate for m ost pat ien t s.
Th e n eed for invasive in t racran ial m on itoring is dictated
by st an dard n eurosurgical criteria (e.g., for pat ien t s w ith
elevated in t racran ial p ressu re du e to h ead injur y).

Medication
An t ithrom bot ic th erapy w ith aspirin (325 m g daily) is in di

cated for m ost pat ient s w ith t raum at ic cerebrovascular injur y.


More aggressive an t ith rom bot ic th erapy, w ith system ic an t icoagulat ion , m ay be n ecessar y for pat ien ts w ith sign i can t
in t ralu m in al arterial or ven ou s th rom bosis.
Du al an t ip latelet th erapy (e.g., asp irin an d clop idogrel) is n ecessar y for all p at ien t s receiving a vascu lar sten t .
In m ost cases, an t ith rom bot ic th erapy for 3 m on th s is
app ropriate.

Radiographic Imaging
Follow -u p im aging of t rau m at ic cerebrovascular lesion s w ith
CTA at a 3- to 6-m on th in ter val is u sefu l to m on itor d issect ion s an d to ch eck for th e developm en t or progression of
t raum at ic an eur ysm s.

Further Management
An out patient clinic follow -up evaluation should be com pleted
3 to 6 m onths after discharge.

Special Considerations
Antithrombotic Therapy
Th e u se of an t ith rom bot ic m edicat ion is a reason able op t ion in pat ien t s w ith cerebrovascular injuries as a m easure
to preven t th rom boem bolic isch em ic st roke. How ever, all

Managem ent of Traum atic Neurovascular Injuries

an t ith rom bot ic m edicat ion s, in clu ding an t iplatelet agen t s


an d an t icoagu lat ion , carr y a risk of h em orrh agic com plicat ion s, part icularly in pat ien t s w ith in t racran ial h em orrh age
or polyt raum a. Alth ough level III clin ical eviden ce an d gu idelin es about th e use of an t ith rom bot ic m edicat ion s in t rau m a
p at ien ts are lacking, th e au th ors of th is ch apter recom m en d
th e use of aspirin in m ost pat ien ts w ith cerebrovascu lar in ju ries. For p at ien ts w ith t rau m at ic in t racran ial m ass lesion s
(e.g., subdural h em atom as or clin ically sign i can t in t racerebral h em orrh age), an d/or for w h om cran ial surger y is an t icip ated or h as been don e, avoiding an t ith rom bot ic m edicat ion s
seem s p ru den t .

References
1. Hugh es KM, Collier B, Green e KA, Ku rek S. Trau m at ic carot id
arter y dissect ion : a signi cant in ciden t al n ding. Am Surg
2000;66(11):10231027
2. Bi W L, Moore EE, Ryu RK, et al. Th e u n recogn ized ep idem ic of
blun t carot id arterial injuries: early diagn osis im proves n eurologic ou tcom e. An n Su rg 1998;228(4):462470
3. Bi W L, Moore EE, O ner PJ, et al. Blunt carotid arterial injuries:
im plications of a n ew grading scale. J Traum a 1999;47(5):845853
4. Bi W L, Moore EE, Elliot t JP, et al. Th e devast at ing p oten t ial of
blun t vertebral arterial injuries. An n Surg 2000;231(5):672681
5. Bi W L, Ray CE Jr, Moore EE, et al. Treat m en t-related ou tcom es
from blu n t cerebrovascu lar inju ries: im p or t an ce of rou t in e follow up ar teriography. An n Surg 2002;235(5):699706; discussion
706707
6. Stein DM, Bosw ell S, Sliker CW, Lu i FY, Scalea TM. Blu n t cerebrovascular injuries: does t reat m en t alw ays m at ter? J Traum a
2009;66(1):132143; discussion 143144
7. Nason RW, Assu ras GN, Gray PR, Lipsch it z J, Bu rn s CM. Pen et rat ing n eck inju ries: an alysis of experience from a Can adian t raum a
cen t re. Can J Surg 2001;44(2):122126
8. Th om a M, Navsaria PH, Edu S, Nicol AJ. An alysis of 203 pat ien t s
w ith penet rat ing n eck injuries. World J Surg 2008;32(12):
27161723
9. Ku eh n e JP, Weaver FA, Papan icolaou G, Yellin AE. Pen et rat ing
t raum a of th e in ternal carot id arter y. Arch Surg 1996;131(9):
942947; discussion 947948
10. Ram adan F, Rutledge R, Oller D, How ell P, Baker C, Keagy B.
Carot id ar ter y t rau m a: a review of con tem p orar y t rau m a cen ter
experien ces. J Vasc Su rg 1995;21(1):4655; d iscu ssion 5556
11. Sekh aran J, Den n is JW, Velden z HC, Miran da F, Fr ykberg ER.
Con t in u ed exp erien ce w ith p hysical exam in at ion alon e for
evalu at ion an d m an agem en t of p en et rat ing zon e 2 n eck inju ries:
result s of 145 cases. J Vasc Surg 2000;32(3):483489
12. McKevit t EC, Kirkpat rick AW, Vertesi L, Granger R, Sim on s RK.
Iden t ifying p at ien t s at risk for in t racran ial an d ext racran ial blu n t
carot id inju ries. Am J Su rg 2002;183(5):566570
13. Ven t ureyra EC, Higgin s MJ. Traum at ic in t racran ial an eur ysm s in
ch ildh ood and adolescen ce. Case repor t s and review of th e literat ure. Ch ilds Ner v Syst 1994;10(6):361379
14. Holm es B, Harbaugh RE. Traum at ic in t racran ial an eur ysm s: a
con tem porar y review. J Traum a 1993;35(6):855860
15. Dusick JR, Esposito F, Malkasian D, Kelly DF. Avoidan ce of
carot id ar ter y injuries in t ran ssph enoidal surger y w ith th e
Dop p ler p robe an d m icro-h ook blad es. Neu rosu rger y 2007;
60(4 Su ppl 2):322328

151

I Cerebral Traum a and Stroke


16. Aarabi B. Trau m at ic an eu r ysm s of brain du e to h igh velocit y m issile h ead w ou nds. Neurosurger y 1988;22(6 Pt 1):10561063
17. du Trevou MD, van Dellen JR. Pen et rat ing st ab w ou n d s to th e
brain : th e t im ing of angiography in p at ien t s presen t ing w ith th e
w eapon already rem oved. Neurosurger y 1992;31(5):905911;
discu ssion 911912
18. Am irjam sh idi A, Rah m at H, Abbassiou n K. Trau m at ic an eu r ysm s
an d ar terioven ou s st u las of in t racran ial vessels associated w ith

152

pen et rat ing h ead inju ries occu rring d u ring w ar: p rin ciples an d
pitfalls in diagn osis an d m an agem en t . A su r vey of 31 cases an d
review of th e literat ure. J Neurosurg 1996;(5):769780
19. Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt
cerebrovascular injuries: analysis of diagnostic m odalities and outcom es. Ann Surg 2002;236(3):386393; discussion 393395
20. Beletsky V, Nadareishvili Z, Lynch J, et al. Cervical arterial dissection:
tim e for a therapeutic trial? Stroke 2003;34(12):28562860

10

Management of Venous Sinus Injuries


Laurence Davidson and Rocco A. Arm onda

Introduction
Major du ral ven ou s sin u ses form at th e d u ral re ect ion s w h ere
th e super cial an d deep layers of th e dura split an d th e deep
layer fu ses to form th e falx cerebri an d th e ten torium cerebelli.
Inju r y to th e du ral ven ou s sin u ses m ay be en cou n tered in p en et rat ing an d n onpen et rat ing h ead t rau m a or can resu lt from
plan n ed or acciden tal disrupt ion during a cran iotom y.13 Th e
dural ven ous sin us h as a th ree-sided lum en th at is teth ered lat erally by th e adjacen t du ra m ater an d deep ly by th e falx cerebri
or ten torium cerebelli. Hem orrh age can arise from th e sin us
roof, lateral w alls, ven ou s lakes, arach n oid gran u lat ion s, em issar y vein s, or cort ical vein t ribu taries.
Th e decision to repair versu s sacri ce th e sin us is dependen t
on th e locat ion of injur y. W h en repair is in dicated, th e t ype an d
exten t of inju r y w ill largely dict ate th e opt im al repair tech n iqu e,
w h ich ranges from direct repair to segm en t al replacem en t .

Cerebral angiography
Alth ough angiography rem ain s th e gold stan dard for im ag-

Medication
An t im icrobial prophylaxis is in it iated.
An t iseizure prophylaxis is in it iated.

Operative Field Preparation


Gen eral pat ien t p osit ion ing
Secu re th e p at ien t to th e table, as u p to 60 degrees of re-

Indications
Trau m at ic injur y resu lt ing in sign i can t h em orrh age or

th rom bosis
Resect ion of an in lt rat ing n eoplasm
Th ree areas require repair to m ain tain paten cy 1,4
Posterior t w o-th irds of th e su p erior sagit t al sin u s
Torcu lar h eroph ili
Dom in an t t ran sverse sin u s
All oth er areas m ay be ligated w ith m in im al risk 1,4

Preprocedure Considerations

Radiographic Imaging
Com puted tom ography (CT)
Du ral ven ou s sin u s inju r y sh ou ld be su sp ected if im aging

sh ow s an ep id u ral h em atom a in th e region of a m ajor ven ou s sin us.5 In on e st u dy, 89% of ep id u ral h em atom as arising from a du ral ven ou s sin us h ad an associated fract ure
th at crossed th e sin us.1 Posterior fossa ep id u ral h em atom as involve th e du ral ven ou s sin u ses in 42.5% of cases.6
CT ven ography (CTV), w hich requires the adm inistration of
intravenous contrast and is taken during the venous phase,
can be diagnostic of sinus throm bosis. The em pt y delta sign
m ay be seen in the area of sinus th rom bosis.7 CTV is indicated
w hen there is a depressed skull fracture over a dural venous
sinus, w hich can cause sinus stenosis and throm bosis.8,9

ing th e du ral ven ous sin uses, it is invasive an d t im e con su m ing, w h ich ren ders it im pract ical in th e set t ing of acu te
t raum a.
Pre o pe rative im aging (Fig. 10.1).

verse Tren delen bu rg m ay be n eeded to m in im ize in t racran ial ven ou s p ressu re if bleeding is p rofu se.
Th e inju red du ral ven ou s sin u s segm en t sh ou ld be at th e
h igh est poin t of th e op erat ive eld.
Avoid excessive n eck rotat ion or exion .
A bilateral craniotom y exposure is indicated to address injury
to the superior sagittal sinus. A supra- and infratentorial ap proach is necessary to address injury to the transverse sinus.
Measu res to m axim ize cran ial ven ou s ou t ow
Avoid com pressive air w ay t ap e.
Min im ize jugu lar com p ression from a rigid cer vical collar.
Avoid excessive n eck rotat ion or exion .
In tern al jugu lar cen t ral ven ou s lin es are con t rain dicated
due to th e possibilit y of iat rogen ic th rom bosis an d im pairm en t of cran ial ven ou s ou t ow.
Blood loss
Large volu m e h em orrh age m ay occu r from th e inju red ven ou s sin u s. Sign i can t losses m ay also occu rboth preop erat ively an d in t raop erat ivelyfrom scalp , bon e, an d brain .
Packed red blood cells, platelet s, an d fresh frozen p lasm a
m u st be available in th e op erat ing room .
Ven ou s air em bolism
Ven ou s air em bolism m ay occu r w h en th e h ead is elevated
above th e h eart , resu lt ing in n egat ive p ressu re in th e du ral
ven ou s sin u sallow ing air to en ter an d becom e t rap ped in
th e righ t at rium .
A fall in th e en d t idal p CO2 an d hypoten sion m ay en sue.
St rong con siderat ion sh ould be given to th e use of cap n ography, a precordial Dop pler probe, an d an ar terial lin e. Air
em bolism p rodu ces w ash ing m ach in e sou n ds by Dop pler.
Rem oval of air from th e righ t at riu m is p ossible if a righ t
at rial cath eterplaced via th e brach ial or subclavian
rou teis in place.

153

I Cerebral Traum a and Stroke

Fig. 10.1 CT sagit tal reconstruction demonstrating extensive, supra- and infratentorial epidural hematoma suggestive of a transverse sinus injury.

Segm en tal sin u s rep lacem en t


If substantial sinus disruption is anticipated, vascular

If sten osis is likely to resu lt from p rim ar y su t u re repair, a

reconstruction equipm ent should be available, including a


properly sized temporary vascular shunt, Fogarty balloon catheters, nonabsorbable vascular suture, and a vein allograft.

Operative Management
Treat m en t is discu ssed sep arately for th e follow ing p ar ts of th e
ven ou s sin u s system : an terior on e-th ird of th e su p erior sagit t al
sin u s, p osterior t w o-th irds of th e su p erior sagit t al sin u s, torcular h eroph ili, an d d om in an t t ran sverse sin us.

General Considerations by Anatomic


Location

Su p erior sagit t al sin u san terior on e-th ird


Th e m ajorit y of inju ries in th is area can be m an aged w ith

154

tam pon ade tech n iques or direct sut ure repair if th e lacerat ion is sm all.
Lacerat ion s th at are too large to su t u re directly often can be
t reated w ith a sut ured, bolstered patch .
Lesion s th at can n ot be repaired can be t reated relat ively
safely w ith sin u s ligat ion via an en circling su t u re or
vascu lar clips.
Su p erior sagit t al sin u sp osterior t w o-th irds
Th is p or t ion of th e sin u s sh ou ld be rep aired or rep laced in
vir t u ally all cases, bu t especially w h en m ajor cor t ical ven ou s drain age is involved.
Avoid p rim ar y su t u re closu re th at com p rom ises greater
th an 50% of th e sin us lu m en , as th is m ay be m ore likely to
resu lt in com prom ised ow an d even t ual sin us occlusion .

patch sh ould be placed.


Rep lacem en t of segm en ts of th e su p erior sagit t al sin u s is
th e m ost ext rem e of in ter ven t ion s, reser ved on ly for th ose
cases involving eith er th e m ajorit y of th e dorsal w all or
both lateral w alls, in w h ich a sut ured patch can n ot recon st ru ct a lu m en at least 50% of th e origin al size.
Kapp et al develop ed an in tern al sh u n t for u se du ring sin u s recon st ru ct ion .3,4 Th is w as m ade of a p ed iat ric en dot rach eal t ube w ith a pediat ric t rach eostom y cu placed at
each en d. Sin dou an d Alvern ia avoided th e balloon sh u n t
an d Fogar t y balloon cath eter du e to risk of inju r y to th e
sin u s en doth eliu m , advocat ing, in stead, for direct packing
of th e lum en w ith h em ost at ic m aterial.2 Both em ph asize
th e n eed for sin us th rom bectom y of th e proxim al an d distal en ds of th e sin u s repair to en sure patency.
Torcular h eroph ili
Inju ries th at su bst an t ially disru pt th e torcu lar h erop h ili are
rarely sur vivable an d, in m ost cases, th e clin ical grade of
th e pat ien t is su ch th at expect an t m an agem en tw ith out
su rgical in ter ven t ion m ay be app ropriate.
Th e tech n iqu es for t am p on ade, prim ar y rep air, an d p atch ing described for inju ries to th e sup erior sagit tal sin u s also
ap p ly to th e torcu lar h erop h ili.1
Dom in an t t ran sverse sin u s
Th e tech n iqu es for t am p on ade, prim ar y rep air, an d p atch ing described for inju ries to th e sup erior sagit tal sin u s also
ap p ly to th e su p erior sagit t al sin u s.
Sin d ou et al d escr ibed a byp ass of t h e t ran sverse sin u s
to t h e exter n al jugu lar vein u sin g a sap h en ou s vein graft
in a p at ien t w it h bilateral t ran sverse sin u s t h rom bosis.10
Met icu lou s w ou n d closu re is n ecessar y to p reven t com p ression an d su bsequ en t t h rom bosis of t h e su bcu t an eou s
vein graft .

10

Managem ent of Venous Sinus Injuries

Operative Procedure
Surgical Approach to Injuries of the Anterior Third of the Superior
Sagittal Sinus
Positioning (Fig. 10.2)

Figure

Procedural Steps

Pearls

Fig. 10.2

The patient is positioned supine, w ith the head


elevated above the heart. The patient should be
secured to the table so as to allow an angle of
elevation up to 60 degrees, if necessary.

Anesthesia m onitoring for venous air em boli (VAE) should

include precordial Doppler, end-tidal pCO2 , and placem ent of a


right atrial catheter (to perm it VAE retrieval).
In severe cases, consider preparation for greater saphenous vein
harvest.

155

I Cerebral Traum a and Stroke

Incision (Fig. 10.3)

156

Figure

Procedural Steps

Pearls

Fig. 10.3

The orientation of the incision w ill be dictated by


the speci c location of the injury.

In general, an incision allowing exposure of both sides of the


superior sagit tal sinus or providing access to the supra- and
infratentorial compartmentsin the case of a transverse/sigm oid
injuryis advised.

10

Managem ent of Venous Sinus Injuries

Craniotomy (Fig. 10.4a, b)

Figure

Procedural Steps

Pearls

Fig. 10.4

The position of bur holes depends upon the anatomy of the speci c fracture.

Fracture fragm ents

(a) If a nondepressed, linear fracture w ith suspected dural sinus laceration is present,
consider leaving a bony shelf adjacent to the sinus in order to permit the use of
epidural tacking stitches that might tamponade the lacerated sinus.

should be elevated in
stages; defer rem oval of
any fragm ent directly
over the sinus until last.

(b) If fracture fragments appear depressed into the sinus, bur holes should be placed
at the outer rim of the depressed segmentallow ing access to normal structures at
the periphery.
If the sinus is transected, bilateral bony exposureboth proximal and distal to the
sinus injuryis necessary.

157

I Cerebral Traum a and Stroke

Tamponade (Fig. 10.5ac)

158

Figure

Procedural Steps

Pearls

Fig. 10.5

(a) Apply digital pressure, supplemented w ith sinus


patties (a combination of 1 3 3 in cotton patties,
hemostatic absorbable gelatin compressed sponge, and
strips of hemostatic oxidized cellulose polymer).
(b) Place epidural tack-up stitches w ith 4-0 braided nylon
suture w hen usable bone is adjacent to the injury.
(c) In some cases, the lateral convexity dura may be rolled
tow ard the midlineover top the injured sinus segment and
packingand secured to form a burrito.

Sinus pat ties should be prepared prior to exposure.


This com bination m ay be supplem ented with
strips of hemostatic oxidized cellulose polym er and
absorbable hemostatic m atrix paste or comparable
hem ostatic agents. Also, cot ton balls and m uscle m ay
be employed to bolster the tamponade.

10

Managem ent of Venous Sinus Injuries

Sinus Ligation (Fig. 10.6)

Figure

Procedural Steps

Pearls

Fig. 10.6

Injuries involving the anterior third of the superior sagittal sinus


(in front of the coronal suture) may be amenable to ligation.

Tamponade sinus bleeding during dissection

The sinusanchored by the falx and convexity dura rst must


be released.
Follow ing release of the sinus, ligation may be performed
by a double ligature technique, using 2-0 nonabsorbable
polypropylene suture or nylon. Make a double circular course
beneath the sinus, into the falx and then more super cially, to be
ligated and divided.

through the use of hemostatic agents and


cot ton pat ties, augm ented with head of bed
elevation (while m onitoring for VAEs).
Alternatively, ligation m ay be perform ed with
a surgical hem ostatic double clip at the inferior
insertion of the sinus into the falx, near the
crista galli. At tention m ust be paid to ensure
that the clips cross the sinus completely.

159

I Cerebral Traum a and Stroke

Sinus Patch (Fig. 10.7)

Figure

Procedural Steps

Pearls

Fig. 10.7

Lacerations that are too large to suture directly may be treated


w ith a sutured, bolstered patch.

This technique does not work well on the

Options for patch material include adjacent dura (curled over


the sinus), temporalis fascia, fascia lata, and synthetic dura or
vascular substitutes.

Avoid direct suturing of the patch to the

lateral sinus walls.

double layers of the sinus.

A layer of muscle or hemostatic absorbable gelatin sponge should


be interposed betw een the patch and underlying sinus laceration.
Secure the patchw ith a series of interrupted, peripherally placed
4-0 braided nylon or nonabsorbable polypropylene stitchesto
the adjacent dura.
Replace the overlying bone to bolster the sinus repair.

Take care to avoid occluding the sinus or m ajor


cortical veins in the area.

160

10

Managem ent of Venous Sinus Injuries

Sinus Interposition Graft (Fig. 10.8a, b)

Figure

Procedural Steps

Pearls

Fig. 10.8

Interposition grafting may be appropriate in cases of complete


sinus disruption (posterior to the coronal suture), in patients
deemed to be salvageable.

Typical synthetic vascular graft m aterial is prone

The greater saphenous vein must be harvested in advance


from the upper portion of the thigh. The graft should be
reversed to prevent the valves from obstructing ow.
(a) A temporary shunt should be placed, w ith heparin uid
irrigation of the shunt tubing as w ell as the proximal and
distal ends of the sinus. (b) The vein graft is placed around the
shunt and incorporated w ith multiple, interrupted, end-to -end
6-0 nonabsorbable polypropylene stitches, leaving a small
dorsal region to remove the shunt and tie the nal stitches.

to throm bosis in this location and should be


avoided, if possible. Likewise, arterial grafts m ay
progressively occlude from extensive arterial wall
throm bosis. Cadaveric vein may be an option in
rare cases.
Historically, the vascular shunt featured a double
balloon conf guration that allowed venous
ow without bleeding around the shunt. More
recently, other authors have described the use of
a Rum ell vessel loop around the shunt proximally
and distally to avoid endothelial sinus injury and
delayed throm bosis.

161

I Cerebral Traum a and Stroke

Variation for Injuries of the Posterior Tw o -thirds of the Superior


Sagittal Sinus, Torcular Herophili, and Dominant Transverse Sinus
Positioning (Fig. 10.9)

Figure

Procedural Steps

Pearls

Fig. 10.9

The approach to these sinus segments is best accomplished w ith


the patient in prone position.

Refer to Fig. 10.2 for details regarding

Injuries involving the middle third of the sinus may be


approached in the supine position. Alternately, the patient may
be in lateral position, w ith the falx cerebri parallel to horizontal
and the head tilted up 45 degrees.

162

anesthetic adjuncts in this set ting.

10

Managem ent of Venous Sinus Injuries

Incision (Fig. 10.10)

Figure

Procedural Steps

Fig. 10.10

An inverted U-shaped incision permits access to the supratentorial and infratentorial compartments.
A transverse, linear incision providing access to the bilateral hemispheres may be used to approach injuries to the
middle third segment of the sagittal sinus.

163

I Cerebral Traum a and Stroke

Craniotomy (Fig. 10.11)

164

Figure

Procedural Steps

Pearls

Fig. 10.11

The position of bur holes depends on the anatomy of


the speci c fracture.

The bony opening should perm it access to both sides of


the sinus in question.

10

Managem ent of Venous Sinus Injuries

Direct Repair (Fig. 10.12)

Figure

Procedural Steps

Pearls

Fig. 10.12

The use of adjuncts discussed in Fig. 10.5


for tamponade may be e ective, but
must be tempered by the risk of sinus
and/or cortical vein occlusion.

Tamponade is particularly poorly tolerated in the region of the central

Primary suture repair of lacerations may


be attempted w ith 6-0 nonabsorbable
polypropylene suture.

Injury involving a single lateral wall at the junction of a venous lake,

sulcus when the vein of Trolard is involved.

which does not respond to tamponade, m ay be isolated and treated with


suturing parallel to the sagit tal plane along the sinus edge.
Avoid prim ary suture closure that com prom ises . 50% of the sinus
lum en.
If stenosis is likely to result from prim ary suture repair, a patch should be
considered.

165

I Cerebral Traum a and Stroke

Sinus Patch (Fig. 10.13)

Figure

Procedural Steps

Pearls

Fig. 10.13

Lacerations that are too large to suture directly may be treated w ith a
sutured, bolstered patch.

Refer to Fig. 10.7 for details regarding

Interposition grafting is a daunting proposition in this area.


The vein graft must be oriented such that the valves allow ow
from the anterior to posterior portions of the sinus in a nonlimiting
fashion.

166

patching of the venous sinus.


Replacement of a superior sagit tal sinus
segm ent is reserved only for cases that
involve both lateral walls or the m ajorit y
of the dorsal wall, where a sutured patch
cannot reconstruct a lum en at least 50% of
the original size.
Refer to Fig. 10.8 for details regarding
interposition grafting.

10

Closing
Du ral closu re is perform ed w ith 4-0 braid ed nylon su t u re.
Th e bon e ap is reapproxim atedif feasiblew ith an in t ra

cran ial plat ing system .


Th e surgical site is irrigated w ith an t ibiot ic solu t ion .
Met icu lou s h em ost asis is at t ain ed along th e skin edges.
A subgaleal drain m ay be left in place if n ecessar y.
Th e galea an d su bcut an eou s t issue are reapproxim ated w ith
2-0 braided absorbable sut ure inver ted st itch es.
Th e skin is closed eith er w ith st aples or 3-0 nylon sut ure.

Managem ent of Venous Sinus Injuries

Medication
An t im icrobial prophylaxis is con t in u ed for 24 h ours.
An t iepilept ic prophylaxis is con t in ued for 7 days.

Radiographic Imaging
A CT scan is perform ed early in th e postoperat ive period to

ru le ou t h em orrh age an d/or isch em ia. Im aging is repeated for


any sign i can t ch ange in n eu rologic stat u s.
Dedicated vascu lar im aging (CTV, m agn et ic reson an ce ven ograp hy, or angiography) m ay be app ropriate if th rom bosis is
su sp ected.
Po sto perative im aging (Fig. 10.14).

Postoperative Management

Monitoring

Special Considerations

Th e pat ien t is m on itored in th e in ten sive care un it set t ing to

p erm it frequ en t n eurologic ch ecks an d con t in uous h em odyn am ic m on itoring.


Invasive blood p ressu re m on itoring an d a cen t ral ven ou s
cath eter are em ployed to provide con t in uous m on itoring of
blood pressure an d volum e st at us. Blood pressure is m ain t ain ed in a n orm al range. Th e goal of in t raven ou s uid th erapy is euvolem ia.
Th e h ead of th e bed is m ain t ain ed at 30 degrees.
Invasive neurologic m onitors are placed if indicated by the patients overall neurologic status (Glasgow Com a Scale score 8).

Late Complications
Post-repair ven ous sin us sten osis or sin us com pression (e.g.,
from a dep ressed sku ll fract u re) in creases th e risk of delayed
sin u s th rom bosis. Ven ou s sin u s th rom bosis m ay lead to p rogressive bilateral en ceph alopathy, in creased in t racran ial
p ressure, cerebral edem a, in t raparen chym al h em orrh age, an d
ven ou s in farct ion . Deep ven ou s h em orrh age an d in farct ion
involving th e th alam us can occur w ith injur y to th e st raigh t
sin u s at th e level of th e ten toriu m .

Fig. 10.14 Sagit tal CT reconstruction demonstrating resolution of extra-axial hematoma following repair of a
transverse sinus injury.

167

I Cerebral Traum a and Stroke


Th e in dicat ion s for delayed cran iotom y or decom pressive cran iectom y in clu de:
Elevated in t racran ial p ressu re n ot resp on sive to m axim al
m edical th erapy
Severe cerebral edem a or th e p resen ce of an in t racran ial
h em atom a w ith im pen ding brain h ern iat ion
Elevat ion of a dep ressed sku ll fract u re or rem oval of a foreign body w h en d u ral sin u s paten cy is com prom ised

References
1. Pricola KL, Zou H, Chang SD. Successful repair of a gunshot wound
to the head w ith retained bullet in the torcular herophili. World
Neurosurg 2011;76(34):e361364
2. Sin dou MP, Alvern ia JE. Resu lt s of at tem pted radical t u m or
rem oval an d ven ous repair in 100 con secut ive m en ingiom as
involving th e m ajor dural sin uses. J Neurosurg 2006;105(4):
514525
3. Kap p JP, Gielch in sky I. Man agem en t of com bat w ou n ds of th e
du ral ven ou s sin u ses. Su rger y 1972;71(6):913917

168

4. Kap p JP, Sch m idek HH. Su rger y of th e cerebral ven ou s system . In :


Kapp JP, Sch m idek HH, eds. Th e Cerebral Venous System an d It s
Disorders. Orlan do: Gr u n e & St rat ton , In c.; 1984:597623
5. Ch ee CP, Habib ZA. Hyp oden se bu bbles in acu te ext radu ral h aem atom as follow ing ven ous sin us tear. A CT scan appearan ce.
Neuroradiology 1991;33(2):152154
6. Bor-Seng-Sh u E, Agu iar PH, de Alm eida Lem e RJ, Man del M,
An drade AF, Marin o R, Jr. Epidural h em atom as of th e posterior
cran ial fossa. Neurosurg Focus 2004;16(2):ECP1
7. Rao KC, Kn ip p HC, Wagn er EJ. Com pu ted tom ograph ic n dings in cerebral sin us an d ven ous throm bosis. Radiology 1981;
140(2):391398
8. Forbes JA, Reig AS, Tom ycz LD, Tulipan N. Intracran ial hypertension
caused by a depressed skull fracture resulting in superior sagit tal
sin us throm bosis in a pediatric patient: treatm ent w ith ven triculoperitoneal shunt insertion. J Neurosurg Pediatr 2010;6(1):2328
9. Yokot a H, Egu ch i T, Nobayash i M, Nish ioka T, Nish im u ra F, Nikaido
Y. Persisten t in t racran ial hyperten sion caused by superior sagitt al sin us sten osis follow ing depressed skull fract u re. Case repor t
an d review of th e literat u re. J Neu rosu rg 2006;104(5):849852
10. Sin dou M, Mercier P, Bokor J, Bru n on J. Bilateral th rom bosis of
th e t ran sverse sin u ses: m icrosu rgical revascu larizat ion w ith
ven ou s byp ass. Su rg Neu rol 1980;13(3):215220

II

Spinal Emergency Procedures

11

Application of Closed Spinal Traction


Nirit W eiss

Introduction

Preprocedure Considerations

Em ergen cy closed spin al t ract ion m ay be perform ed for


p at ien ts w h o p resen t w ith cer vical spin al m isalign m en t an d/
or in st abilit y secon dar y to t raum a. Use of ligh ter w eigh t
(510 lb) can m ain t ain align m en t an d im m obilize an un st able
sp in e, if closed t ract ion redu ct ion is n ot d eem ed app rop riate
at th e t im e. Reduct ion of fract ure dislocat ion an d realign m en t
w ith in creased w eigh t (1080 lb) can decom press th e spin al
cord an d n er ve root s. After su ccessful applicat ion of t ract ion ,
bracing or su rger y m ay be deem ed appropriate. If t ract ion
is un su ccessfu l, su rger y likely follow s. Man ipulat ion u n der
an esth esia (MUA) m ay be h elp ful in pat ien ts w h o fail aw ake
in lin e t ract ion redu ct ion .1 Weigh ted in lin e h alo ring t ract ion can
be converted to long-term h alo-vest im m obilizat ion if n eeded.
Most com m on ly u sed t ract ion opt ion s are Gard n er-Wells (G-W)
tongs an d Halo rings.

Radiographic Imaging
X-ray an d/or com p u ted tom ograp hy (CT) eviden ce of fract u re,

Indications
Cer vical spin al m isalign m en t due to t raum at ic fract ure/

170

dislocat ion
Sp in al cord/n er ve root com p ression du e to m isalign m en t
Cer vical spin al in st abilit y du e to t rau m at ic fract u re or ligam en tou s in stabilit y requ iring im m obilizat ion th at can n ot be
adequ ately ach ieved w ith extern al orth oses alon e
Aw ake, coop erat ive p at ien t
Availabilit y of radiographic/clinical m onitoring during reduction
Absen ce of skull fract ure or prior bur hole at proposed pin sites
Absen ce of occipitoatlan tal or atlan toaxial dissociat ion or
com plete ligam en tous injur y at any level
Absen ce of fract ure/in st abilit y at level rost ral to in ten ded
level of t reat m en t
Absen ce of kn ow n sign i can t associate t raum at ic cer vical
disk h ern iat ion , w h ich can w orsen n eurologic de cit un der
t ract ion

su blu xat ion , m isalign m en t , in stabilit y (Fig. 11.1).


Role of p ret ract ion m agn et ic reson an ce im aging (MRI) rem ain s con t roversial2 : On e-th ird to on e-h alf of pat ien t s w ith
facet su blu xat ion h ave eviden ce of disk h ern iat ion or disru p t ion on MRI. In lin e t ract ion in th e presen ce of ven t ral cord
com pression m ay lead to n eurologic injur y. How ever, less
th an 1% of pat ien t s have been foun d in st u dies to h ave perm an en t n eu rologic deteriorat ion resu lt ing from app licat ion
of cer vical t ract ion despite th e presen ce of h ern iated ven t ral
disks. Depen ding on th e t im e n eeded to obtain th e MRI, th e
ben e t s of early reduct ion sh ould be w eigh ed again st th e risk
of reduct ion in th e face of poten t ial un iden t i ed ven t ral com pression from disk h ern iat ion . In aw ake, cooperat ive p at ien ts,
physical exam can be m onitored w h ile in creasing t ract ion
w eigh t , an d p ret raction MRI m ay h ave low er u t ilit y. In u n conscious pat ien t s, sign i can t e ort s to obt ain pret ract ion
MRI sh ou ld be m ad e. Pat ien t s w ith in com p lete inju ries h ave
greatest risk of n eu rologic d eteriorat ion .

Medication
System ic: Non sedat ing pain m edicat ion (m orph in e, fen t anyl)

an d m u scle rela xan t (diazep am ) in t raven ou sly (IV) as n eeded


to allow for pat ien t cooperat ion an d successful reduct ion .
Local: 1% lidocain e or 1% lidocain e/0.5% bu p ivacain e (1:1
m ixt u re) ap p lied to scalp an d pericran iu m of p lan n ed p in
site locat ion s.

Operative Field Preparation


Alcoh ol prep follow ed by povidone/iodine to plann ed pin sites.
An t ibacterial (bacit racin ) oin t m en t to pin s prior to placem en t .

11

Application of Closed Spinal Traction

b
Fig. 11.1 Lateral radiograph in patient with high-grade spondylolithesis at C4-5
due to bilateral facet dislocation after traction tongs placement and prior to weight
application.

171

II Spinal Em ergency Procedures

Operative Procedure
Positioning (Fig. 11.2)

172

Figure

Procedural Steps

Pearls

Fig. 11.2

Patient is positioned for


application of traction,
typically supine, head in
neutral position.

It is easier to place an open halo ring than a closed ring while supine. Check lateral
X-ray in position prior to proceeding. If one needs to reduce kyphosis, a shoulder roll can
be placed. If the plan is to eventually place in halo vest, one can preplace the back of
the halo vest for the patient to lie on.3

11

Application of Closed Spinal Traction

Selection of Pin Sites (Fig. 11.3a, b)

Figure

Procedural Steps

Pearls

Fig. 11.3

(a) Gardner-Wells tongs. Tw o pin sites are required.


(A, green) The ideal pin site placement is along the
superior temporal line, above the temporalis muscle belly
(mark as transparency below skin), approximately 3 to
4 cm above pinna. For neutral traction, pin directly in
line above external auditory meatus (EAM). To induce a
exion correction (e.g., of jumped facets), (B, red) place
3 cm posterior to EAM; to induce an extension (e.g., for
subluxation), (C, blue) place 3 cm anterior to EAM, along
the superior temporal line. After preparation w ith alcohol
and povidone iodine, local anesthetic is injected. (b) Halo
ring. Select four pin sites, each marked w ith a pen: tw o
anterior, tw o posterior. The tw o anterior sites should
be 1 cm above orbital rim, above lateral half of the orbit
(to avoid the supraorbital and supratrochlear nerves and
the frontal sinus). Posterior pins should be in region of
mastoid. After preparation w ith alcohol and povidone
iodine, local anesthetic is injected.

Halo rings are available in MRI compatible m odels which

can facilitate later im aging. Weights are t ypically not


MRI-compatible and m ust be removed for MRI im aging.
Ensure there are no skull fractures or bur holes in
region of proposed pin sites. Do not place pins into thin
squam ous temporal bone.
Select pin sites while assistant holds the halo ring in place,
or use suction cup stabilizing posts to hold ring while
selecting appropriate sites. Pin sites should be selected to
allow for the ring to sit symmetrically around the head.
Pin sites should be selected to allow for a 1- to 2-cm
space circum ferentially bet ween the scalp and the halo
ring. Pins should be placed in holes that allow for m ost
perpendicular entry into skull.4
Prep with alcohol followed by povidone iodine. Inject
lidocaine or lidocaine/bupivacaine mixture as above into
proposed pin sites, into scalp and pericranium. May incise
scalp prior to pinning to avoid contamination with skin ora.

173

II Spinal Em ergency Procedures

Placement of Pins (Fig. 11.4a, b)

Figure

Procedural Steps

Pearls

Fig. 11.4

(a) Gardner-Wells tongs. Place pins through the tongs into


scalp and pericranium. Tighten both pins simultaneously,
until torque indicator on one pin protrudes approximately
1 to 2 mm, indicating adequately tightened screws.

Pay at tention to eyes and eyebrows to avoid pinning

(b) Halo ring. Tighten two diametrically opposed screws


simultaneously until nger tight. Then tighten the other
two screw s simultaneously until nger tight. At this point,
use torque w rench to adequately and safely secure pin
tightness to preset maximal torque (8 in-lb for adults).

174

eyes open or closed.


For children: Use lower nal torque for tightening
(48 in-lb for children age 310, 24 in-lb for children
under age 3).5 Use multiple (610) pins in order to
distribute pressure evenly circum ferentially and avoid
fracture or excessive skull penetration. Also, use
specially supplied pediatric pins with short tips and wide
ange, if available.6

11

Application of Closed Spinal Traction

Placement of Traction Weights and Counter-Traction (Fig. 11.5)

Figure

Procedural Steps

Pearls

Fig. 11.5

Secure a knotted rope to


tongs or halo ring, through
a pulley at head of bed, and
hang weights from there.

If stabilizing an unstable fracture bet ween occiput and C2, begin with 5 lb, and advance to

Secure ankles, wrists, and


shoulders w ith padded
roped restraints to foot of
bed to prevent patient from
sliding up on bed w hen
placed in traction.

10 lb if radiographs show no change.


Below C2, begin with 10 lb to overcome weight of head through C2, and then 5 lb per level
below C2 (e.g., 20 lb for C4 fracture).
Cervical traction is best perform ed under uoroscopy, or obtain serial X-rays im m ediately
after weight change, and in 30-m in intervals to gauge progress. Follow the neurologic
exam every 10 m inutes. One m ay add weights in 5-lb intervals and recheck radiograph.
Stop when observe: (1) successful spinal realignm ent radiographically, (2) neurologic
deterioration, (3) undesired radiographic changes (worsening m isalignm ent, distraction
at more rostral disk level with widened disk space or splayed spinous processes or facet
joints), and/or (d) patient complains of severe discom fort.

175

II Spinal Em ergency Procedures

Placement of Vest (Fig. 11.6)

Figure

Procedural Steps

Pearls

Fig. 11.6

Select correct vest size for the patient. Connect posterior


ring to posterior vest w ith upright post.

Important note: Every brand and st yle of halo vest and

Connect anterior ring to anterior vest w ith upright


posts. Connect anterior/posterior halves of vest to each
other. Once in place, secure the ring to the posts at each
point w ith torque w rench, maintaining head in correct
alignment. Check post-placement X-rays immediately
after placement and w hen upright day 1 and day 3.

176

head ring com es with a detailed set of instructions


for application. It is recom m ended to review these
instructions carefully prior to applying the apparatus
Incorrect sizing of vest can lead to loss of alignm ent.
If posterior vest has not be preplaced, patient can be
logrolled, or elevated 30 degrees while head held in gentle
manual traction.
Tape wrench to anterior vest for easy access in em ergency.
Watch for pressure ulcers at sites of excess pressure on
shoulders, back, and chest.

11

Application of Closed Spinal Traction

Postoperative Imaging (Fig. 11.7)

Figure

Procedural Steps

Fig. 11.7

Lateral radiograph of cervical spine after tongs traction in patient depicted in Fig. 11.1. Spinal alignment at C4-5 has
improved after serial w eights w ere applied, but the patient required open reduction and xation.
It is important to obtain imaging after halo or traction placement to verify alignment of the injured segment.

177

II Spinal Em ergency Procedures

Postoperative Management
Monitoring
Mon itor n eu rologic st at u s an d vital sign s ever y 2 h ou rs.
Mon itor for skin breakdow n /decu bit is u lcers.

Medication
Pain m an agem en t an d m u scle relaxat ion can be adm in istered.

correct ion w ith th e goal of reducing th e spin e to th e prefract ure


sagit tal cu r vat u re. Over-dist ract ion or correct ion w ith h eavier
w eigh t s qu ickly lead s to u n con t rolled re- or m isalign m en t an d
n eu rologic inju r y.
For t ract ion in pat ien ts w ith locked facet s, apply gen tle
exion force for bilateral locked facet s, or exion plu s gen tle
rot at ion tow ard side of locked facet for u n ilateral locked facet s.
In crem en t al in creases in w eigh t can be ap p lied u n t il locked
facets becom e p erch ed. On ce p erch ed, slow ly redu cing w eigh t s
to 5 to 10 lb w h ile gen tly exten ding (by sliding in a sh oulder
roll) redu ces th e dislocat ion . On ce redu ced, m ain t ain 5 to 10 lb
w eigh t s for st abilizat ion u n t il de n it ive t reat m en t (i.e., su rger y)
is accom plish ed.

Radiographic Imaging
Obt ain lateral X-ray w ith any w eigh t ch ange, w ith any bed
t ran sfer, an d on ce daily as rout in e.

Pin Site Management


Gardner-Wells pins are checked at 24 and 48 hours to ensure

that the spring-loaded force indicator is protruding. Halo pins


are re-torqued to 8 in-lb once at 24 hours, and again at 48 hours.
Additional tightening beyond this point can lead to skull
penetration, skull fracture, pin loosening, and/or infection.
Maintain t w ice-daily pin site cleaning w ith hydrogen peroxide
or povidon e iodine oin tm ent.

Further Management
After su ccessfu l realign m en t , decide to brace, p lace in h alo

vest (see Fig. 11.6), or operate.


After failed realign m en t , a decision to op erate is u su ally
m ade.

Special Considerations
Pediat ric pat ien t s h ave special con cern s regarding n u m ber of
pin s an d pin torque pressures (see above). In pat ien t s w ith an kylosing spon dylit is,7,8 ligh t cer vical t ract ion (, 5 or 10 lb) is ad vised. Prolonged t ract ion w ith ligh t w eigh ts m ay lead to desired

178

References
1. Lu K, Lee T, Ch en H. Closed redu ct ion of bilateral locked facet s
of th e cer vical spin e un der gen eral an esth esia. Act a Neuroch ir
(Wein ) 1998;40:10551061
2. Sect ion on Disord ers of th e Sp in e an d Perip h eral Ner ves of
th e Am erican Associat ion of Neu rological Su rgeon s an d Th e
Congress of Neu rological Su rgeon s: In it ial closed redu ct ion
of cer vical spin e fract u re-dislocat ion injuries. Neurosurger y
2002;50(suppl 3):s4450
3. Goldstein R, Deen HG, Zim m erm an RS, Lyon s MK. Preplacem en t
of th e back of th e h alo vest in pat ien t s un dergoing cer vical
t ract ion for cer vical spin e injuries: a tech n ical n ote. Surg Neurol
1995;44:476478
4. Cop ley LA, Pep e MD, Tan V, Sh eth N, Dorm an s JP. A com p arison of
variou s angles of h alo p in in ser t ion in an im m at u re sku ll m od el.
Spin e 1999;24:17771780
5. Arkader A, Hosalkar HS, Dru m m on d DS, Dorm an s JP. An alysis of
h alo-or th osis applicat ion in children less th an th ree years old.
J Ch ild Or th op 2007;1:337344
6. Cop ley LA, Pep e MD, Tan V, Dorm an s JP, Gabriel JP, Sh eth NP,
Asada N. A com p arat ive evalu at ion of h alo p in d esign s in an
im m at ure skull m odel. Clin Orth op 1998;357:212218
7. Kan ter AS, Wang MY, Mu m m an en i PV. A t reat m en t algorith m
for th e m anagem en t of cer vical spin e fract ures an d deform it y
in pat ien t s w ith ankylosing spon dylit is. Neurosurg Focus
2008;24(1):E1117
8. Th u m bikat P, Harih aran RP, Ravich an d ran G, McClellan d MR,
Math ew KM. Sp in al cord inju r y in pat ien t s w ith an kylosis
spon dylit is: a 10-year review. Spin e 2007;32(26):29892995

12

Emergency Management of
Odontoid Fractures
Sanjay Yadla, Benjam in M. Zussm an, and Jam es S. Harrop

Introduction

Indications

Th e od on t oid p rocess, or d e n s, is t h e b ony con ical p roje ct ion


of t h e a xis (C2), arou n d w h ich t h e r in g-sh a p e d at las (C1 )
e n a bles rot at ion al m ove m e n t of t h e h ea d . Fract u res of t h e
od on toid p rocess con st it u t e ap p roxim at ely 15 % of all ce r vical fra ct u res. Th ey a re p r im a r ily cau se d by h igh -velocit y
t ra u m a in t h e you n g a n d by falls in t h e eld e rly. Od on t oid
fract u res m ay ca u se at lan t oa xia l in st a b ilit y, p la cin g t h e sp in a l cord at r isk for com p ressive inju r y. Fract u res m ay resu lt
in p rogressive n e u rologic d a m age or fat alit y. Th e goal of
t reat m e n t is t o st ab ilize or im m ob ilize t h e at la n toa xial join t
an d a ch ieve solid fu sion of t h e fra ct u re d d e n s.1 Pat ie n t s w it h
a cu t e od on toid fract u re rarely p rese n t w it h seve re n e u ro logic in ju r y b u t com m on ly com p lain of a xial n e ck p ain
su bse qu e n t to t rau m a .
Alt h ough evid en ce-based m an agem en t recom m en dat ion s
for od on toid fract u res are lackin g, p at ien t ou tcom es for t h e
m ost com m on con ser vat ive an d su rgical t reat m en t s h ave
been rep or ted .1 Th is ch apter d iscu sses t h e em ergen cy m an agem en t of od on toid fract u res w it h a sp eci c focu s on t h e
m ost com m on ly p er for m ed t reat m en t s, in clu d in g: (1) an ter ior fu sion tech n iqu es (od on toid screw ) an d (2) p oster ior fu sion tech n iqu es (C1- C2 t ran sar t icu lar screw s; C1 lateral m ass/
C2 p ars/C2 p ed icle screw s). Con t rain d icat ion s for od on toid
screw p lacem en t in clu d e od on toid fract u res w it h an an ter iorly an gled t ip fragm en t , osteop orosis, t ran sverse ligam en t d isr u pt ion , or accom p anyin g at lan toa xial fract u res. Body bu ild
or in abilit y to red u ce t h e fract u re can be p roh ibit ive w it h t h is
tech n iqu e. In t h ese cases, p oster ior at lan toa xial fu sion m ay
be w ar ran ted .

Disru pt ion of th e t ran sverse ligam en t cau sing atlan toa xial

in st abilit y.
Type II odon toid fract ures w ith eviden ce of in st abilit y
(i.e., greater th an 6 m m of displacem en t).
Movem en t at th e fract u re site in h alo vest dem on st rated on
su p in e an d u prigh t X-rays.

Preprocedure Considerations
Radiographic Imaging
Radiological st u diesin it ial lm s sh ou ld in clu de an terop os

terior, lateral, an d open -m outh odon toid view s.


Com pu ted tom ography (CT) scan s w ith reform at ted im ages
m ay be u sed to d eterm in e th e t ype of odon toid fract u re an d
m ay p rovide m ore det ail of bony an atom y th an plain lm s.
Carefu l preoperat ive review of CT im ages w ith iden t i cat ion
of fract ure sites, bony an atom y, an d vertebral ar ter y course
is n ecessar y to determ in e w h eth er in st rum en tat ion can be
placed safely.
Th e An derson an d DAlon zo classi cat ion system , w h ich
classi es fract ure t ypes I, II, an d III, is com m on ly applied
(Figs. 12.1 an d 12.2; Table 12.1).2

Medication
Periop erat ive an t ibiot ics are in it iated an d m ain t ain ed for
24 h ours after in cision .

179

II Spinal Em ergency Procedures

Fig. 12.1 Commonly applied classi cation of odontoid fractures.

Table 12.1 Documented treatment options for odontoid fractures


Type of odontoid fracture

Management

Reported fusion rates

Type 1

Conservative

External im m obilization

100%

Type II

Conservative

External im m obilization

55-65%

Surgical

Anterior approach, odontoid screw

Type III

90%

Posterior approach, atlantoaxial fusion


or trans-articular screws

74-87%

Conservative

External im m obilization

50-84%

Surgical

Posterior approach, atlantoaxial fusion

100%

b
Fig. 12.2a, b (a) Sagit tal and (b) coronal preoperative CT images demonstrating a t ype II odontoid fracture.

180

12

Em ergency Managem ent of Odontoid Fractures

Operative Procedure
Odontoid Screw
Positioning (Fig. 12.3)

Figure

Procedural Steps

Pearls

Fig. 12.3

The patient is positioned


supine on the operating table w ith the head extended
in traction. The patient is
intubated. Biplanar uoroscopy is used to monitor the
head and dens during the
procedure.

The anteroposterior (AP) view is obtained transorally using a C-arm uoroscope, and
a radiolucent prop m ay be used to open the m outh to improve AP visualization. The
lateral view is obtained by a second C-arm uoroscope, oriented horizontally. Using
uoroscopy as a guide, the head and neck are positioned to align the fracture edges.
Finally, because blockage of screw insertion due to body obstruction (e.g., barrel chest)
or body positioning (e.g., xed cervical kyphosis) m ay lim it this procedure, a Kirschner
wire (K-wire) m ay be used to estim ate screw/instrum ent trajectory and ensure that the
patients body will perm it clearance during screw placem ent prior to incision.

181

II Spinal Em ergency Procedures

Cervical Dissection and Entry Site Preparation (Fig. 12.4ae)

182

12

Em ergency Managem ent of Odontoid Fractures

Figure

Procedural Steps

Pearls

Fig. 12.4

(a) A transverse incision is made at approximately


the C4-C5 level similar to an anterior cervical
diskectomy. The platysma is incised. (b) Incision of
the cervical fascia and plane is developed to the spine.
(c) Dissection of the longus colli muscles. (d) Placement
of radiolucent retractors. (e) The C3 body is notched
and the C2-C3 ventral annulus brosis is incised.

The spine is approached anteriorly at the C4-C5 level using


ne dissection bet ween the m idline structures and carotid
sheath and then blunt dissection from the longus colli m uscles
to the vertebral bodies.3 Radiolucent retractors are used to
perm it intraoperative uoroscopy. To prepare the screw entry
site, the C3 vertebral body is notched anterosuperiorly, and
the C2-C3 ventral annulus brosis is incised.

183

II Spinal Em ergency Procedures

Screw Trajectory and Placement (Fig. 12.5a, b)

184

Figure

Procedural Steps

Pearls

Fig. 12.5

(a) A K-w ire is advanced through the


C2 body to establish the trajectory.
(b) A single lag screw is rostrally directed
through the entry site, the C2 vertebral
body, and the tip of the odontoid process.
This compresses the tw o bony segments
together, achieving rigid internal
stabilization at the fracture site.

To establish the trajectory for screw placem ent, a drill or K-wire is


advanced up through the C2 body into the m idpoint of the odontoid
fragm ent. Con rm atory visualization of this pilot trajectory is achieved
with uoroscopy. The drill is removed and a lag screw is advanced
through the guide hole through the C2 body and through the bony
cortex of the odontoid tip. Because the lag screw head is restrained by
the C2 body, screw tightening pulls the odontoid fragment inferiorly,
internally reducing the fracture.3,4

12

Em ergency Managem ent of Odontoid Fractures

Completed Construct (Fig. 12.6a, b)

Figure

Procedural Steps

Fig. 12.6

(a) AP and (b) lateral X-ray images of nal odontoid screw construct.

185

II Spinal Em ergency Procedures

C1-C2 Transarticular Screw (Magerl Technique)


Positioning (Fig. 12.7a, b)

186

Figure

Procedural Steps

Pearls

Fig. 12.7

(a) The patient is positioned prone under general


anesthesia w ith the neck
exed in the three -pinion
head holder. (b) The screw
trajectory is established
w ith w ire and uoroscopy
prior to prepping.

The operating table and room should be arranged to accom m odate lateral uoroscopy
with a com fortable viewing angle for the operating surgeon. A three-pinion head holder
is used to secure the head in the m ilitary tuck position, which will allow access to the
atlantoaxial joint at the appropriate angle with surgical instruments. Lateral uoroscopy
can be used to con rm that no displacem ent has occurred and that the neck rem ains
neutral after positioning. Screw entry sites and trajectories can be estim ated using
uoroscopy at this point. In older patients with a pronounced thoracic kyphosis, an
adequate trajectory may not be at tainable.

12

Em ergency Managem ent of Odontoid Fractures

Surgical Site Preparation (Fig. 12.8)

Figure

Procedural Steps

Pearls

Fig. 12.8

The area is prepped and draped in a sterile fashion to include


the cervical and midthoracic spine. Three separate incisions are
made : (A) midline from occiput to C4; (B, C) tw o stab incisions
are made at the C7-T1 level for screw -inserting instruments.

Three separate incisions are required: a m idline


incision from the occiput to C4 to expose the C1-C2
levels and t wo stab incisions at approxim ately the
C7-T1 level for instrum ent access.

187

II Spinal Em ergency Procedures

Tissue Dissection and Exposure (Fig. 12.9a, b)

188

Figure

Procedural Steps

Pearls

Fig. 12.9

(a) Tissue dissection is carried dow n through the midline along the
relatively avascular midline raphe betw een the paraspinal muscles. The
dissection is taken dow n to the spinous processes and articulating pro cesses of C1 and C2. (b) Brisk venous bleeding may be encountered upon
exposure of the C1 facet. This should be anticipated and can be controlled
w ith a thrombin-soaked gelatin sponge. The exiting C2 nerve root is
encountered betw een the posterior arch of C1 and lamina of C2. It can be
protected by dow nw ard retraction using a Pen eld no. 4.

A localizing X-ray or uoroscopy can


be used to con rm localization. The C2
spinous process is often bi d and m ore
prom inent than the C1 or C3 spinous
processes. The C1 and C2 lam inae are
exposed by subperiosteal dissection
with care taken to avoid disruption of
the C2-C3 joint.

12

Em ergency Managem ent of Odontoid Fractures

Screw Trajectory and Placement (Fig. 12.10a, b)

Figure

Procedural Steps

Pearls

Fig. 12.10

(a) The screw entry point is typically 3 mm lateral and 3 mm


superior to the inferomedial corner of the inferior articulating facet
of C2. A K-w ire is used to establish the trajectory follow ed by a
cannulated screw, w hich is inserted over the K-w ire. (b) The ideal
trajectory (approximately 40 degrees superior to the entry site)
ends at a point that overlies the shadow of the anterior C1 tubercle
on lateral uoroscopy. A cannulated bit is passed over the K-w ire to
create a pilot hole, w hich is tapped, and a 3.5- or 4-mm cannulated
cortical screw is then advanced to the ideal target. 5

A K-wire is advanced through the stab


incision and ideal screw entry point, down the
pars of C2, and across the C1-C2 joint under
uoroscopic guidance. The K-wire is advanced
to a point 4 m m shallow to the ideal target.
The operating surgeon must be aware of the
position of the K-wire at all tim es during its
use to avoid inadvertent advancem ent into
vital structures.

189

II Spinal Em ergency Procedures

Completed Construct (Fig. 12.11)

190

Figure

Procedural Steps

Fig. 12.11

(a) AP and (b) lateral radiographs of C1-C2 transarticular screw placement.

12

Em ergency Managem ent of Odontoid Fractures

C1-C2 Lateral Mass Fusion w ith Polyaxial Screw s and Rods


Positioning and Surgical Site Preparation (Fig. 12.12)

Figure

Procedural Steps

Pearls

Fig. 12.12

The patient is positioned prone under general anesthesia under cervical traction w ith skull tongs. The incision is marked from occiput to C4.
After prepping, a midline incision is made. Soft tissue dissection is conducted w ith monopolar cautery along the midline. A relatively avascular
plane can be found in the midline raphe betw een the paraspinal muscles
(see Fig. 12.9a).

Intraoperative X-ray or uoroscopy


is used to check alignm ent after
positioning. A three-pinion head
holder could also be used in lieu of
traction.

191

II Spinal Em ergency Procedures

Tissue Dissection and Exposure (Fig. 12.13)

192

Figure

Procedural Steps

Pearls

Fig. 12.13

The dissection is taken dow n to the


spinous processes and then to the
lamina. Dissection along the inferior
border of C1 lamina is performed to
expose the C1 lateral mass. Epidural
venous bleeding is controlled w ith
gelatin sponge and cotton pledgets.

A localizing X-ray or uoroscopy can be used to con rm localization. The C2


spinous process is often bi d and m ore prom inent than the C1 or C3 spinous
processes. The C1 and C2 vertebrae are exposed by subperiosteal dissection.
Bleeding from the epidural venous plexus is t ypically encountered during
dissection of the C1-C2 joint. It is usually controlled with a combination of
bipolar electrocautery, gelatin sponge, and cot ton pledgets.6 The lateral and
m edial borders of the C1 lateral m ass are identi ed for accurate placem ent
of the C1 lateral m ass screw. The C2 dorsal root ganglia can be retracted
caudally to clearly view the C1 lateral m ass.

12

Em ergency Managem ent of Odontoid Fractures

C1 Screw Trajectory and Placement (Fig. 12.14)

Figure

Procedural Steps

Pearls

Fig. 12.14

The ideal screw entry point for the C1 screw


is at the middle of the C1 lateral mass in the
lateral-medial direction and at the midpoint
betw een the inferior border of the C1 lateral
mass and the junction of the posterior arch
to the C1 lateral mass in the craniocaudal
direction.

The ideal screw trajectory is 10 degrees m edial and 10 degrees

superior (in the direction of the anterior C1 tubercle) to the entry


point. The hole is tapped and a 3.5-m m screw is inserted. The screw
length should be estim ated on preoperative im aging so that the screw
head sits beyond the posterior arch of C1 (t ypically 3035 m m ).
Harm s and Melcher popularized this C1-lateral mass and C2-pedicle
screw construct. It can also be easily m odi ed to accom m odate a C2pars interarticularis screw depending on patient anatomy. As with the
transarticular approach, careful preoperative review of CT scans with
identi cation of fracture sites, bony anatomy, and vertebral artery
course is necessary to determ ine whether screws can be placed safely.

193

II Spinal Em ergency Procedures

C2 Screw Placement and Trajectory (Fig. 12.15)

194

Figure

Procedural Steps

Pearls

Fig. 12.15

C2 xation can be achieved w ith either a pars interarticularis or


pedicle screw. (right side) The ideal entry point for a C2 pars screw
is 3 mm lateral and 3 mm superior to the inferomedial corner of
the C2 inferior articulating facet, similar to the C1-C2 transarticular
screw. The pars screw should be aimed at a point in line w ith the
middle of the C1 lateral mass in the lateral-medial direction and
40 degrees cranial to the entry site in the craniocaudal direction.
(left side) The ideal entry site for a pedicle screw is 6 mm lateral
and 6 mm superior to the inferomedial corner of the C2 inferior
articulating facet. The ideal trajectory for the pedicle screw is 20
degrees medial and 20 degrees cranial from this point. The screw
length should be measured on preoperative CT. The pilot hole
should be tested w ith a ball-tip probe prior to tapping and place ment of a 3.5-mm polyaxial screw.

The lim itations of transarticular screw


placem ent and the advent of polyaxial head
screws contributed to the developm ent of
further C1-C2 fusion m ethods. In 2001,
Harm s and Melcher popularized this novel
technique of C1-C2 polyaxial screw-and-rod
xation that minimizes risk to the vertebral
artery, allows for intraoperative reduction of
the atlantoaxial joint, and elim inates the need
for supplemental bone wiring.6 The relative
technical ease and improved risk pro le of
this technique has m ade it the predom inant
m ethod of posterior atlantoaxial fusion at the
authors institution.7

12

Em ergency Managem ent of Odontoid Fractures

Completed Construct (Fig. 12.16)

Figure

Procedural Steps

Fig. 12.16

(a) AP and (b) lateral radiographs of nal C1-C2 xation.

195

II Spinal Em ergency Procedures

Closing
Th e w oun d is h eavily irrigated.
An opt ion al su bcu t an eou s d rain m ay be placed.
For an terior procedures, th e plat ysm a is reapproxim ated us

ing 3-0 absorbable sut u res in an in terrupted fash ion .


Th e paraspin al m u scles an d overlying fascia are approxim ated
u sing 1-0 absorbable su t ures in an in terru pted fash ion .
Th e su bcut an eou s t issues are approxim ated using 3-0
absorbable su t u res in an in terru pted fash ion .
Th e w oun d is closed using 3-0 m on o lam en t nylon sut ure in
a ru n n ing fash ion .

Postoperative Management
Monitoring
It is th e sen ior au th ors (JSH) p ract ice to p lace th e p at ien t in a
m on itored set t ing overn igh t .

Medication
Periop erat ive an t ibiot ics are m ain t ain ed for 24 h ou rs after
in cision .

Further Management
Drain s are rem oved on p ostoperat ive day 1 or 2.
Skin su t u res are rem oved after 2 w eeks.
For posterior procedures, pat ien ts are t ypically kept in a rigid

cer vical collar for 6 to 12 w eeks after th e procedure, at w h ich


poin t X-rays are taken to assess fusion .
For an terior procedures, a form al sw allow evaluat ion m ay be
requ ired prior to st art ing a diet becau se of th e h igh in ciden ce
of postoperat ive dysph agia, par t icu larly in elderly pat ien ts.

Special Considerations
The senior author (JSH) prefers not to use additional bone w iring techniques though several have been described. A posterior
bone w iring technique is often perform ed to provide three-point
xation. The C1-C2 transarticular screw, as initially described by
Magerl in 1987, was the rst m ajor advance from bone w iring
techniques.8 Using this technique, im m ediate three-dim ensional
unisegm ental fusion can be achieved and, w hen perform ed in
com bination w ith bone w iring techniques, the use of external
im m obilization (e.g., halo vest) is not necessary. One advantage
of this technique is that it elim inates rotational m otion at C1-C2,
w hich increases the chance of bony fusion. However, its popularit y
has been lim ited by its relative technical com plexit y and associated risks such as hypoglossal nerve and vertebral artery injuries.5
Th e basic prin ciples of m ult isystem t rau m a m an agem en t
sh ou ld n ot be foregon e in th e set t ing of sp in al cord inju r y (SCI).
The ABCs (air w ay, breath ing, circulat ion ) sh ould be m on itored
an d t reated app ropriately. SCI p at ien t s m ay p resen t w ith oth er
life th reaten ing inju ries th at m ake op erat ive in ter ven t ion for

196

atlan toaxial in st abilit y u n safe in th e acute set t ing. If th e fract ure can be reduced an d th e pat ien t does n ot h ave a progressive
n eu rologic de cit th en th e p at ien t can be im m obilized in a rigid
cer vical collar, h alo vest , or t ract ion un t il con curren t injuries
are st abilized. In th e au th ors exp erien ce, p at ien ts w ith h igh
cer vical injuries are best m on itored in th e in ten sive care un it
un t il de n it ive t reat m en t .
Th ere are no stan dards regarding th e ideal t im ing of surgical in ter ven t ion . In the on ly publish ed ran dom ized t rial on this
top ic (for spin al cord inju r y pat ien ts), Vaccaro et al fou n d n o
di eren ce in length of in ten sive care un it stay, length of inpat ien t
reh abilit at ion , or Am erican Spin al Injur y Associat ion (ASIA)
score im provem en t bet w een early (, 72 h ours from inju r y) an d
late (. 5 days from inju r y) surgical in ter ven t ion in 123 pat ien t s
w ith C3 to T1 injuries.9 In a recen t Coch ran e Database system at ic review, Bagnall et al foun d in su cien t eviden ce to establish
recom m en dat ion s on t im ing of surger y.10 Early eviden ce from
th e Surgical Treat m en t for Acute Spin al Cord Injur y St udy (STASCIS), a m ult i-inst it ut ion al ran dom ized t rial of early (, 24 h ours)
versus late su rger y for isolated cer vical SCI, suggests th at early
decom pression m ay be associated w ith im proved neurologic recover y at 1-year follow -up.11 Subsequen t result s dem on st rated
safet y in early su rger y w ith im provem en t in at least t w o grades
of the ASIA im pairm en t scale at 6 m onths follow -up.12

References
1. Sm ith HE, Malten fort M, Harrop JS, et al. Od on toid fract u res an d
th eir m an agem en t . Top ics in Sp in al Cord Inju r y Reh abilit at ion
2010;15(3):6572
2. An derson LD, DAlon zo RT. Fract u res of th e odon toid process of
th e axis. J Bon e Join t Su rg Am 1974;56(8):16631674
3. Su bach BR, Moron e MA, Haid RW Jr., McLaugh lin MR, Rodt s
GR, Com ey CH. Man agem en t of acute odontoid fract ures w ith
single-screw an terior
xat ion . Neurosurger y 1999;45(4):
812819; discu ssion 819820
4. Apfelbau m RI, Lon ser RR, Veres R, Casey A. Direct an terior screw
xat ion for recen t an d rem ote odontoid fract ures. J Neurosurg
2000;93(2 Su ppl):227236
5. Haid RW Jr., Su bach BR, McLaugh lin MR, Rodt s GE Jr., Wah lig
JB, Jr. C1- C2 t ran sar t icu lar screw xat ion for atlan toaxial in st abilit y: a 6-year experien ce. Neurosu rger y 2001;49(1):6568;
discu ssion 6970
6. Harm s J, Melch er RP. Posterior C1- C2 fu sion w ith polyaxial screw
an d rod xat ion . Sp in e (Ph ila Pa 1976) 2001;26(22):24672471
7. Sm ith HE, Vaccaro AR, Malten for t M, et al. Tren ds in su rgical m an agem en t for t ype II odon toid fract u re: 20 years of exp erien ce at a
region al spin al cord injur y cen ter. Or th opedics 2008;31(7):650
8. Grob D, Magerl F. [Su rgical st abilizat ion of C1 an d C2 fract u res].
Or th op ad e 1987;16(1):4654
9. Vaccaro AR, Daugh er t y RJ, Sh eeh an TP, et al. Neu rologic ou tcom e
of early versu s late surger y for cer vical spin al cord injur y. Spin e
(Ph ila Pa 1976) 1997;22(22):26092613
10. Bagn all AM, Jon es L, Du y S, Riem sm a RP. Sp in al xat ion su rger y
for acute t raum at ic spin al cord injur y. Coch ran e Dat abase Syst
Rev 2008(1):CD004725
11. Feh lings MG, Ar vin B. Th e t im ing of su rger y in pat ien t s w ith cen t ral spin al cord injur y. J Neurosurg Spin e 2009;10(1):12
12. Feh lings MG, Vaccaro A, Wilson JR, et al. Early versu s delayed decom pression for t raum at ic cer vical spin al cord injur y: result s of
th e su rgical t im ing in acu te sp in al cord inju r y st u dy (STASCIS).
PLoS On e 2012;7:e32037

13

Cervical Burst Fractures


Teresa S. Purzner, Jam es G. Purzner, and Michael G. Fehlings

Introduction
Cer vical burst fract ures are th e result of exion com pression
inju ries an d are ch aracterized by loss in vertebral body (VB)
h eigh t , cor t ical fract ure of th e posterior VB w all, ret ropulsion of
fragm en t s in to th e can al, an d an in crease in in t rap edicu lar distan ce (IPD). Burst fract ures th at presen t w ith n eurologic de cit
h ave p ersisten t can al com pression or th at involve th e posterior
elem en t s usually require surgical in ter ven t ion t ypically in
th e form of corpectom y an d an terior recon st ruct ion . How ever,
burst fract ures th at do n ot a ect th e posterior elem en t s an d
presen t n eurologically in tact can be m an aged w ith extern al
or th osis. In th e follow ing ch apter w e discuss the su rgical in dicat ion s, m edical m an agem en t , radiograph ic n dings, surgical
ap proach , an d p ostop erat ive care of pat ien t s w ith su baxial cervical sp in e bu rst fract u res.

Indications
Th ere are a variet y of classi cat ion system s for su baxial cervical bu rst fract u res. Th e Allen classi cat ion 1 categorized
su baxial spin e inju ries in to six m ajor grou p s of inju r y: th ree
com pressive injuries ( exion com pression [20%], exten sion
com pression [25%], an d vert ical com pression ); t w o dist ract ion
inju ries ( exion dist ract ion [40%], exten sion -dist ract ion ); an d
n ally on e lateral exion inju r y. Bu rst fract u res belong to both
exion com p ression an d vert ical com p ression categories.
Perh aps th e m ost clin ically useful classi cat ion system w as
put for w ard in 2007 by Vaccarro et al w h o developed th e sub axial cer vical spin e classi cat ion system (SLIC) gu idelin es
(Table 13.1).2 Th ese guidelin es are u n iqu e in th eir con siderat ion
of bony m orph ology, involvem en t of th e discoligam en tous
com plex (DLC), an d n eurologic presen t at ion . Num erical values are given u n der each categor y dep en d ing on th e severit y
of involvem ent . W h en th e sum of all th ree categories am oun ts
to less th an 4 p oin t s, th en con ser vat ive m an agem en t sh ou ld
be con sidered. Greater th an 4 poin t s is suggest ive of surgical
m an agem en t . Based on th e SLIC scale, bu rst fract u res w ith ou t
disrupt ion of th e DLC or ch ange in n eurologic st at us w ould be
given 3 to 4 poin t s an d be t reated w ith extern al orth osis w h ile
th ose w ith deteriorat ion in n eurologic stat us an d disrupt ion of
th e DLC w ould h ave . 4 p oin ts an d th erefore requ ire su rgical
stabilizat ion . Th e p roposed algorith m in clu ded in th is ch apter
is also dependen t on n eu rologic stat u s an d th e st at us of th e
posterior ligam en tous com plex (Fig. 13.1). Isolated burst fract ures w ith out n eurologic de cit are m an aged w ith extern al orth osis w h ile th ose presen t ing w ith n eurologic sym ptom s an d

disrupt ion of th e posterior elem en ts require both an terior decom pression an d posterior recon st ru ct ion .
Panjabi an d W h ite p roposed an altern at ive p oin t-based classi cat ion system t argeted tow ard th e su baxial cer vical sp in e as
w ell as th oracic an d lu m bar inju ries. Th ey con sidered angu lat ion . 11% or . 3.5 m m of sublu xat ion as un stable.3 Cooper
et al based th eir decision on th e p resen ce of irred u cible facet
fract u res, ret ropu lsed fragm en t s cau sing p ersisten t can al com prom ise in an in com plete SCI, progressive n eurologic de cit
from sp in al in st abilit y, root decom pression , or ch ron ic progressive deform it y w ith in com p lete sp in al cord inju r y or n er ve root
de cit .4 Hadley et al recom m en ded th e follow ing in dicat ion s
for su rger y: irredu cible bon e align m en t , irredu cible sp in al cord
com pression , in st abilit y post reduct ion , ligam en tous injur y
w ith facet in st abilit y, . 15% kyph osis, or . 20% su blu xat ion .5
To bet ter determ in e th e correlat ion of radiograph ic n dings
of can al com prom ise an d n eurologic outcom e, Feh lings et al
perform ed an eviden ce-based an alysis of publish ed criteria in
pat ien t s w ith acute cer vical SCI.6,7 Th ey w en t on to develop a
prospect ive st udy invest igat ing m agn et ic reson an ce im aging

Table 13.1 SLIC guidelines


Category

Points

Morphology
No abnorm alit y
Compression
Burst
Distraction
Rotation/translation

0
1
2
3
4

Discoligamentous complex
Intact
Indeterm inate
Disrupted

0
1
2

Neurologic status
Intact
Root injury
Complete cord injury
Incomplete cord injury
Continuous compression

0
1
2
3
11

Note: Subaxial cervical spine injury classi cation system based on


bony morphology, involvement of the discoligamentous complex, and
clinical presentation. Injuries with a score of less than 4 are managed
with rigid orthosis while injuries with a score of greater than 4 should be
considered for surgical xation. Injuries with a score of 4 can be treated
with either rigid orthosis or surgical instrumentation.

197

II Spinal Em ergency Procedures

198

13
Cervical Burst Fractures

199

II Spinal Em ergency Procedures


(MRI) n dings associated w ith can al com prom ise an d foun d
th at m axim um spin al cord com pression as w ell as spin al cord
h em orrh age an d cord sw elling w ere m ost associated w ith a
poor progn osis for n eurologic recover y.8

Initial Evaluation and Medical


Management
Th e in it ial m an agem en t of cer vical bu rst fract ures occurs outside of th e h osp ital at th e scen e of inju r y. Th ese fract u res often
occur in th e set t ing of polyt rau m a w h ere oth er life-th reaten ing
inju ries can dist ract from possible n eu rologic deteriorat ion . Full
cer vical spine precaut ion s w ith im m obilizat ion an d t ran sfer to
an ap prop riate t rau m a cen ter sh ou ld be p erform ed e cien tly
an d safely. On ce at th e t rau m a cen ter, th e Advan ced Trau m a Life
Su p p or t p rotocol is in st it u ted. In th e set t ing of ret rop u lsed segm en t s an d com pressive sp in e inju r y, part icu lar at ten t ion is paid
to oxygen at ion an d m ain ten an ce of adequ ate p erfu sion . St rict
blood pressu re con t rol is im port an t w ith a t arget m ean arterial
pressure (MAP) above 80. Hypoten sion can in it ially be m an aged
w ith uid boluses; h ow ever, in it iat ion of vasopressors sh ould
be con sidered if adequate perfusion is n ot ach ieved w ith uid
boluses alon e. Th e role of steroids rem ain s am biguous an d is
w ell review ed elsew h ere. On ce th e p at ien t is st abilized , a th orough h istor y can reveal th e m ech an ism of injur y an d t im ing of
n eurologic deteriorat ion . Cer vical exion com p ression injuries
are p ar t icu larly con cern ing for bu rst fract u res.
Follow ing th e prim ar y sur vey, a th orough physical exam is
requ ired. In it ial in spect ion an d palpat ion can iden t ify obvious deform it ies, extern al soft t issue injuries, an d local areas
of ten dern ess or asym m et r y. W h en a h istor y is n ot available,
pat tern s of injuries can som et im es suggest th e m ech an ism
of injur y. Next , a dedicated n eu rologic exam sh ould focus on
lim b st rength , sen sat ion an d re exes, t run cal sen sat ion , an d
perspirat ion as w ell as bow el an d bladder sph in cter fun ct ion .
Th e Am erican Spin al Injur y Associat ion classi cat ion system
(ASIA) is a com m on clin ical classi cat ion system th at allow s for
an organ ized ap proach to th e n eu rologic exam an d categorizes
degree of injur y in to four groups.9 ASIA A inju ries are com p lete
SCIs w h ere n o sen sor y or m otor fu n ct ion is p reser ved. ASIA E
inju ries h ave n o m otor or sen sor y de cit . ASIA B to D injuries
are in com plete SCIs w h ere sen sory fu n ct ion is p reser ved bu t
w ith var ying degrees of loss in m otor fun ct ion . Im port an tly,
ongoing progression of n eurologic de cit s can suggest ongoing
or progressive com pression w h ether by un st able or ret ropulsed
fract u re fragm en t s or an expan ding h em atom a. Th ese are im port an t to iden t ify early as t im ely decom pression can h ave sign i can t im p act on overall ou tcom e.
Early opt im izat ion of m edical m an agem en t h as been sh ow n
to ben e t long-term p rogn osis; h ow ever, th e t im ing of su rgical
in ter ven t ion rem ain s som ew h at m ore con t roversial. Th ere exist s a large body of literat u re invest igat ing th e role of early surgical in ter ven t ion . Th e best eviden ce to date w as pu t for w ard by
Feh lings et al in th e Su rgical Tim ing in Acu te Spin al Cord Injur y
St u dy (STASCIS t rial).10 Th is in tern at ion al m ult icen ter prospect ive coh ort st udy looked at 313 pat ien t s w ith acute cer vical SCI.
Of th ese, 182 u n der w en t early su rger y (w ith in 24 h ou rs) an d
131 un der w en t late surger y (after 24 h ours). Prim ar y ou tcom e
w as ch ange in ASIA Im p airm en t Scale (AIS) grade at 6 m on th s.

200

Secon dar y ou tcom es w ere rates of com plicat ion an d m or talit y.


Tw en t y percen t of pat ien t s un dergoing early su rger y sh ow ed a
2 grade im provem en t com pared to 8.8% in th e late decom pression group. Mort alit y an d rates of com plicat ion w ere n ot
st at ist ically sign i can t bet w een th e t w o grou p s. Th is st u dy
w ou ld suggest th at decom p ression w ith in 24 h ou rs is ben e cial.
Closed redu ct ion , if at tem pted, is a relat ively w ell-tolerated
procedure w ith an overall reduct ion rate of approxim ately 80%,
30% recurren t displacem en t or m alalign m en t , 2 to 4% chan ce
of t ran sien t de cit , an d 1% ch an ce of perm an en t de cit . Overall rates of failu re in com pression fract u res of th e su ba xial
C-spin e w ere fou n d to be aroun d 5%. Sim ilarly, Koivikko et al
fou n d a rate of reop erat ion in p at ien t s t reated w ith orth osis to
be 4%(com pared to 3%in surgically m an aged pat ien ts).11 W h ile
n on surgical m an agem en t is cert ain ly th e appropriate decision
in a large percen tage of pat ien ts, th ere is som e eviden ce th at
n eu rologic im p rovem en t , kyp h ot ic deform it y, an d can al sten osis w ere all im p roved in pat ien t s t reated su rgically.11 Most st u dies, h ow ever, w ere ret rospect ive review s an d outcom es w ere
gen eralized to a sp ect ru m of fract u re p at tern s. Furth erm ore,
th e di eren ces in recover y bet w een surgical an d non surgical
m an agem en t is far ou t w eigh ed by th e stat u s at presen t at ion
th an ch oice of t reat m en t . Pat ien ts w h o are t reated w ith a h alo
vest or h ard cer vicoth oracic orth osis for 2 to 3 m on th s sh ou ld
be follow ed up w ith exion -exten sion X-rays to h elp determ in e
su ccess of fu sion .

Preprocedure Considerations
Radiographic Imaging
Th e ch oice of im aging in su spected cer vical burst fract ures

h as ch anged over th e past few decades. Tradit ion ally, an teroposterior (AP), lateral, an d odon toid plain lm s of th e
C-spin e w ere th e rst-lin e im aging of choice. Th ere are several radiograp h ic feat u res suggest ive of bu rst fract u resm ost
im port an tly, loss of ver tebral body h eigh t , cort ical fract ure
of th e posterior VB w all, ret ropu lsion of fragm en t s in to th e
can al result ing in loss of th e dorsal ver tebral body lin e, an d
an in crease in in t rapedicu lar distan ces or sp laying of th e facet
join t s. Th is is occasion ally accom pan ied by VB kyph ot ic or
t ran slat ion al deform it y.
In m any cen ters, com p u ted tom ography (CT) scan is n ow th e
rst-lin e im aging m odalit y of ch oice in cases su sp iciou s of
n eck t rau m a. Typ ically, bu rst fract u res w ill h ave d isru pt ion of
th e posterior VB w all w ith or w ith ou t ret ropulsed fragm en t s.
As in plain lm s, th ey w ill dem on st rate an in creased IPD w ith
splaying of th e vertebral arch . CT angiograp hy (CTA) sh ou ld
also be con sidered w h en th ere is con cern of com p rom ise of
th e ver tebral can al an d, in m any in st it ut ion s, it h as becom e
part of th e st an dard im aging protocol for con rm ed C-spin e
inju ries.
MRI can often be h elp fu l in bet ter visu alizing soft t issu e
st ru ct u res, disk, can al sten osis as w ell as cerebrospin al u id
(CSF) e acem en t , cord im pingem en t , or sign al ch anges23%
of all blu n t t raum a pat ien t s presen t ing w ith a cer vical in jur y h ave eviden ce of disk injur y on MRI. Th is in creases to
as h igh as 36% of th ose p at ien ts w ith com p lete SCI, 54% of

13

in com p lete SCI, an d 47% of p at ien t s w ith u n st able SCI.12 MRI


sh ou ld be p erform ed in a t im ely m an n er, part icu larly w h en
th e clin ical exam is n ot explain ed by radiograph ic n dings. In
th ose pat ien t s w ith equivocal exam or radiograph ic n dings,
15.5% h ave been fou n d to h ave both disk an d ligam entous
disrupt ion , w h ile 20% h ave isolated ligam en tous abn orm alit y.13 T1-w eigh ted im ages are useful for th eir en h an cem en t
of subacute h em orrh age w h ile T2 w eigh ted im ages w ill sh ow
hyperin ten sit y at areas of edem a. Sh or t inversion recover y
(STIR) im aging is a fat suppression sequ en ce th at is part icularly h elpful in h igh ligh t ing areas of ligam en tous injur y.
Gradien t ech o im aging an d su scept ibilit y-w eigh ted im aging
w ill fur th er evaluate th e presen ce of h em orrh age. Di u sion w eigh ted im aging (DW I) u ses rap id ech o p lan ar sequ en ces to
h igh ligh t acu te isch em ic even t s. It h as been u sed ver y su ccessfully in evaluat ing t rau m at ic brain injur y an d cerebral
isch em ia bu t is st ill lim ited in th e spin al cord given th e cardiorespirator y m ot ion ar t ifact , CSF pulsat ion , an d th e sm aller
region of in terest . Non eth eless, it is an area of act ive research
th at h as been sh ow ing prom ising prelim in ar y results. MRI
sh ould be st rongly con sid ered in th e set t ing of bu rst fract u res
p ar t icularly w h en th ere is con cern of a t rau m at ic disk prot ru sion or to assess th e degree of can al sten osis resu lt an t from
ret rop ulsion of th e posterior elem en ts. Eith er of th ese w ou ld
be im port an t in surgical plan n ing.
Preoperat ive im aging (Fig. 13.2).

Approach
On ce th e decision to operate h as been m ade, th e role of an terior,
posterior, or com bined approaches m ust be con sidered. There
are risks an d ben e ts to both an d approach is ult im ately determ in ed by th e areas of com pression , n eurologic stat u s, stat us of
the posterior elem en ts, an d com fort of th e surgeon. In cer vical
burst fract ures the approach of choice is predom inantly ventral.
Neurologic com pression is a result of retropu lsed an terior elem en ts w h ich can be rem oved un der direct vision w ith an an terior approach and therefore on e can provide opt im al decom pression . Fu rth erm ore, corpectom y w ith an terior recon st ruction
provides excellent biom echanical stabilit y and correction of kyphotic deform it ies. The resected vertebral body provides large
am oun ts of excellen t m aterial for autologous bon e graft ing.
An terior approach es also h ave less blood loss an d postoperat ive pain. Indeed, w hen directly com pared, Toh et al found an terior fusion preferred to posterior fusion in cer vical burst and
teardrop fract ures.14 This w as echoed by several biom echanical

Cervical Burst Fractures

st udies looking at th e stabilit y of th e cer vical spin e after an terior


fu sion , posterior fusion , an d com bin ed fusion s in pat ien ts w ith
VB fract ures. It w as found th at alth ough posterior fusions w ere
stronger th an an terior fusion s both w ere stronger th an th e intact spine. This w as true in both isolated anterior injur y or com bined anterior/posterior injuries. Therefore, particularly in the
set t ing of in tact posterior elem en ts, th e role of corpectom y w ith
an terior recon struct ion provides adequate stabilizat ion for longterm bony fusion. Nonunion rate is approxim ately 3%.15
More exten sive recon st ru ct ion s, involving com bin ed an terior
an d p osterior app roach es, are n ecessar y in cases w ith su bopt im al bon e qu alit y, involvem en t of th e posterior elem en t s, or existing long fused segm en ts. Bon e m in eral den sit y h as a sign i cant im pact on overall fu sion rates 16 an d th e degree of fu sion
m u st be t ailored to both th e den sit y of h ealthy bon e an d degree
of bony disrupt ion . Gen erally, at least th e caudal th ird of th e
caudal vertebral body an d caudal endplate of th e rost ral vertebral body sh ou ld be in tact for appropriate fusion . Com bined
an terior an d posterior fu sion is u sed in p at ien t s w ith ver y st i
or spon dylot ic spin es (di use idiopath ic skeletal hyperostosis
[DISH], an kylosing spon dylit is) or in th e set t ing of injur y to th e
posterior elem en ts. Com bin ed operation s h ave been sh ow n to
provide im m ediate rigid st abilizat ion , increased fusion , an d decreased rates of ven t ral plate failu re. Par t icularly w h en both can
be perform ed un der a single an esthet ic, a com bin ed approach
can avoid th e requirem en t of postoperat ive h alo xat ion in
com plex spin al injuries. Isolated posterior approach es are t ypically con sidered in th e set t ing of facet fract u res or dislocat ion s
w ith en dplate disru pt ion w ith out sign i can t com pression or
disru pt ion of th e vertebral body. Posterior approach es are usefu l w h en pat ien t s h ave failed closed red u ct ion an d th ere is su spicion th at in t raoperat ive reduct ion w ill be di cult .

Operative Field Preparation


Fiberopt ic in t ubat ion w h ile th e pat ien t is asleep is recom m en ded in all u n stable cer vical bu rst fract u res w h en p ossible.
Povidin e iodin e or ch lorh exidin e is applied to th e surgical site
an d allow ed to dr y for 3 m in u tes. Th e u se of p reop erat ive local
an esth et ic is u p to th e d iscret ion of th e su rgeon ; t yp ically th e
m arked in cision is in lt rated w ith 1% lidocain e w ith ep in ep h rin e 1:100,000.
Prophylact ic an t ibiot ics sh ou ld be given an d dexam eth ason e
sh ou ld be con sidered p art icu larly in th e set t ing of cord com p ression or n eurologic com prom ise.

201

II Spinal Em ergency Procedures

Fig. 13.2 These lms (a, b) depict a patient with a C4 tear drop fracture of the vertebral body (c, d) that was associated with posterior C4-5 facet
and laminar disruption.

202

13

Cervical Burst Fractures

Operative Procedure
Positioning (Fig. 13.3)

Figure

Procedural Steps

Pearls

Fig. 13.3

The patient is positioned supine w ith the


face midline. A small bolster is placed
betw een the scapula and the neck is put
in general extension w ith the occiput
resting on a donut. Shoulders are taped
dow n.

Right-handed surgeons tend to prefer right-handed incisions, while the


opposite is true with left-handed surgeons. Anatom ically, the recurrent
laryngeal nerve runs a less predictable course on the right-hand side
while the thoracic duct is a unilateral structure found only on the lefthand side. Previous surgery is a relative indication to approach from the
ipsilateral side given the potential for bilateral vocal cord paralysis in the
set ting of bilateral anterior cervical approaches.

203

II Spinal Em ergency Procedures

Incision and Subplatysmal Dissection and Identi cation of Omohyoid


(Fig. 13.4)

Figure

Procedural Steps

Fig. 13.4

A right longitudinal paracervical incision is made w ith a no. 20 blade along the anterior border of the
sternocleidomastoid muscle. The incision is extended dow n through skin, subcutaneous tissue, and platysma.
Subplatysmal aps are elevated and the omohyoid muscle is isolated and divided w ith diathermy cautery.

204

13

Cervical Burst Fractures

Identi cation of the Deep Cervical Investing Fascia (Fig. 13.5)

Figure

Procedural Steps

Pearls

Fig. 13.5

The carotid triangle is entered betw een


the carotid sheath and the pretracheal
fascia by exploiting the avascular planes
of the deep cervical investing fascia.

Through the superior end of incision, the superior thyroid artery and
superior laryngeal nerve can be identi ed and protected. At the lower end
of the incision the inferior thyroid vein can occasionally be visualized. At
all points it is important to identify and protect the pharynx/esophagus.

205

II Spinal Em ergency Procedures

Identi cation of the Prevertebral Fascia (Fig. 13.6)

206

Figure

Procedural Steps

Fig. 13.6

Blunt dissection is used to identify the prevertebral fascia w hich is then opened w ith sharp dissection. Superior
osteal dissection ensues under the longus colli muscle bilaterally.

13

Cervical Burst Fractures

Placement of Self-retaining Retractors (Fig. 13.7)

Figure

Procedural Steps

Pearls

Fig. 13.7

Retractors are positioned to displace


esophagus, trachea, and strap muscles
medially. The carotid, internal jugular, and
sternocleidomastoid muscle are retracted
laterally.

Retractors should be interm it tently released to m inim ize pressure


on the soft tissues. In addition, the endotracheal cu can be
de ated to m inim ize pressure on the tracheoesophageal groove
and thereby decrease the risk of injury to the recurrent laryngeal
nerve.

207

II Spinal Em ergency Procedures

Diskectomy (Fig. 13.8)

208

Figure

Procedural Steps

Fig. 13.8

Disk spaces above and below the injured vertebra are evacuated using a combination of high speed bur, pituitary
rongeurs, Kerrison punches, and microsurgical curettes. A longitudinal trough is then fashioned longitudinally in
line w ith the uncovertebral joints. The endplates are thoroughly burred dow n to posterior longitudinal ligament.

13

Cervical Burst Fractures

Corpectomy (Fig. 13.9)

Figure

Procedural Steps

Fig. 13.9

The injured vertebral body is resected w ith Leksell rongeurs and high-speed burs. The posterior longitudinal
ligament is then opened and all retropulsed fragments are carefully removed via microsurgical dissection under
microscopic magni cation.

209

II Spinal Em ergency Procedures

Placement of Allograft (Fig. 13.10)

210

Figure

Procedural Steps

Fig. 13.10

Distraction pins are placed in the vertebral body above and below the level of injury. Fibular allograft is cut to the
appropriate length and packed w ith local corpectomy bone graft. These are gently tapped in to position. Distraction
pins are removed and the security of t is assessed. Bleeding from the pin sites is controlled w ith bone w ax.

13

Cervical Burst Fractures

Placement of Anterior Locking Plate (Fig. 13.11)

Figure

Procedural Steps

Pearls

Fig. 13.11

Calipers are used to assess the


length of bony defect and an
anterior locking plate is chosen.
Four 14-mm locking screw s are
used to xate the plate.

The literature supporting dynamic or static locking plates is divergent 17 and the
decision to use one over the other is typically related to the preference of the
surgeon. While locking screws do have bene t over nonlocking screws,18,19 unicortical
and bicortical screws have both shown immediate stability so either is a reasonable
choices depending on the experience of the surgeon and risk of protrusion through
the posterior vertebral bodies.20 Approximately 4 mm should be left at both the
rostral and caudal end to diminish the risk of future adjacent level disease.

211

II Spinal Em ergency Procedures

Closing
Ret ractors are rem oved an d soft t issues are carefu lly in spect -

ed for bleeding. Hem ostasis is m et icu lou sly ch ecked an d


secu red . Jackson -Prat t drain can be p laced in th e prevertebral
space an d extern alized th rough sep arate st ab in cision an d
con n ected to th e bulb suct ion .
Th e w oun d is repaired in layers using 2-0 braided absorbable
su t u re for su bcu t an eou s t issu e an d sim ilar 4-0 su bcu t icu lar
for skin .

Postoperative Management
Monitoring
Pat ien t s sh ou ld be m on itored for blood pressu re an d n eurologic fu n ct ion postoperat ively w ith a t arget of MAP . 80.
A p lain CT of th e cer vical sp in e w ill h elp con rm p lacem en t
of in st rum en t at ion .

Medication
Th e u se of postoperat ive an t ibiot ics is con t roversial. Th ere is

n o good evid en ce th at rou t ing postoperat ive an t ibiot ics provides any advan t age to p ostop w ou n d in fect ion s.
The use of steroids in acute SCI is also controversial and its poten tial ben e t m ust be w eigh ed again st th e risk of pn eu m on ia,
poor w ound healing, and recover y from associated injuries.

Radiographic Imaging (Fig. 13.12)

Fig. 13.12 The patient was treated with a C4 corpectomy and C3-5
anterior reconstruction with a bular allograft (packed with local
corticocancellous autograft), and anterior screw-plate xation. Under
the same anesthetic, the patient was turned (using May eld cranial
xation and a Jackson table) in the supine position and a C3-5 posterior
lateral mass reconstruction was undertaken.

212

Further Management
Dep en ding on th e degree of inju r y, u se of an extern al or th osis
postoperat ively m ay ben e t th e pat ien t in term s of both stabilit y an d pain con t rol.

Special Considerations
Th e term cer vical burst fract ure is used in a variet y of con text s. Th e im port an t factors in determ in ing th e role of su rgical xat ion are th e involvem en t of th e posterior com plex an d
ongoing n eurologic de cit secon dar y to ongoing cord com pression . Th ey are often con sidered in th e con text of su baxial
cer vical spin e classi cat ion system s, m ost n ot ably th e SLIC
classi cat ion . W h ile th ese can aid in determ in ing th e st abilit y
of th e injur y, ult im ately each pat ien t an d th eir inju r y is un iqu e
an d requ ire in dividu al con sid erat ion .

References
1. Allen BL, Jr., Fergu son RL, Leh m an n TR, OBrien RP. A m ech an ist ic
classi cat ion of closed, in direct fract ures an d dislocat ions of th e
low er cer vical spin e. Spin e (Ph ila Pa 1976 ) 1982;7(1):127
2. Vaccaro AR, Hu lber t RJ, Patel AA, et al. Th e su baxial cer vical
spin e injur y classi cat ion system : a n ovel approach to recogn ize
th e im por t an ce of m orph ology, n eurology, an d integrit y of th e
disco-ligam en tou s com p lex. Sp in e (Ph ila Pa 1976 ) 2007;32(21):
23652374
3. W h ite AA, III, Panjabi MM. Update on th e evalu at ion of in st abilit y of th e low er cer vical spine. In st r Cou rse Lect 1987;36:
513520
4. Coop er PR, Maravilla KR, Sklar FH, Moody SF, Clark W K. Halo im m obilizat ion of cer vical spin e fract u res. In dicat ions an d result s.
J Neu rosu rg 1979;50(5):603610
5. Hadley MN, Walters BC, Grabb PA, et al. Gu idelin es for th e m an agem en t of acu te cer vical sp in e an d sp in al cord inju ries. Clin
Neurosu rg 2002;49:407498
6. Feh lings MG, Rao SC, Tator CH, et al. Th e opt im al rad iologic m et h od for assessing sp in al can al com p rom ise an d cord
com p ression in p at ien t s w it h cer vical sp in al cord inju r y.
Par t II: Resu lt s of a m u lt icen ter st u dy. Sp in e (Ph ila Pa 1976)
1999;24(6):605613
7. Rao SC, Feh lings MG. Th e opt im al radiologic m eth od for assessing spin al can al com prom ise an d cord com pression in pat ien t s
w ith cer vical spin al cord injur y. Par t I: An eviden ce-based analysis of th e publish ed literat ure. Spin e (Ph ila Pa 1976 ) 1999;24(6):
598604
8. Miyanji F, Fu rlan JC, Aarabi B, Arn old PM, Feh lings MG. Acu te
cer vical t raum at ic spin al cord injur y: MR im aging n dings
correlated w ith n eurologic outcom eprospect ive st udy w ith
100 con secut ive pat ien t s. Radiology 2007;243(3):820827
9. Marin o RJ, Barros T, Biering-Soren sen F, et al. In tern at ion al st an dards for n eurological classi cat ion of spin al cord injur y. J Spin al
Cord Med 2003;26 Su p pl 1:S50S56
10. Feh lings MG, Vaccaro A, Wilson JR, et al. Early versu s delayed decom pression for t rau m at ic cer vical spin al cord injur y: result s of
th e Su rgical Tim ing in Acu te Spin al Cord Inju r y St u dy (STASCIS).
PLoS On e 2012;7(2):e32037

13
11. Koivikko MP, Myllyn en P, Karjalain en M, Vorn an en M, San t avir t a
S. Con ser vat ive an d operat ive t reat m en t in cer vical burst fract ures. Arch Or th op Traum a Surg 2000;120(7-8):448451
12. Rizzolo SJ, Vaccaro AR, Cotler JM. Cer vical sp in e t rau m a. Sp in e
(Ph ila Pa 1976 ) 1994;19(20):22882298
13. Benzel EC, Hart BL, Ball PA, Baldw in NG, Orrison W W, Espinosa
MC. Magnetic resonance im aging for the evaluation of patients
w ith occult cervical spine injur y. J Neurosurg 1996;85(5):824829
14. Toh E, Nom u ra T, Wat an abe M, Moch ida J. Su rgical t reat m en t
for inju ries of th e m iddle and low er cer vical spin e. Int Or th op
2006;30(1):5458
15. Zigler J, Eism on t F, Gar n S, Vaccaro A. Sp in e Trau m a. Rosem on t ,
IL: Am erican Academ y of Or th opaedic Su rgeon s; 2011
16. Dvorak MF, Pit zen T, Zh u Q, Gordon JD, Fish er CG, Oxlan d TR. An terior cer vical plate xat ion : a biom echan ical st u dy to evaluate

17.

18.

19.

20.

Cervical Burst Fractures

th e e ect s of p late d esign , en dp late p rep arat ion , an d bon e


m in eral den sit y. Spin e (Ph ila Pa 1976 ) 2005;30(3):294301
Leh m an n W, Briem D, Blauth M, Sch m idt U. Biom ech an ical com parison of anterior cer vical spin e locked an d u n locked platexat ion system s. Eur Spin e J 2005;14(3):243249
Spivak JM, Ch en D, Ku m m er FJ. Th e e ect of locking xat ion
screw s on th e st abilit y of an terior cer vical plat ing. Spin e (Ph ila
Pa 1976 ) 1999;24(4):334338
DuBois CM, Bolt PM, Todd AG, Gupt a P, Wet zel FT, Ph illips FM.
St at ic versus dyn am ic plat ing for m ult ilevel an terior cer vical discectom y an d fusion . Spine J 2007;7(2):188193
Leh m an n W, Blauth M, Briem D, Sch m idt U. Biom echan ical
an alysis of anterior cer vical spine plate xat ion system s w ith
un icort ical an d bicor t ical screw purch ase. Eur Spin e J 2004;
13(1):6975

213

14

Cervical Facet Dislocation


Daniel Resnick and Casey Madura

Introduction
Dislocat ion of th e facets join t s of th e spin e can occu r at all levels,
but it is m ost com m on ly an injur y fou n d in th e cer vical spin e.
First , th e coron al orien t at ion of th e join t s th em selves leaves
th em suscept ible to dislocat ion w ith hyper exion . Secon d, un like th e su bstan t ial size of th e lum bar ar t icu lat ing processes,
th ose in th e cer vical spin e are m uch less robust .1 Th erefore,
th e ar t iculat ing processes in th e cer vical spin e are m uch m ore
p ron e to fract u re an d dislocat ion . Th ird , th e cer vical spin e is
n at u rally h igh ly m obile in com p arison to th e th oracic an d lu m bar spin e w ith th e h eads w eigh t ser ving as a con t ribut ing factor. Th is ch aracterist ic leaves th e cer vical spin e vuln erable to
su dden ch anges in m ovem en t su ch as th at w h ich occu rs in a
h ead-on collision .
Dislocat ion of th e cer vical facet join ts can be both u n ilateral
an d bilateral. In th e case of u n ilateral facet dislocat ion , th ere
is often a rotator y force experien ced along w ith th e hyper exion . Th e hyp er exion force vector is en ough to raise th e in ferior
ar t icu lat ing processes of both facet join ts at th e a ected level
w ith respect to th e superior ar t iculat ing process. The rotat ion
exp erien ced at th e sam e t im e cau ses on ly on e of th e t w o elevated in ferior art icu lat ing p rocesses to t ran slate for w ard, locking an terior to th e su perior art icu lat ing p rocess of th e ver tebra
below it .2 A pu rely hyp er exion m om en t w ith ou t rot at ion is
m u ch m ore likely to cau se bilateral facet dislocat ion as th e force
vectors exp erien ced by each facet are th eoret ically sim ilar. In
eith er scen ario, th e dislocat ion is visu alized as eith er a p erch ed
facet (on e in w h ich th e in ferior p roject ion of th e in ferior ar t icu lat ing p rocess of th e p roxim al ver tebral body ar t iculates w ith
th e superior project ion of th e superior ar t icu lat ing process of
th e dist al ver tebral body) or a locked facet (in w h ich th e in ferior
art icu lat ing process of th e p roxim al ver tebral body is an terior
to th e su perior art iculat ing process of th e dist al ver tebral body).
All region s of th e cer vical spin e are n ot created equ al. Un like
th e su baxial cer vical spin e, th e C1-C2 facet join t s are orien ted
in an axial plan e m aking th em less vuln erable to dislocat ion
from hyper exion . Th e occip itocer vical ju n ct ion is su bject to
a n u m ber of part icu lar inju r y pat tern s th at are discu ssed elsew h ere. It is th e su baxial cer vical spin e, speci cally C4- C7, th at is
m ost p ron e to hyper exion inju ries.3 In large p art , th is is du e to
th e dyn am ic forces th e cer vical spin e experien ces as a collision
evolves. At th e on set of a h ead -on collision , th e low er cer vicoth oracic jun ct ion of th e spin e com presses an d extends w h ile
th e subaxial cer vical spin e exes w ith great force. As th e forces
evolve, th e cer vical sp in e is even t u ally th row n in to exten sion .
Th is evolut ion of forces, com m on ly referred to as w h iplash ,
causes th e spin e to assum e an S-shape, a ph en om en on referred
to as sn aking. Th e hyper exion , if severe en ough , can lead to
facet dislocat ion by it self.

214

In rear end collisions, th e dam age can be even m ore severe.


Initially, the victim s neck m ay hyperextend, forcing the inferior
articulating process dow n in to the superior articulating process.
If the articular surface fails, fracture of the inferior articulating
process can occur, weakening the facet joint as a w hole. The inevitable hyper exion that follow s then causes the dislocation, unhindered by the norm al ligam entous and joint capsule restraints.
The ultim ate result of any facet dislocation in the cervical spine
is an unstable spine that requires im m ediate treatm ent. Treatm ent
options include nonoperative m anagem ent w ith closed reduction
followed by im m obilization in an external xation device such as
a halo vest or Minerva brace versus operative xation follow ing
either closed or open reduction. The details of the di erent op tions are discussed below, but there is a general agreem ent that
the universal presence of ligam entous injury in facet dislocations
m akes operative xation a preferred technique for treatm ent of
both unilateral and bilateral facet dislocations of the cervical spine.

Indications
Hyp er exion inju r y resu lt ing in u n ilateral or bilateral facet

dislocat ion such as a h ead-on m otor veh icle collision .


Com bin ed hyperexten sion /hyper exion injur y result ing rst
in facet fract ure due to hyperexten sion w ith su bsequen t facet
dislocat ion due to hyper exion as is experien ced during a severe rear-en d collision .
If th e exam in at ion reveals n o n eu rologic de cit or a com p lete
sp in al cord inju r y, su rgical st abilizat ion sh ou ld occu r as soon
as th e p at ien t is m edically st able an d an ap p rop riate team is
available.
If th e exam in at ion reveals n dings con sisten t w ith a p art ial
sp in al cord inju r y, u rgen t redu ct ion an d st abilizat ion is recom m en ded as soon as th e pat ien t is h em odyn am ically st able.
Hyp oten sion sh ou ld be avoid ed in all p at ien ts, esp ecially
th ose w ith n eurologic de cits.

Examination
Any pat ien t th at su ers a cer vical facet dislocat ion h as su s-

t ain ed forces su cien t to cause a m yriad of oth er life-th reat en ing inju ries; th erefore, a fu ll t rau m a w orku p sh ou ld be
com pleted w ith priorit y given to th e ABCs (air w ay, breath ing,
circulat ion ). Im m obilizat ion of th e cer vical spin e du ring th is
evalu at ion m u st be a priorit y.
A full n eurologic exam in at ion sh ould be perform ed as th is
h as im plicat ion s regarding th e t im ing of in ter ven t ion .
Ad dit ion ally, evalu at ion of n eu rologic st at u s m ay allow localizat ion of th e injur y prior to im aging.

14

ReductionClosed or Open

Guidelines,6 Hurlburt,7 NASCIS I8 an d II9 as w ell as subsequen t


publications,10 the standard at our in stit ution is to not adm in ister steroids.

Class III eviden ce suggest s early redu ct ion of cer vical facet

fract u re/d islocat ion m ay be associated w ith im p roved n eu rologic ou tcom e.


If th e p at ien t is aw ake, th is can be perform ed w ith m ild sedat ion .5 If th e pat ien t is un respon sive or u nable to cooperate, m agn et ic reson an ce im aging (MRI) is in dicated prior to
redu ct ion as th e n eu rologic exam in at ion can n ot be follow ed
an d th e p resen ce of a large ven t ral lesion m ay be a relat ive
in dicat ion for an open redu ct ion via an an terior approach .
Closed redu ct ion tech n ique in cludes h alo or tongs t ract ion ,
w h ich is discu ssed in Ch apter 11. Closed reduct ion an d extern al bracing is associated w ith in creased m orbidit y an d m ort alit y related to prolonged bedrest .
Su ccess of closed redu ct ion is 80%.
Risk of su ering ad dit ion al p erm an en t n eu rologic inju r y du ring closed reduct ion is , 1%.
Risk of su ering addit ion al t ran sien t n eu rologic inju r y du ring
closed reduct ion is 2 to 4%.
If reduction fails, the likelihood of other injuries such as facet
fracture or herniated disks is increased. This necessitates further
im aging studies such as MRI prior to open reduction to determ ine the initial direction of approach (anterior versus posterior).

Cervical Facet Dislocation

Operative Management 11
Approach
If closed redu ct ion h as been ach ieved, an terior xat ion an d

fu sion , p osterior xat ion an d fu sion , or h alo im m obilizat ion


are t reat m en t opt ion s. In gen eral, h alo im m obilizat ion is associated w ith a relat ively h igh failu re rate an d th e vast m ajorit y of su rgeon s w ill o er a direct xat ion p rocedu re.
If th e dislocat ion requ ires op en redu ct ion , th e su rgeon m ay
ch oose bet w een an terior or posterior approach es depen ding on th e an atom y of th e injur y an d th e experien ce of th e
su rgeon . Th e p resen ce of a large ven t ral disk h ern iat ion m ay
be a relat ive in dicat ion for an an terior approach as a kn ow n
u n ilateral ver tebral arter y inju r y. In th ese cases, th e use of
MRI is app ropriate. If th e dislocat ion is com p lete en ough th at
th e surgeon does n ot believe an an terior approach feasible for
reduct ion , th en a posterior approach is in dicated.

Techniques

Preprocedure Considerations
Radiographic Imaging

Opt ion s in clu de: an terior fu sion w ith or w ith ou t p late xa

Com puted tom ography (CT) scan: CT is the workhorse of cervi-

cal spine traum a evaluation. Identi cation of osseus abnorm alit y is straightforward w hile ligam entous injury is not always
detectable. Ligam entous injury m ay be detected due to enlarged
spaces bet ween otherw ise norm al appearing osseus structures.
MRI: Th is test h as, in th e past , been advocated as a n ecessar y
p ar t of any pre-reduct ion w orkup, w h eth er th at reduct ion be
in th e in ten sive care un it (ICU) or operat ing room set t ing. Th e
rat ion ale for th is w as to iden t ify any ven t ral in ter vertebral
disk h ern iat ion s th at m ay cause n eurologic injur y du ring reduct ion . According to an eviden ce-based review, th ere w as
n o relat ion sh ip bet w een th e p resen ce of h ern iated disks an d
risk of n eu rologic inju r y du ring closed redu ct ion of facet dislocat ion s in th e presen ce of a ven t rally h ern iated disk.4 W h ile
p re-redu ct ion or preop erat ive MRI m ay be useful in term s of
de n ing associated injuries an d in som e cases dict at ing surgical approach , as in th e obt un ded pat ien t , in th e absence of a
clear in dicat ion for MRI, reduct ion of th e dislocat ion sh ould
n ot be delayed in a p at ien t w ith a severe n eu rologic inju r y.
Cervical X-ray: The role of plain radiographs in the initial assessm ent of severe traum a has been lim ited by the advent of aggressive use of CT im aging. Plain lm s are quite helpful for diagnosing
cervical facet dislocations and are em ployed serially (or w ith uoroscopy) during the process of either open or closed reduction.

t ion , posterior fusion an d w iring, an d posterior fusion w ith


lateral m ass p late, rod, clam p, or cable xat ion .
Posterior fusion w ith lateral m ass plate, rod, clam p, or cable
xat ion p rovides in st an t stabilit y (allow ing early m obilizat ion of th e pat ien t). Ch oice of tech n iqu e is based on th e in tegrit y of th e bony st ru ct u res an d th e exp erien ce of th e su rgeon .
Posterior fu sion w ith w iring m ay also be associated w ith an
in creased risk of late kyph ot ic angulat ion com p ared to m ore
rigid tech n iqu es. In on e st u dy, 22 of 165 pat ien t s w ith cer vical facet dislocat ion t reated via posterior fusion an d w iring
developed kyph osis com pared to just 1 of 40 pat ien t s t reated
via p osterior fu sion an d lateral m ass xat ion .11
Anterior fusion w ithout plating is associated w ith a h igh er
in ciden ce of graft displacem ent and late developm en t of kyph osis th an posterior fusion w ith xat ion. Six of 101 pat ient s
t reated in th is fash ion developed late instabilit y com pared to 6
of 237 pat ients t reated via a posterior fusion w ith lateral m ass
xat ion .11 Th e use of an terior fu sion w ith plate xation is w ell
described an d is associated w ith excellen t outcom es.1216

Operative Field Preparation


Cer vical im m obilizat ion m ust be m ain t ain ed at all t im es.
With regards to anesthesia, the inherent instability of this

Medication

Steroids: Methylprednisolone for spinal cord injur y is a topic of

great con troversy. Draw ing from the 2002 an d 2013 AANS/CNS

t ype of spinal colum n injury encourages beroptic intubation.


Regardless of th e n al posit ion (pron e or su pin e), th e n eck
sh ou ld be kept in a n eu t ral p osit ion at all t im es.
Th e operat ive area is cleared of h air u sing clippers on ly an d
clean sed w ith alcoh ol.
Povidin e iodin e or ch lorh exidin e prep is used to sterilize
th e operat ive eld w idely.
Th e in cision s are m arked. In lt rat ion w ith 1% lidocain e
w ith 1:100,000 epin eph rin e is opt ion al.

215

II Spinal Em ergency Procedures

Operative Procedure
Posterior Approach (Fig. 14.1a, b)

Fig. 14.1a, bCaseexample:posterior xation.Thisyoungmanwasinvolvedinamotorvehicleaccidentandpresentedwithacompletespinal


cordinjuryatC6-C7.(a, b)CTim agesdemonstratethebilateralfacetsubluxationinjuryalongwithsomeadditionalposteriorelem entinjuriesand
distractionindicatingcircumferentialligamentousdisruption.Becauseofthedegreeofdistractionandposteriorelementinjuries,alongsegment
posterior xationwasplanned.

216

14

Cervical Facet Dislocation

Positioning (Fig. 14.2)

Figure

Procedural Steps

Pearls

Fig.14.2

Cervical immobilization is maintained at all times. The neck is


maintained in neutral alignment. Tongs w ith traction are maintained
to stabilize the spine.

Fiberopticintubationisanecessit yinthese
patients.May eldpinsmayalsobeusedto
stabilizethespine.

217

II Spinal Em ergency Procedures

Subcutaneous Dissection (1) (Fig. 14.3)

218

Figure

Procedural Steps

Pearls

Fig.14.3

After a midline skin incision is made, dissection is carried dow n


through the subcutaneous adipose tissue and cervical fascia until the
spinous processes are exposed.

Maintainingm idlineiscrucialnotonlyfor
localizationbutalsoform aintenanceof
hem ostasis.

14

Cervical Facet Dislocation

Subcutaneous Dissection (2) (Fig. 14.4)

Figure

Procedural Steps

Pearls

Fig.14.4

Dissection of the paraspinous musculature is carried


out laterally, exposing the facet joints. The muscle is
mobilized in the subperiosteal plane.

Carem ustbetakentoleavenorm alfacetjointsintact,


especiallydirectlyaboveandbelowtheinjuredlevel(s).The
lengthoftheskinincisiondeterm inestheextentoflateral
exposure.Lengthentheincisionifneeded.

219

II Spinal Em ergency Procedures

Decompression and Reduction (Fig. 14.5)

220

Figure

Procedural Steps

Pearls

Fig.14.5

Once the injured level has been identi ed (visually and via
intraoperative X-ray), removal of compressive bony elements and
reduction of the dislocated segment can begin using a series of
rongeurs, punches, and curettes. Reduction may require drilling of the
superior facet. Care is taken to save all bony elements for the fusion.

Bonerem ovalshouldbelim itedtothat


whichisrequiredfordecompression.
Reductionofthedeform it yitselfusually
providesthedecompression.

14

Cervical Facet Dislocation

Preparation for Fusion (Fig. 14.6)

Figure

Procedural Steps

Fig.14.6

Follow ing decompression, decortication of the lateral elements and usually the facet joint itself should be carried
out to provide an adequate fusion substrate.

221

II Spinal Em ergency Procedures

Screw Placement (1) (Fig. 14.7ac)

222

Figure

Procedural Steps

Pearls

Fig.14.7

The entry point is 1 mm medial and inferior to the


midpoint of the lateral mass. The screw trajectory
may be estimated by aligning the drill guide
w ith the rostral edge of the subadjacent spinous
process. The angle should be up (b) and out (c),
aiming aw ay from the vertebral artery (running
underneath the medial half of the lateral mass)
and the exiting nerve root and subadjacent facet
(generally vulnerable if the screw trajectory is too
caudal).

Screwlengthisindividualandshouldbedeterm ined
preoperativelyonCT.Eitherunicorticalorbicorticalpurchase
isassociatedwithexcellentoutcom esandclinicallyadequate
purchaseinboththeanteriorandposteriorapproaches.17,18
Iftheconstructcrossesthecervicothoracicjunction,polyaxial
screwsa ordthegreatest exibilit yinrodplacem ent.In
thesubaxialcervicalspine,eitherrod-basedorplate-based
system sm aybeusedwithhighsuccessrates.

14

Cervical Facet Dislocation

Rod Placement (Fig. 14.8)

Figure

Procedural Steps

Fig.14.8

A rod is fashioned to recreate the natural cervical lordosis and is placed in the screw heads. The caps are tightened
in place.

223

II Spinal Em ergency Procedures

Posterolateral Fusion (Fig. 14.9)

224

Figure

Procedural Steps

Fig.14.9

The bone fragments removed during the decompression, having been cleaned of all soft tissue and morselized, are
placed in the decorticated facet joints and over the available lateral mass to complete the fusion.

14

Closing

Th e deep subcut an eous t issue is closed using 2-0 absorbable

Posterior
Follow ing ach ievem en t of h em ost asis, drain p lacem en t is

opt ion al. If placed, th e drain sh ould be placed in a su bfascial


fash ion to allow closu re of th e cer vical fascia.
Th e deep cer vical fascia is closed using n o. 0 absorbable
braided sut u res in eith er an in terrupted or run n ing fash ion .

Cervical Facet Dislocation

braided su t ures in an in terrupted fash ion . Th e purpose is to


decrease th e dead space available for in fect ion . Th is is n ot a
st rength layer.
Th e deep derm is is closed u sing 2-0 or 3-0 absorbable braided
su t u res in an in terru pted , inverted fash ion .
Th e skin m ay be closed w ith staples, a ru n n ing n on absorb able su t u re, or an absorbable su bcu t icu lar su t u re.

Anterior Approach (Fig. 14.10ac)

Fig. 14.10acCaseexample:reductionandanterior xation.Thismiddle-agedwomanpresentedfollowingafallwithasevereC6(ASIAB)spinal


cordinjury.(a)Sagit taland(b)parasagit talCTimagesdemonstratethefacetsubluxationinjuryandfracture.(c)Shewasbroughtdirectlytothe
operatingroomwheretractionwasapplied,almostcompletelyreducingthesubluxation.

225

II Spinal Em ergency Procedures

Positioning (Fig. 14.11)

226

Figure

Procedural Steps

Pearls

Fig.14.11

The patient is positioned


supine w ith the neck in a
neutral position.

GardnerWellstongsm aybeplacedifdesiredforintraoperativeaxialtraction.
Removalofim mobilizationdevicesshouldbeperform edbyatrainedm em berof
thesurgicalteamwhoisresponsibleform aintaininganeutralalignment.

14

Cervical Facet Dislocation

Opening (Fig. 14.12)

Figure

Procedural Steps

Pearls

Fig.14.12

An incision along the contour of the skin of the neck is made.


The dissection is carried dow n to the platysma w ith monopolar
electrocautery. The platysma is then divided sharply along its
bers using Metzenbaum scissors.

Theincisiont ypicallyist wo-thirdsanteriorto


andone-thirdposteriortotheanteriorborder
ofthesternocleidomastoidmuscle.

227

II Spinal Em ergency Procedures

Exposure of the Spinal Column (Fig. 14.13)

228

Figure

Procedural Steps

Pearls

Fig.14.13

With the carotid sheath and its contents retracted laterally and
the trachea and esophagus medially, the prevertebral fascia and
longus colli muscles can be seen overlying the bony elements of
the cervical spine.

Thespacebet weenthecarotidsheathisa
potentialspacethatcanbecreatedusing
blunt ngerdissection.

14

Cervical Facet Dislocation

Exposure of the Vertebral Bodies and Intervertebral Disks (Fig. 14.14)

Figure

Procedural Steps

Pearls

Fig.14.14

The appropriate level is identi ed by intraoperative


X-ray. The longus colli are elevated and retracted
laterally so that the uncovertebral joints are exposed
bilaterally. Self-retaining retractors are inserted to
a ord continuous exposure of the spinal column.

Thetransverseprocessesliealongthesuperiorborderof
eachvertebralcolum nsothatinjurytothevertebralartery
ispreventedhere.Theoppositeistrueattheinferior
aspectsofthevertebralbodiesandcareshouldbetakento
avoidindiscrim inateuseofm onopolarelectrocautery.

229

II Spinal Em ergency Procedures

Diskectomy (Fig. 14.15)

230

Figure

Procedural Steps

Fig.14.15

The intervertebral disk and the posterior longitudinal ligament are removed using Kerrison punches and pituitary
instruments, resulting in exposure of the spinal cord dura.

14

Cervical Facet Dislocation

Reduction (if necessary) (Fig. 14.16)

Figure

Procedural Steps

Fig.14.16

Caspar pins are placed into the vertebral bodies and distraction and hyper exion is applied using either the Caspar
pin appliers or pliers. Usually, the facet reduction is palpable and the vertebral bodies are then allow ed to return
to an anatomic position. Fluoroscopy or a lateral radiograph is used to check alignment prior to graft placement.

231

II Spinal Em ergency Procedures

Graft Placement and Fusion (Fig. 14.17a, b)

232

Figure

Procedural Steps

Pearls

Fig.14.17

(a) The vertebral endplates are decorticated. (b) A tricortical graft is


then tted in the intervertebral space. The graft should be recessed
below the anterior cortical margin to avoid migration of the graft.

Carem ustbetakentoavoidoverdistraction
duetoanoversizedgraft.

14

Cervical Facet Dislocation

Plating (Fig. 14.18)

Figure

Procedural Steps

Pearls

Fig.14.18

An appropriate size plate is placed in the midline of the


vertebral column and a xed using unicortical screw s.

Thescrewsaredirectedm ediallyandeithersuperiorly
orinferiorlyintothesuperiorandinferiorvertebralbody,
respectively.

233

II Spinal Em ergency Procedures

Closing

Radiographic

Anterior

A postoperat ive CT scan m ay be obtain ed to evaluate th e

Ret ract ion is rem oved slow ly w ith all poin t s of bleeding

coagu lated u sing bipolar elect rocauter y.


Th e plat ysm a is closed using 2-0 absorbable braided sut ures.
Th e pu rpose is reapproxim at ion an d does n ot h ave to be
w ater-t igh t .
Dead-space closu re of th e su bcu t an eou s t issu e w ith 2-0 ab sorbable braided su t u res is opt ion al.
Closure of th e deep derm is is com pleted using 3-0 absorbable
braided sut ures.
Th e skin m ay be closed using a subcut icu lar st itch , t ypically
4-0 braided or m on o lam en t absorbable sut ure, a layer of
brin glue, or a com bin at ion of th e t w o.

Postoperative Management
Monitoring
Pat ien t s w ith severe n eu rologic inju ries are adm it ted to th e

ICU for aggressive blood pressu re m on itoring w ith th e in ten t


to m ain tain at least a n orm al m ean arterial p ressu re. Pat ien t s w ith severe injuries frequen tly require uid an d pressor su p port to m ain tain m ean arterial p ressu res of at least
85 to 90 m m Hg.19 Pu lm on ar y care as w ell as recogn it ion of
associated m edical issu es is facilitated by ICU placem en t .
Pat ien t s w ith n o n eu rologic de cit s w ith u n com p licated p rocedures m ay be adm it ted to a gen eral care oor w h ere m on itoring is rou t in e an d m ost com m on ly related to th e t reat m en t
of injur y-related an d postoperat ive discom fort .

Medication
Pain Management
Acetam in oph en 1000 m g by m ou th (PO) th ree t im es a day
Oxycodon e 5 to 15m g (u p to 20 m g) PO ever y 3 to 4 h ou rs as

n eeded
Gabapen t in 300 m g (up to 900 m g) PO th ree t im es a day
Diazepam 5 to 10 m g PO ever y 6 h ou rs as n eeded for m u scle
spasm s (opt ion al)
Longer act ing oxycod on e 10 m g PO t w ice a day (in crease as
n eeded)
Narcot ics an d gabap en t in are w ean ed as rapidly as p ossible.

Other
All n on steroidal an t i-in am m ator y drugs are avoided for at

234

least 3 m on th s.
Proch lorperazin e an d droperidol are avoided if possible due
to th eir sedat ing e ects w h ile th e p at ien ts are requ iring sign i can t doses of pain m edicat ion s.

placem en t of th e screw s an d th e exten t of reduct ion .


Pat ien ts are follow ed on an ou t pat ien t basis w ith an teroposterior an d lateral plain lm s of th e cer vical spin e at 1 m on th ,
3 m on th s, an d 6 m on th s for evaluat ion of th e exten t of fusion . Fig. 14.19 sh ow s n al con st ruct of posterior approach
an d Fig. 14.20 sh ow s n al con st ru ct of an terior ap p roach .

Further Management
It is ou r pract ice to rem ove drain s w h en th e ou t pu t drops be

low 100 m L in a sh ift .


Skin su t u res/st ap les th at are n ot absorbable are rem oved
2 w eeks postoperat ively.

Special Considerations
It is im portant to consider th e exten t of the injur y in ch oosing an
operat ion. W hile closed reduct ion follow ed by extern al im m obilizat ion is overall a safe m odalit y that can be perform ed at the
bedside,4,20,21 it is gen erally m ost su ccessfu l in inju ries lim ited to
the osseous com ponen ts of th e spine.20,21 In gen eral, facet dislocation involves the ligam entous st ruct ures of the spine in addition to the osseous elem en ts. Therefore, internal xation is usually felt to be m ore appropriate. Th e ch oice of approach is m ore
debatable. Posterior fusion has been thoroughly st udied an d
foun d to be appropriate for cer vical facet dislocat ions.22,23 Both
an terior an d posterior approach es h ave been su ccessful, but th e
gu idelin es adopted by th e Am erican Associat ion of Neurological Surger y and the Congress of Neurological Surgeon s favor the
posterior approach w ith som e t ype of lateral m ass xation.12
Th e quest ion of im aging for evaluat ion of vertebral arter y in jur y is on e of sign i can t con t roversy. A 2006 m et a-an alysis 24
fou n d th e in ciden ce of vertebral arter y inju r y (VAI) in facet
dislocat ion w ith or w ith out associated fract ure to be 21 to 75%
(m ean , 35%). VAI w as m ore likely to occur in un ilateral rath er
th an bilateral facet dislocat ion s. Due to sign i can t collateral
ow, on ly 12 to 20% of th e VAIs iden t i ed w ere sym ptom at ic.
Th e 2002 guidelin es,25 in a st atem en t regarding VAI, recom m en d ed again st an t icoagu lat ion for asym ptom at ic p at ien ts as
th e in h eren t risk of an ticoagulat ion itself w as rough ly equivalen t to th e risk of st roke in h eren t to a VAI. Th e 2013 guidelin es 26
su p p or ts CT angiography in select p at ien ts m eet ing clin ical
(sym ptom s an d sign s) an d radiograph ic criteria. In addit ion ,
t reat m en t decision for VAI (an t icoagulat ion , an t iplatelet th erapy, obser vat ion ) sh ou ld be based u pon clin ical circu m st an ces.
Th e qu est ion th en is w h eth er to im age th e pat ien t in order to
detect th ese injuries. In follow ing th e gu idelin es, if th e pat ien t
is asym ptom at ic, vascular st udies to iden t ify asym ptom at ic in juries are n ot n ecessar y as th ey w ou ld n ot ch ange m an agem en t .
If th ere are im aging st u dies p lan n ed for oth er reason s, con siderat ion can be given to im aging of th e ver tebral arteries.

14

Cervical Facet Dislocation

Fig. 14.20PostoperativeimageofpatientinFig. 14.10.Ananterior


cervicaldiskectomyandfusionwereperformedwithcompletionofthe
reductionachievedthroughdirectmanipulationofthevertebralbodies
usingvertebralpins.Plate xationprovidedimmediatestabilizationand
shewasdischargedtorehabilitationinacollarfor6weeks.

References

a
Fig. 14.19a, bPostoperativeimagesofpatientdepictedinFig. 14.1.
(a)Oncestabilized,hewasbroughttotheoperatingroomforanopen
posteriorreductionand(b)stabilizationusinglateralmassscrewsinthe
midcervicalspineandpediclescrewsinC7andT1.

1. Da n er RH. Evalu at ion of cer vical ver tebral inju ries. Sem in
Roen tgen ol 1992;27:239253
2. Ben zel EC. Trau m a, t u m or, an d in fect ion . In : Biom ech an ics of
Spin e St abilizat ion . New York: Th iem e; 2001:79
3. Wickst rom JK, Mar t in ez JL, Rodrigu ez R Jr. Hyperexten sion
an d hyper exion injuries to th e h ead an d n eck of prim ates.
In : Gu rdjian ES, Th om as LM, eds. Neckach e an d Backach e:
Proceedings Worksh op of th e Am erican Associat ion of Neurological Su rger y an d th e Nat ion al In st it u te of Health . Spring eld,
IL: Th om as; 1970
4. Gelb DE, Hadley MN, Aarabi B, et al. In it ial closed redu ct ion
of cer vical spin e fract ure-dislocat ion injuries. Neurosurger y
2013;72(suppl):7383

235

II Spinal Em ergency Procedures


5. Cotler JM, Herbison GJ, Nasu t i JF, Dit u n n o JF Jr, An H, Wol BE.
Closed reduct ion of t raum at ic cer vical spin e dislocat ion using t ract ion w eigh t s up to 140 poun ds. Spin e 1993;18(3):
386390
6. Hadley MN, Beverly CW, Grabb PA, et al. Ph arm acological th erapy after acute cer vical spin al cord injur y. In : Neu rosurger y
Sect ion on Disorders of th e Spin e an d Periph eral Ner ves of the
Am erican Associat ion of Neu rological Surgeon s an d th e Con gress of Neurological Surgeon s Gu idelin es for th e m an agem en t
of acute cer vical spin e an d spin al cord injuries. Neu rosurger y
2002;50(S3):S6372
7. Hu rlber t RJ, Hadley MN, Walters BC, et al. Ph arm acological
th erapy for acute spinal cord injur y in Guidelin es for th e m an agem en t of acu te cer vical sp in e an d spin al cord inju ries. Neu rosu rger y 2013;72 [suppl 2]:93105
8. Bracken MB, Sh epard MJ, Hellen bran d KG, et al. Methylpredn isolon e an d n eurological fun ct ion 1 year after spin al cord injur y. Resu lt s of th e Nat ion al Acu te Spin al Cord Injur y St udy. J Neu rosurg
1985;63:704713
9. Bracken MB, Sh ep ard MJ, Collin s W F, et al. A ran d om ized, con t rolled t rial of m ethylpredn isolon e or n aloxon e in th e t reat m en t
of acute spin al-cord injur y. Result s of th e Secon d Nat ional Acute
Spin al Cord Inju r y St udy. N Engl J Med 1990;322:14051411
10. Bracken MB, Sh ep ard MJ, Collin s W F Jr, et al. Methylp redn isolon e or n aloxon e t reat m en t after acu te spin al cord inju r y: 1-year
follow -up dat a. Result s of th e secon d Nat ion al Acute Spin al Cord
Injur y St udy. J Neurosu rg 1992;76(1):2331
11. Gelb DE, Aarabi B, Dh all SS, et al. Treat m en t of su baxial cer vical
spin e injuries. Neurosurger y 2013;72[suppl 2]:187194
12. Rein dl R, Ou ellet J, Har vey EJ, et al. An terior redu ct ion for cer vical
spin e dislocat ion . Spin e 2006;31:648652
13. Joh n son MG, Fish er CG, Boyd M, et al. Th e rad iograp h ic failu re of
single segm en t an terior cer vical plate xat ion in t raum at ic cervical exion dist ract ion inju ries. Spin e 2004;29:28152820
14. Maim an DJ, Barolat G, Larson SJ. Man agem en t of bilateral locked
facet s of th e cer vical spin e. Neu rosu rger y 1986;18:542547

236

15. De Iu re F, Scim eca GB, Palm isan i M, et al. Fract u res an d dislocat ion s of th e low er cer vical spin e: surgical t reat m ent . A review of
83 cases. Ch ir Organ i Mov 2003;88:397410
16. Ordon ez BJ, Ben zel EC, Naderi S, et al. Cer vical facet d islocat ion :
tech n iques for ven t ral reduct ion an d st abilizat ion . J Neurosurg
2006;92:1823
17. Leh m an n W, Blauth M, Briem D, Sch m idt U. Biom ech an ical analysis of anterior cer vical spin e plate xat ion system s w ith un icort ical and bicor t ical screw purchase. Eur Spine J 2004;13(1):6975
18. Seybold EA, Baker JA, Criscit iello AA, Ordw ay NR, Park CK, Con n olly PJ. Ch aracterist ics of un icor t ical an d bicor t ical lateral m ass
screw s in th e cer vical spin e. Spin e 1999;24(22):23972403
19. Ryken TC, Hu rlber t RJ, Had ley MN, et al. Th e acu te cardiop u lm on ar y m an agem en t of pat ien t s w ith cer vical spin al cord injuries.
Neurosu rger y 2013;72[suppl 2]:8492
20. Bucholz RD, Chang KC. Halo vest versus spinal fusion for cervical injury: Evidence from an outcom e study. J Neurosurg 1989;71(6):955
21. Son t ag VK, Hadley MN. Non operat ive m an agem en t of cer vical
spin e injuries. Clin Neurosurg 1988;34:630649
22. Hadley MN, Fit zp at rick BC, Son n t ag VK. Facet fract u re- dislocat ion
injuries of the cer vical sp in e. Neu rosurger y 1992;30:661666
23. Mon roe MA, Ball PA. Spin al t ract ion . In : Ben zel EC, ed. Sp in e
Surger y: Tech n ique, Com plicat ion , Avoidan ce, an d Man agem en t .
Ph iladelph ia: Saun ders; 1999:13531362
24. In am asa J. Gu iot BH. Ver tebral ar ter y inju r y after blu n t cer vical
t raum a: an update. Surg Neurol 2006;65:238246
25. Hadley MN, Beverly CW, Grabb PA, et al. Man agem en t of vertebral arter y injuries after n onpen et rat ing cer vical t raum a. In :
Neurosu rger y Sect ion on Disorders of th e Spin e an d Periph eral
Ner ves of th e Am erican Associat ion of Neurological Surgeons
an d th e Congress of Neu rological Su rgeon s Gu idelin es for th e
m an agem en t of acute cer vical spin e an d spin al cord injuries.
Neurosu rger y 2002;50(3):S173S178
26. Harrigan MR, Hadley MN, Dh all SS, et al. Man agem en t of ver tebral arter y injuries follow ing n on -pen et rat ing cer vical t raum a.
Neurosu rger y 2013;72[suppl 2]:234243

15

Classi cation and Treatment of


Thoracic Fractures
Joseph Hsieh, Doniel Drazin, Michael Turner, Ali Shirzadi, Kee Kim , and J. Pat rick Johnson

Introduction
Th oracic fract ures in h ealthy in dividuals are un com m on due
to th e st abilizing e ect of th e rib cage. How ever, h igh en ergy
t raum a an d predisposing con dit ion s can in crease th e likelih ood of fract u re.1 Alth ough th ere is n o id eal st an dard for classi cat ion of th oracolu m bar (TL) inju ries, th e evolu t ion of th e
th ree- colu m n m odel of Den n is, th e AO/Magerl com p reh en sive
classi cat ion , an d th oracolu m bar injur y severit y scale an d
score (TLISS)/th oracolu m bar inju r y classi cat ion an d severit y
score (TLICS) poin t system h ave provided sign i can t in sigh t
in to an atom y, m ech an ism of injur y, an d th e im plicat ion s an d
th erapies for in st abilit y.24 Mu lt iple su rgical tech n iqu es add ress
spin al in st abilit y, bu t th e ch oice of su rger y d ep en ds on th e level
of injur y an d an atom y.

Facets
Th e art icular processes arise from th e su perior an d in ferior

Ribs
Th e m ost dist inguish ing feat ures of th e th oracic spin e are th e

Indications
Th e goal of th oracic spin e fract ure t reat m en t is preven t ing deform it y, p roviding st abilit y, an d p rotect ing th e n eu ral elem en t s.
If con ser vat ive m an agem en t is deem ed in su cien t to p rovide
th ese goals, th en surgical m an agem en t sh ould be con sidered.
Su rger y sh ou ld be also con sidered as an adju n ct to h asten reh abilitat ion , sh or ten h ospit al st ays, an d par t icu larly in cases of
m u lt iple inju r y.

Anatomy
Th e th oracic spin e is th e longest spin e segm en t an d a com m on
site for t rau m a, esp ecially at it s low er segm en t s (T10-T12).5 Th e
th oracic spin e con sist s of 12 vertebrae w ith a physiologic kyph ot ic cur ve due to w edging of th e th oracic ver tebrae (a 2- to
3-m m di eren ce in an terior an d posterior h eigh t).6

Th e th oracic can al is n arrow ed w ith less free space for th e

Bony Structure

arch es posteriorly resist ten sion . Th e an terop osterior (AP)


diam eter of th e VB in creases from T1 to T12, w h ile th e t ran sverse d iam eter decreases from T1 to T3 an d th en in creases
to T12.7
Th e VB sides are con cave an d th e lam in ae are broad an d
h eavily overlapp ed. Th e pedicles p roject from th e sup erior
VB posteriorly. Th e lam in ae exten d dorsom edially from th e
pedicles to fu se an d form th e dorsal w all of th e spin al can al.

ribs an d th eir t w o vertebral art icu lat ion s. Sp eci cally, th e


rib h ead s art icu late w ith th e vertebrae an d th e disk. Th e rib
t ubercle ar t iculates w ith th e t ran sverse process at th e costot ran sverse ar t icu lat ion .
Dem ifacets above and below the disk articulate w ith the head of
the rib to form the costovertebral joint (a synovial joint divided
by an intraarticular ligam ent into t wo separate com partm ents).
Overall, th e rib cage provides th e th oracic spin e w ith t w o to
three t im es the load bearing capacit y before in stabilit y relat ive
to oth er spin e segm en ts. Sagit tal an d lateral exion - exten sion
are also stabilized. Th erefore, h igh m ech an ical forces m u st occur to cause thoracic vertebral injuriesoften w ith con current injuries to the ch est, cer vical spin e, and head.9
Th e radiate an d costot ran sverse ligam en t s bin d th e ribs to
th eir ver tebrae addit ion ally an d provide st abilizat ion .10

Spinal Cord

Th e ver tebral bodies (VB) an teriorly are load bearing an d th e

lam in ar surfaces.
From T1 to T10, the thoracic facets are oriented coronally. This
m inim izes an terior translation during exion. From T11 to T12,
the facets have an oblique sagittal orientation to lim it rotation.
Th e coron al facet orien t at ion of th e upper th oracic spin e allow s for rotat ion aroun d th e cran iocaudal axis (75 degrees of
rot at ion to each side) w ith th e greatest rot at ion at T8-T9.8 In
con t rast , lu m bar spin e rot at ion is lim ited by th e orien tat ion
of th e facet s an d an terior an n ulus to on ly 10 degrees.

spin al cord com pared to th e cer vical spin e.


Th e cen t ral th oracic spin e also h as a lim ited blood su pply,
w ith a low er th resh old for vascular cord injur y on kyph osis
or com pression th an th e lum bar spin e.
Sp in al cord inju r y to th e u p per th oracic spin e can h ave d evast at ing sequ elae w h ile root inju r y in th e th oracic sp in e is far
less fun ct ion ally relevan t th an in th e lu m bar sp in e.

Evaluation and Diagnosis


In it ial evalu at ion of t rau m a involves assessm en t for seriou s
life-th reaten ing injuries w ith rapid resu scitat ion as n ecessar y.

237

II Spinal Em ergency Procedures


Sp in al inju r y, w h ile com m on in m u lt ip le-system t rau m a, is frequen tly un recogn ized.11

Indications for Surgical


Management

Physical Spine Examination

Su rgical d ecom p ression is in dicated w h en th ere is n eu ral

A th orough sp in e exam in at ion is crit ical in th e in it ial com p re

h en sive t rau m a evalu at ion .


Direct exam in at ion in clu des visu al in sp ect ion an d palp at ion
of all spin al segm en t s.
A step -o , localized ten dern ess, or a soft sp ot (from lacerat ion , sw elling, or ecchym osis) m ay be th e on ly sign of
in st abilit y.
Soft-t issu e t rau m a to th e ch est or abdom en m ay suggest a
seat-belt inju r y w ith a TL exion -dist ract ion inju r y.

Neurologic Examination
Neu rologic exam sh ou ld in clu de m otor st rength , sen sor y

fu n ct ion , an d re exes.
If sp in al cord inju r y is su sp ected, serial exam s are n ecessar y
as th e n eu rologic exam m ay ch ange, esp ecially in set t ings of
in st abilit y.
Grading by th e Am erican Spin al Inju r y Associat ion (ASIA) Im pairm en t Scale docum en t s th e level an d severit y of th e spin al
cord injur y.
A rep eat evalu at ion sh ou ld be perform ed if in it ial evalu at ion
is in adequ ate.
Pat ien t s w ith sp in al cord inju r y sh ou ld be tested for perian al
sen sat ion , rect al ton e, an d bu lbocavern osu s re ex. Any su sp icious n dings w arran t im aging.
Sp in e precau t ion s sh ou ld rem ain in place u n t il sp in al t rau m a
is exclu ded.
Sp in al fract u res are m issed frequ en tly in set t ings of m u lt ip le
inju ries.1215

Indications for Conservative


Management
Con ser vat ive m an agem en t sh ould be con sidered anyt im e
a p at ien t can m ain t ain align m en t an d n eu rologic st abilit y w ith ou t su rger y.1 St able fract u res su ch as un com plicated
com pression fract ures m ay n ot require bracing as th e rib cage
an d stern u m bu t t ress th e sp in e.

Orthoses
If su pport is n eeded, com pression fract ures are rout in ely

238

t reated w ith an orth osis often w ith in clusion of th e cer vical


sp in e. Cer vical su p port cou ld in clu de a m an dible, occipital
pads, or halo ring an d m ay consist of a cer vicoth oracic orth osis
(CTO) or cer vicothoracolum bosacral orth osis (CTLSO).
Orth oses an d casts sh ou ld be u sed w ith cau t ion
Sen sor y de cits m ay lead to w ou n d breakdow n du e to
pressure ulcerat ion s from an orth osis. Skin con t act sh ould
be ch ecked frequen tly an d rout in ely. Em aciated pat ien t s
w ith poor soft t issue padding are especially at risk.
Orth oses an d cast s m aybe di cu lt for p at ien t s to rem ove
an d th e t m ay n eed to be adju sted over t im e.

com pression w ith w orsen ing n eu rologic de cit , w h ich m ay


in clu de w orsen ing m yelopathy or radicu lopathy.1
In cases w h ere th e inju r y is com plete, ASIA A, su rger y w ill
likely n ot resu lt in n eu rologic im provem en t; h ow ever, st abilizat ion of th e spin e m ay be ben e cial in facilit at ing reh abilitat ion an d pat ien t t ran sfers.
Su rgical stabilizat ion is in dicated for w orsen ing n eu rologic
de cit , disrupted posterior ligam en tous com plex (PLC), dislocat ion of th e th oracic spin e, failure to obtain or m ain t ain
correct ion by n on surgical m ean s, un acceptable deform it y,
an d in toleran ce to n on su rgical m an agem en t .
Den is described a th ree-colu m n m odel of th e spin e.2 Many
believe th at m ech an ical in st abilit y results from disrupt ion
of t w o or th ree of th e th ree colum n s.
Th e TLICS/TLISS p rovides gu id elin es for w h en su rgical in ter ven t ion is w arran ted. 4
W h ile a com pression fract ure of th e an terior colum n m ay be
m ech an ically stable in th e sh ort term , sign i can t kyp h osis or
VB collapse m ay lead to progressive deform it y over t im e.
Coh en et al recom m en d operat ive redu ct ion an d fu sion
for any n eu rologic dysfu n ct ion th at m eets th e follow ing
criteria 16 :
If any of th e com pressed vertebrae w edge fract ures m easu re over 40% in a you ng or m iddle aged adu lt
If th e com pression p ercen tages for th e adjacen t ver tebral
w edge fract u res com bin e to greater th an 50%
Acute kyph osis is presen t
Mu n t ing recom m en ds su rger y w h en sign i can t pain com bin ed w ith altered fun ct ion is reported for a post t raum at ic
deform it y exceeding 20 degrees of sagit t al in dex.17
Pain is often located abou t th e apex of th e deform it y.
Th is kyph ot ic deform it y m ay lead to com pen sator y hyperlordosis in th e lu m bar spin e an d/or hypokyph osis or
even lordosis in th e th oracic sp in e above th e lesion an d
cause pain ful m uscle spasm .
Oth er in dicators for surger y in clude in abilit y to m ain t ain
st raigh t vision du e to severe kyp h osis, pseu doar th rosis,
disk degen erat ion , progressive n eurologic de cit , an d
cosm esis.

Preprocedure Consideration
Radiographic Imaging
Correct diagnosis w ith physical exam m ay be di cult, particularly
in patients w ith altered m ental status, patients w ho are intubated
or sedated, and patients w ith m ultiple pelvis or lim b fractures.
Initial im aging (plain radiography or CT) is crucial in these cases.

Plain Radiography
AP an d lateral plain X-rays of th e th oracic an d lu m bar spin e
allow th e p hysician to cou n t th e n u m ber of rib - bearing vertebrae an d th e n um ber of lum bar vertebrae to en sure accu racy

15 Classi cation and Treatm ent of Thoracic Fractures


of surgical plan n ing. Care sh ou ld be taken to evaluate for
p ossible an atom ic varian t s (e.g., cer vical ribs or lu m barized
sacral ver tebrae). How ever, th e u p per th oracic colu m n is
p oorly visu alized on plain radiography.

Computed Tomography
Modern com puted tom ography (CT) allow s rapid characteriza-

tion of spinal fracture m orphology and provides critical detail


in the acute and therapeutic setting.1 In a study by Sm ith et al,
nonreconstructed CT detected TL fractures m ore accurately than
plain radiographs and is recom m ended for diagnosis of TL fractures in acute traum a for patients w ith altered m ental status.18
In form at ion in clu des can al n arrow ing d u e to ret rop u lsed
fragm en t s, bet ter evalu at ion of u n st able rot at ion al inju ries,
an d in d irect assessm en t of ligam en tou s an d d isk inju ries.
Facet dislocat ion an d posterior in terspin ous w iden ing due to
dist ract ion m ay dem on st rate a n aked facet sign .
CT m yelogram m ay dem on st rate areas of com p ression of th e
th ecal sac.

Magnetic Resonance Imaging


Magn et ic reson an ce im aging (MRI) dem on st rates associated

soft t issu e inju r y th at w ill n ot be visible on th e CT.


Occasion ally decom pression of th e sp in al cord from th ese
soft t issu e elem en ts w ill be in dicated even for fract u res th at
app ear to be st able on CT.
If th e fract u re ap pears to be associated w ith som e p ath ology,
th en it m ay be h elpful to in clude en h an ced im ages in th e MRI
to determ in e if th e bon e appears to h ave an associated in fect ion or t um or.

Medication

Steroids h ave had w axing an d w an ing p opularit y in th e set-

t ing of acute spin al cord injur y. If th ere is a neurologic injur y,


som e report s h ave in d icated th at h igh dose m ethylp redn isolon e h as given som e ben e t .19 How ever, th ese in it ial repor t s
h as n ot been replicated, an d th e risk to th e p at ien t con com it an t w ith steroid use in clu ding life-th reaten ing in fect ion s is
n ot in con siderable.20 Recen t gu idelin es h ave recom m en ded
again st th eir u se.21
An t ibiot ics: If th e pat ien t h as an associated in fect ion , it m ay
be ben e cial to obtain a specim en for cult ure prior to st ar t ing
an t ibiot ics. Oth er w ise st an dard preoperat ive an t ibiot ics are
u sed, t ypically cefazolin .

Operative Management

Guidelines for Management


Th ere is n o con sen sus on th e best t reat m en t for TL spin e
inju ries. As a rule of th um b, posterior decom p ression
(e.g., lam in ectom y) m ay be e ect ive for posterior spin al cord
com pression in a st able spin e. How ever, lam in ectom y w ith out in st rum en t at ion m ay dest abilize a spin e th at already h as
dam age to an oth er colu m n an d th erefore is in appropriate
w h en ever stabilit y is in quest ion . For an terior com pression ,

t ypically an terior approach is preferred w ith con siderat ion of


an atom ic lim it at ion s.
McAfee et al p rovided on e of th e earliest gen eral t reat m en t
gu id elin es based on sp eci c inju r y p at tern s.22
Com p ression fract u re: obser vat ion w ith follow -u p or p refabricated brace im m obilizat ion for 12 w eeks
St able bu rst: cu stom t t ing orth osis or cast im m obilizat ion
for 12 w eeks. L4 an d above: TLSO; L5: HTLSO; if kyp h osis
. 15 degrees, hyperexten sion cast .
Un stable bu rst: su rgical decom p ression an d st abilizat ion
(approach con t roversial). Con sider em ergen t posterior
sh or t-segm en t d ecom p ression an d fu sion (w ith extern al
im m obilizat ion in a custom TLSO for 12 w eeks), an d delayed an terior decom pression an d fusion if th e p at ien t h as
n eu rologic d e cit an d residu al cord/root com pression .
Flexion -dist ract ion (an d Ch an ce inju r y): con sider hyperexten sion cast for a p u rely osseou s inju r y w ith n o associated n eurologic de cit . Con sider posterior sh or t-segm en t
st abilizat ion an d fu sion for associated n eu rologic inju r y
or abdom in al injur y or w h en spin e injur y is prim arily
ligam en tou s.
Fract u re-d islocat ion : p osterior long-segm en t su rgical st abilizat ion w ith pedicle screw xat ion t w o to th ree levels
above an d below th e inju r y w ith local bon e graft fu sion .
In t h e 1990s, t h e rst m u lt icen ter st u dy (MCSI) of t h e Sp in e
St u dy Grou p of t h e Ger m an Associat ion of Trau m a Su rger y
sh ow ed lim it at ion s for isolated p oster ior in st r u m en t an d
fu sion tech n iqu es in cases w it h a com p rom ised an ter ior
colu m n .
Sin ce then , operat ive approach es an d adju n cts h ave advan ced
con siderably to in clude en doscopic an d m in im ally invasive
su rger yadvan ces in in terbody su p p or t an d in t raoperat ive
n avigat ion .
Th e secon d m ult icen ter st udy (MCSII) of th e Spin e St udy
Group of th e Germ an Associat ion of Trau m a Su rger y review ed t rau m at ic TL (T1-L5) inju ries as an u p date to MCSI. Of
733 pat ien ts w ith acu te TL injuries t reated surgically 23 :
380 (51.8%) p at ien t s w ere op erated on by posterior st abilizat ion an d in st rum en tat ion alon e
34 (4.6%) h ad an an terior p rocedu re alon e
319 (43.5%) h ad com bin ed p osteroan terior p rocedu res.
Overall th ey fou n d:
Sh or t angular stable im plan t system s h ave replaced con ven t ion al n on angu lar stabilizat ion system s.
Post t rau m at ic deform it y w as restored best w ith com bin ed posteroan terior surger y.
Di eren t surgical approach es did n ot h ave a sign i can t
in uen ce on n eurologic recover y on 2-year follow -up .
Five percen t of all pat ien ts required revision surger y for
p erioperat ive com p licat ion s.
Th e m ost com m on surgical in ter ven t ion s for th oracic inju ries
are described below.

Operative Field Preparation


Positioning
Th e pat ien t is in t u bated supin e an d th en posit ion ed carefully

as n eeded.
Pressu re poin t s are padded.

239

II Spinal Em ergency Procedures


In t raoperat ive m on itoring in clu ding som atosen sor y evoked
poten t ials (SSEP) an d m otor evoked poten t ials sh ould be
con sidered.

Localization
Im aging an d p hysical exam review is crit ical to d eterm in e
th e su rgical levels. Preoperat ive im aging m ay in clu de localizat ion u sing cross t able lateral p lain lm s w ith a radiopaqu e
m arker.

Prior to Incision
Th e skin is prepped in sterile fash ion an d th e in cision is in lt rated w ith lidocain e 1% w ith epin eph rin e 1:100,000

Approaches
Su rgical ap proach es to th e th oracic sp in e can be divided in to
posterior, posterolateral, an d an terior. These approach es can
also be com bin ed in th e sam e p roced u re or staged . Ult im ately,
th e approach w ill depen d on th e path ology, locat ion , spin al
cord com pression , in st abilit y, an d m edical con dit ion .

Posterior Approach
Poster ior ap p roach es to t h e t h oracic sp in e are t h e m ain st ay of sp in e p roced u res. Th e id eal p at h ology for t h ese ap p roach es is gen erally p oster ior to t h e sp in al cord . Th e m ost
com m on p oster ior ap p roach (lam in ectom y w it h or w it h ou t
in st r u m en t at ion ) is u sed com m on ly for rad icu lom yelop at hy
from t h oracic d isk h er n iat ion , sp on dylosis, an d t rau m a w it h
st able sp in e alon g w it h som e t u m ors an d in fect ion . How ever,
it is d i cu lt to access ven t ral p at h ology w it h ou t r isk of sp in al
cord inju r y.
Th ese approach es can be tailored for access to a region of in terest from directly m idlin e to th e spin al can al (e.g., lam in ectom y) to fu rth er p osterolateral in at tem pt s to reach an terior
to th e can al (e.g., t ran sp ed icu lar, costot ran sversectom y, lateral
ext racavit ar y ap proach es).

240

Posterolateral Approaches to the


Anterior Thoracic Spine
Posterolateral approaches to the anterior thoracic spine include
the transpedicular, costotransversectomy, and posterolateral extracavitary. These provide progressively greater visualization of the
anterior spine as exposure extends farther laterally from m idline
w ith greater dissection of the ribs. The transpedicular corpectom y
is the easiest progression from the direct m idline approach and is
illustrated here. It avoids surgical m orbidit y of anterior exposure
w hile providing relatively good access to the anterolateral spinal
cord and m ay be perform ed in com bination to lam inectom y. The
costotransversectomy utilizes a m idline or param edian incision
and involves com plete rem oval of the rib head and transverse process and provides greater visualization for partial vertebrectom y.
The lateral extracavitary approach utilizes a hockey stick posterolateral incision w ithout violating the chest cavit y and provides
good visualization and decom pression of the anterior thecal sac.
These approaches are discussed in Special Considerations

Anterior Approach: Thoracotomy


Anterior exposure to the thoracic spine is often critical in traum a.
Anterior exposure m akes it far easier to perform m ultilevel decom pression and stabilization through a single approach w ith
possibilit y of anterior stabilization. For fractures involving the anterior elem ents of T1 or T2, an anterior approach can be used that
is sim ilar to an anterior cervical corpectom y and fusion. However,
T3-T5 cannot be reached e ectively from the front unless the chest
is opened by perform ing a m anubrial resection or sternotom y and
are often best accessed through a transthoracic approach.
Tran sth oracic app roach es (e.g., th oracotom y an d th oracoscopy) provide several ben e ts in com parison to posterior or
posterolateral approach es. A t ran sth oracic approach provides
opt im al exposure of th e an terior dura an d posterior longit udin al ligam en t . How ever, th e t radeo in clu des redu ced exp osu re
to th e posterior sp in e. Th ere are also associated com p licat ion s
in clu ding pn eu m oth orax, pu lm on ar y con t u sion , pn eu m on ia,
pleural e usion , em pyem a, an d possible n eed for an access
su rgeon . W h ile th oracotom y is th e m ain stay, th oracoscopy h as
becom e in creasingly an opt ion .

15 Classi cation and Treatm ent of Thoracic Fractures

Operative Procedure
Posterior Approach (Fig. 15.1ac and Fig. 15.2)

Fig. 15.1ab Twent y-six-year-old man involved


in an all-terrain vehicle accident. CT showed a
T10-T11 fracture-dislocation with signi cant
angulation of the thoracic spine. The spinous
process of T10 is (a) fractured along with
(b) dislocated and (c) jumped facets.

241

II Spinal Em ergency Procedures

Fig. 15.2 MRI in same patient showed narrowing of the spinal canal with cord compression at that level. Fortunately,
the patient was moving his lower extremities.

242

15 Classi cation and Treatm ent of Thoracic Fractures

Positioning and Localization (Fig. 15.3)

Figure

Procedural Steps

Pearls

Fig. 15.3

The patient is positioned prone on a radiolucent


table w ith chest bolsters. Pressure points are
padded. The level of surgery is determined and a
posterior midline incision is planned. The surgical
eld is prepped and draped.

Positioning can lead to deterioration of the patient. In patients

with severe stenosis or instabilit y, it is helpful to obtain baseline


SSEP prior to positioning. Surface electrodes are placed on the
patient in the preoperative area to save tim e during patient
positioning. Needle electrodes are placed after anesthesia is
induced. Baseline is run in the room after anesthesia is induced
for comparison after the patient is positioned and throughout
the case.
The level is determ ined anatom ically and m arked by taping a
paperclip to the chest wall at the surgical level. A cross table
lateral plain X-ray is taken and the surgical site m arked. It is
optim al to count from the top and bot tom if possible. Prep a large
area rostrally and caudally to allow for extension of the incision
and to allow drain placem ent.

243

II Spinal Em ergency Procedures

Skin, Subcutaneous, and Subperiosteal Dissection (Fig. 15.4)

244

Figure

Procedural Steps

Pearls

Fig. 15.4

The skin is in ltrated w ith lidocaine and the incision is opened w ith a no. 10 blade
to the subcutaneous tissue. Hemostasis is obtained w ith monopolar cautery.
The subcutaneous tissue is dissected dow n to the fascia w ith monopolar cautery.
Cerebellar retractors are used at this point to re ect the tissue. The bone of the
spinous process is palpated and a subperiosteal dissection is made by cutting
the muscular and tendinous attachments directly o the bone. Dissection should
continue dow n, follow ing the lamina, and out laterally to the beginning of the facet
complex. If there is signi cant bleeding then it may be more e ective to sw itch to
bipolar cautery to achieve hemostasis. The levels are veri ed by placing tw o metal
instruments in the incision such that the tips mark the rostral and caudal extent of
the anticipated bony dissection. A cross-table plain X-ray or uoroscopic image is
taken to verify the correct level of surgery.

A cell salvage m achine, if

available, should be utilized.


Care m ust be taken to
prevent the monopolar
cautery from slipping though
the interlam inar space.

15 Classi cation and Treatm ent of Thoracic Fractures

Spinous Process Removal (Fig. 15.5)

Figure

Procedural Steps

Fig. 15.5

The interspinous ligament can be cut using monopolar cautery or scissors allow ing removal of the spinous process
w ith a Horsley.

245

II Spinal Em ergency Procedures

Laminectomy, if Indicated (Fig. 15.6)

246

Figure

Procedural Steps

Pearls

Fig. 15.6

Using a high speed drill, the lamina is thinned to a layer of cortical bone
over the ligamentum avum. The bone can then easily be removed
w ith a 2-mm Kerrison punch. Hemostasis should be achieved by
application of bone w ax to the bleeding cut surface of the bone.

Take care to avoid downward pressure


with the Kerrison.

15 Classi cation and Treatm ent of Thoracic Fractures

Removal of Ligament (Fig. 15.7)

Figure

Procedural Steps

Pearls

Fig. 15.7

Once the laminectomy has extended anteriorly beyond the


attachment of the ligamentum avum, it is easy to elevate aw ay
from the thecal sac and remove w ith a Kerrison punch. Removal
of the ligament w ill likely result in bleeding of epidural veins.
If these are visible, these can be cauterized w ith bipolar cautery.
Remove any remaining bone and ligament in the lateral recess
(1). Probe the foramen w ith a ball probe or Woodson to make
sure that the nerve roots are not severely compressed (2).

Decrease the strength of the bipolar cautery

prior to using the instrum ent near the thecal sac.


For hem ostasis, apply bone wax to bleeding
bone, and then apply a line of gelatin-throm bin
matrix down the length of each gut ter. Cover
with a pat tie and wait a few m inutes to allow
clot form ation. Wash out the excess and repeat
as needed.

247

II Spinal Em ergency Procedures

Thoracic Pedicle Screw Entry Point (Fig. 15.8)

248

Figure

Procedural Steps

Pearls

Fig. 15.8

Start the entry point w ith an aw l or high speed drill. Use


uoroscopy to verify position. Insert the pedicle nder
through the cancellous bone of the pedicle (1). Use
uoroscopy to verify position. Using a ne ball tipped probe,
feel all four sides and the bottom of the hole to make sure
that there is no breach (2).

Screw entry point di ers at each level but is generally


toward the m edial anterior quadrant of the facet
complex. The pedicle nder generally has a slight
curve to it and should be facing out ward initially,
and then turned inward when the vertebral body
is reached.

15 Classi cation and Treatm ent of Thoracic Fractures

Screw Placement (Fig. 15.9)

Figure

Procedural Steps

Fig. 15.9

Tap the hole w ith the appropriate sized tap (1). Insert the screw into the hole (2). Use uoroscopy to verify position.

249

II Spinal Em ergency Procedures

Rod Placement (Fig. 15.10)

250

Figure

Procedural Steps

Fig. 15.10

When all pedicle screw s have been placed, insert a malleable temporary rod through the polyaxial screw heads to
determine the shape and length of the rod. Cut the rod to the appropriate size, and bend it to t. Fit the rod though
the screw heads and a x screw caps. When the rod ts and all screw caps are in place, use the nal tightener to
lock the screw caps dow n.

15 Classi cation and Treatm ent of Thoracic Fractures

Posterolateral Approach: Transpedicular Corpectomy (Fig. 15.11)

b
Fig. 15.11 Sagit tal CT reconstructions of an 18-year-old woman who was involved in a motorcycle accident, sustaining thoracic fracture
dem onstrating (a) T6 and (b) T10 burst fractures with kyphotic angulation. (a) In addition, at the T5-6 level she had a fracture-dislocation with T5
laminar and spinous process fractures. The patient was able to move her lower extremities with some sensation. However, due to the fact that she
had grossly unstable spine, she was kept on bedrest until surgical stabilization could be performed.

251

II Spinal Em ergency Procedures

Removal of Facet Complex (Fig. 15.12)

252

Figure

Procedural Steps

Pearls

Fig. 15.12

After pedicle screw placement, a single rod contralateral to the side of


surgical approach is placed to stabilize the spine during the corpectomy.
The muscular and tendinous attachments need to be removed w ider than
w ith a laminectomy. Remove tissue using monopolar cautery out to the
edge of the facet complex and rib head.

Prior to perform ing the corpectomy,


the spine will need to be stabilized
to prevent stretching, torque, or
translocation.

15 Classi cation and Treatm ent of Thoracic Fractures

Drill (Fig. 15.13)

Figure

Procedural Steps

Fig. 15.13

Using a high speed drill, remove the facet complex, lamina, pars interarticularis, and pedicle on the side of the
chosen approach. The neurovascular complex is ligated. The exposure should be from the pedicle of the level above
to the pedicle of the level below.

253

II Spinal Em ergency Procedures

Corpectomy and Diskectomy (Fig. 15.14)

254

Figure

Procedural Steps

Pearls

Fig. 15.14

The corpectomy is done w ith a combination of drilling and using the Kerrison
rongeur (1). Use curette to scrape disk material o the endplate (2). Remove
the disk w ith a pituitary.

Use uoroscopy to check depth


often so as not to overshoot the
depth of the vertebral body.

15 Classi cation and Treatm ent of Thoracic Fractures

Rib Head Trap Door Osteotomy (Fig. 15.15)

Figure

Procedural Steps

Pearls

Fig. 15.15

Partially cut through the rib head until the deep surface
becomes thin enough to bend. When this is achieved,
the spacer can be slid past the rib head for placement.
Size the distance from the rostral to caudal endplates of
the levels above and below. Then insert the spacer lateral
to the thecal sac taking care not to put any pressure on
the cord.

Expandable titanium cages, nonexpendable graft,


cadaveric fem ur, and other implants are all possibilities
following corpectomy. Regardless of option, fusion across
a corpectomy is often hindered by the long distances that
the fusion needs to occur. Therefore, additional m easures
m ust be taken to ensure adequate stabilization.

255

II Spinal Em ergency Procedures

Pedicle Screw s (Fig. 15.16)

256

Figure

Procedural Steps

Fig. 15.16

Insert the remaining pedicle screw s on the operative side then t and lock in a second rod.

15 Classi cation and Treatm ent of Thoracic Fractures

Anterior Approach: Transthoracic Vertebrectomy (Fig. 15.17a, b)

b
Fig. 15.17 (a) Sagit tal CT and (b) MRI images of a 38-year-old man who was riding on a monster truck at a rally when he crashed, sustaining a T12
burst fracture with spinal cord injury. The imaging shows retropulsion of the T12 vertebral body with approximately 50% canal compromise with a
conus injury and cord signal changes. There was also associated kyphotic deformit y.

257

II Spinal Em ergency Procedures

Transthoracic Vertebrectomy
Positioning and Approach Planning (Fig. 15.18)

258

Figure

Procedural Steps

Pearls

Fig. 15.18

The patient is positioned in the lateral


decubitus position. An axillary role is placed
to prevent injury to the brachial plexus.
The dependent leg is bent forw ard and the
upper leg is supported on pillow s. A dual
lumen endotracheal tube is used so that
the dependent lung is ventilated and the
superior lung, ipsilateral to the lesion, is
collapsed. A w ide area is included in the prep
to allow exposure of the entire thoracic spine
and ipsilateral rib cage. The table is elevated
under the patients chest to spread the ribs
on the ipsilateral side.

The patient m ust be intubated with a double lum en endotracheal

T1 to T4 can be approached anteriorly


utilizing resection of the third rib. The
incision w ill follow the medial border of the
scapula and extend caudally. The incision w ill
end at the sternocostal junction of the third
rib. For levels T5 to T9, the rib above the level
to be operated on is removed. For levels T10
to T12, the rib tw o levels above the level in
question is removed.

Often the lesion will determ ine the lateralit y but in cases of m idline

tube in order to allow single lung ventilation. This underscores the


fact that the patient m ust be able to tolerate single lung ventilation
for the procedure. If the patient has too m any com orbidities, then this
approach m ay be rejected over a posterior approach. If direct lateral
mini thoracotomy with specialized retractors is utilized, single lum en
ventilation will su ce.

lesions or lesions that span the entire vertebral body, the vascular
anatomy m ay dictate the approach. The position of the aorta needs to
be reviewed on CT to determ ine if it will be in the way. The vena cava
is t ypically m idline and rarely a ects the choice of left versus right.
The aorta has a m ore variable position, but often surgery above T9
is best approached from the right. Below T9 the left side is an easier
approach as the liver pushes up on the diaphragm on the right.

15 Classi cation and Treatm ent of Thoracic Fractures

Dissection (Fig. 15.19)

Figure

Procedural Steps

Fig. 15.19

The muscular layers are divided using electrocautery. The muscles transected are the trapezius, latissimus dorsi,
then the rhomboids, and nally serratus. The rib is identi ed, dissected free, and resected. The neurovascular
bundle is identi ed, ligated, and cut.

259

II Spinal Em ergency Procedures

Vertebrectomy (Fig. 15.20)

260

Figure

Procedural Steps

Pearls

Fig. 15.20

The vertebral body is removed w ith the drill and Kerrison


rongeurs. The disks above and below are removed dow n
the endplates. The thecal sac should be protected at all
times if decompression is required.

Remem ber that from T1 to T9 the rib articulates with


the vertebral bodies of the corresponding thoracic level
and the level above. Below T9, the rib articulates with
the sam e thoracic level.

15 Classi cation and Treatm ent of Thoracic Fractures

Fusion and Instrumentation (Fig. 15.21a, b)

Figure

Procedural Steps

Fig. 15.21

(a) An appropriately sized spacer, either rib autograft, femoral allograft, or cage is inserted. (b) A plate and
screw s are placed to provide rigid xation.

261

II Spinal Em ergency Procedures

Closing
Su rgical w ou n ds are closed in layers.
A drain is placed above the fascia to prevent hem atom a form ation.
Th e skin is closed w ith inverted 3-0 absorbable sut ures fol

low ed by ben zoin an d adh esive st rips.


An terior procedu res requ ire w ou n d closu re arou n d a ch est
t ube to allow drain age from th e pleu ral space. A ch est t ube
is p laced un der d irect visualizat ion . It can be placed directly
on w ater seal if n o leak is suspected. Th e w oun ds are closed.
A p ostoperat ive ch est X-ray is obt ain ed to ch eck for p n eu m oth orax or h em oth orax. Th e ch est t ube can be rem oved w h en
out pu t is less th an 100 m L/day.

Postoperative Management
Pat ien t s sh ou ld be follow ed closely p ostop erat ively w ith n eurologic ch ecks. Th e acu it y of care w ill dep en d on th e exten t
of th e surger y an d th e exten t of n eurologic com prom ise.
Pat ien t s w ith m ore exten sive procedu res th at are at risk for
m ore exten sive blood loss sh ou ld be obser ved overn igh t in
th e in ten sive care un it .

Medication
Postop erat ive an t ibiot ics sh ou ld be adm in istered for 24 h ou rs
or as long as th e drain is in place.

Radiographic Imaging
Postop erat ive

lm s sh ou ld be obtain ed to visu alize th e


con st ru ct an d th e degree of realign m en t of th e spin e. Th is
allow s com parison of th e fusion con st ruct during follow -u p
(Figs. 15.22, 15.23, an d 15.24).
If th e p at ien t h as any n ew sym ptom s or fails to im prove, th en
m ore detailed im aging is in dicated su ch as MRI.

Further Management
Th e pat ien t sh ould h ave lim ited physical act ivit y w ith n o

ben ding, lift ing, or t w ist ing un t il th e fusion h as h ad t im e for


com plet ion , best visualized by postoperat ive X-ray or CT.
After th at t im e, th en th e pat ien t m ay ben e t from physical
th erapy to regain st rength .

b
Fig. 15.22a, b Postoperative (a) AP and (b) lateral radiographs of the patient depicted in Figs. 15.1 and 15.2 underwent open
reduction and T9 to T12 arthrodesis instrumentation using pedicle screws, rods, and a cross connector with in situ autograft,
cancellous allograft 90 mL, and demineralized bone matrix 20 mL. He was fully recovered at his 1-year postoperative visit.

262

15 Classi cation and Treatm ent of Thoracic Fractures

b
Fig. 15.23a, b (a) Lateral and (b) AP radiographs of open reduction procedure in patient depicted in Fig. 15.11. This procedure included
anterior T6 and T10 corpectomies using t wo titanium cages packed with in situ autograft. Also performed were T5 laminectomy,
T6-7 decompression laminotomies, and T3-T11 arthrodesisinstrumentation using sublaminar hooks, pedicle screws, rods, and
cross links, supplemented with in situ autograft, demineralized bone matrix, and cancellous allografts.

a
Fig. 15.24a, b Postoperative (a) sagit tal and (b) coronal images of the same patient depicted in Fig. 15.17. He underwent a minimally
invasive transthoracic transdiaphragmatic exposure from T11 to L1 and T12 corpectomy and decompression on spinal cord. T11 to
L1 arthrodesis instrumentation was performed using an expandable titanium cage packed with in situ autograft, rib strut autograft,
and thoracolumbar plate with screws.

263

II Spinal Em ergency Procedures

Special Considerations
Posterolateral app roach es su ch as th e costot ran sversectom y
an d lateral ext racavit ar y ap proach es p rovide greater exposu re
to th e lateral p or t ion of th e ver tebral can al an d th e an terolateral port ion of th e th oracic vertebral bodies. Costot ran sversectom y m ay be u sed in th e rem oval of t rau m at ic bon e fragm en t s
or oth er foreign bodies in t raum a an d is u seful in cases w h ere
a pat ien t m ay n ot tolerate a form al th oracotom y eith er du e to
age or p u lm on ar y p ath ology. It is less u seful in cases w h ere th e
an terior can al n eeds to be fu lly visu alized or for oth er m idlin e
path ology.
In costot ran sversectom y, th e pat ien t m ay be placed pron e,
sem ip ron e, or in m odi ed lateral decu bit u s p osit ion . In t u bat ion
w ith a double lum en cu ed en dot rach eal t ube is again recom m en ded as p n eu m oth orax is a possibilit y. Th e ap proach sh ou ld
be on th e side of th e inju r y, or if m idlin e, on th e righ t to avoid
th e arter y of Adam kiew icz w h ich usually origin ates on th e left
side bet w een T8 to L2. Th e in cision is m idlin e (som et im es w ith
a T) or p aram ed ian w ith or w ith ou t a h ockey st ick rela xing
in cision . If th e in cision is param edian , th e m uscles (t rapezius
an d lat issim u s dorsi) are re ected m edially. Midlin e in cision s
requ ire subperiosteal dissect ion s. Th e ribs to be rem oved are
skeleton ized su bperiosteally. En t ran ce to a d isk sp ace requ ires
exp osu re of th e in ferior rib (e.g., T9-T10 disk sp ace requ ires exposure of th e 10th rib). Th e art icu lat ion s th at m ust be addressed
in clu de th e su perior an d in ferior costal facet an d t ran sverse
cost al facet . Th e pleura is m obilized an d re ected from th e un derside th e rib an d an terolateral posit ion of th e spin e. Th e rib
of in terest is th en t ran sected approxim ately 5 cm from th e rib
h ead. Th e foram en can then be iden t i ed by follow ing th e n eu rovascular bu n dle t ravelling on th e in ferior surface of th e rib.
Th e pedicles can th en be iden t i ed above an d below th e foram en w h ich can be resected to visu alize th e lateral th ecal sac.
Th e pleu ral an d in tercost al m uscles are blun tly dissected aw ay
from th e vertebral body. Bon e from th e lateral ver tebral body
or disk m ay be rem oved as required w ith care n ot to dam age
th e radicular arteries. On ce th e decom pression or diskectom y
is com p lete, in st ru m en ted or n on in st rum en ted fusion m ay be
con sidered based on path ology. Again , par t ial vertebrectom y
m ay be ach ieved. Pleu ral tears are rep aired if p resen t an d ch est
t ubes are used if n ecessar y.
Th e lat e ral ext racavit ar y ap p roach is a m ore exte n sive p oste rolat e ral ap p roach w h ich again d oes n ot violat e t h e ch est
cavit y. Th e p at ie n t is p lace d in a p ron e p osit ion . A h ockey
st ick (m id lin e in cision cu r ve d 4 5 d egre es o m id lin e for 6 to
8 cm in t h e low e r p or t ion ) or p aram e d ian in cision (ce n t e re d
ove r t h e lat e ral p arasp in al m u scles) can be u se d . A p lan e is
d evelop e d b et w e e n t h e su p e r cial an d d e e p p arasp in al m u scles, an d a m yocu t an e ou s ap is lift e d o to exp ose t h e lat eral p arasp in al m u scles an d r ib cage. Th e p arasp in al m u scles
are t h e n m ob ilize d from t h e r ib an d t ran sve rse p rocess. Th e
r ibs, ligam e n t ou s at t ach m e n t s, an d associate d t ran sve rse
p rocesses are t h e n re m ove d . Sim ilarly to ab ove, t h e n e u ro vascu lar b u n d le is isolat e d an d act s a gu id e for id e n t i cat ion of t h e resp e ct ive foram e n an d p e d icles. Th e re m ain d e r
of exp osu re is com p let e d sim ilarly t o t h e ot h e r p oste rolate ral
te ch n iqu es.

264

References
1. Vialle LR, Vialle E. Th oracic sp in e fract u res. Inju r y 2005;36
Suppl 2:B6572
2. Den is F. Th e th ree colu m n sp in e an d it s sign i can ce in th e classi cat ion of acu te th oracolum bar spin al injuries. Spin e (Ph ila Pa
1976) 1983;8(8):817831
3. Magerl F, Aebi M, Ger t zbein SD, Harm s J, Nazarian S. A com p reh ensive classi cat ion of th oracic an d lu m bar injuries. Eur Spin e J
1994;3(4):184201
4. Vaccaro AR, Leh m an RAJ, Hu rlber t RJ, et al. A n ew classi cat ion
of th oracolum bar injuries: th e im por t an ce of injur y m orph ology,
th e in tegrit y of th e p osterior ligam en tou s com p lex, an d n eu rologic st at us. Spin e (Ph ila Pa 1976) 2005;30(20):23252333
5. el-Kh ou r y GY, W h it ten CG. Trau m a to th e u p p er th oracic sp in e:
an atom y, biom ech an ics, an d un ique im aging feat ures. AJR Am J
Roen tgen ol 1993;160(1):95102
6. Maim an DJ, Pin t ar FA. An atom y an d clin ical biom ech an ics of th e
th oracic spin e. Clin Neu rosu rg 1992;38:296324
7. Lou is R. Su rger y of th e Sp in e. New York: Sp ringer; 1983
8. W h itesid es TEJ. Trau m at ic kyp h osis of th e th oracolu m bar sp in e.
Clin Orth op Relat Res 1977;(128):7892
9. Boh lm an H. H. Treat m en t of fract u res an d d islocat ion s of th e
th oracic an d lu m bar spin e. J Bon e Join t Su rg Am 1985;67(1):
165169
10. An driacch i T, Sch u lt z A, Belyt sch ko T, Galan te J. A m odel for st u dies of m ech an ical in teract ion s bet w een th e h um an spin e an d rib
cage. J Biom ech 1974;7(6):497507
11. Sm ith JS, Bh at ia N. Th oracic sp in al st abilit y: d ecision m aking.
In Patel V, Burger E, Brow n C, eds. Spin e Traum a: Surgical Tech n iques. Berlin : Springer, 2010: 213228
12. An derson S, Biros MH, Reardon RF. Delayed diagn osis of th oracolum bar fract ures in m u lt iple-t raum a pat ien t s. Acad Em erg Med
1996;3(9):832839
13. St an islas MJ, Lath am JM, Por ter KM, Alpar EK, St irling AJ. A h igh
risk group for th oracolum bar fract ures. Inju r y 1998;29(1):1518
14. van Beek EJ, Been HD, Pon sen KK, Maas M. Up p er th oracic sp in al fract ures in t raum a pat ient s - a diagn ost ic pitfall. Injur y
2000;31(4):219223
15. Argen son C. Traitem en t des fract u res d u rach is d orso-lom baire
ch ez ladu lte. Cah iers den seignem en t de la SO FCOT Con feren ces
. 1984
16. Coh en MS, BlairB. Th oracolu m bar com p ression fract u res. AM
Levin e. 1998
17. Mu n t ing E. Su rgical t reat m en t of p ost-t rau m at ic kyp h osis in
th e th oracolu m bar sp in e: in dicat ion s an d tech n ical asp ect s. Eu r
Spin e J 2010;19 Suppl 1:S6973
18. Sm ith MW, Reed JD, Facco R, et al. Th e reliabilit y of n on recon st ru cted com p u terized tom ograp h ic scan s of th e abdom en an d
pelvis in detect ing th oracolu m bar sp in e inju ries in blu n t t rau m a pat ien t s w ith altered m en t al st at us. J Bon e Join t Surg Am
2009;91(10):23422349
19. Bracken MB, Sh epard MJ, Collin s W F, et al. A ran dom ized, con t rolled t rial of m ethylpredn isolon e or n aloxon e in th e t reatm en t of acute spin al-cord injur y. Result s of th e Secon d Nat ion al
Acu te Spin al Cord Injur y St udy. N Engl J Med 1990;322(20):
14051411
20. Gern dt SJ, Rodrigu ez JL, Paw lik JW, et al. Con sequ en ces of h igh dose steroid th erapy for acute spin al cord inju r y. J Traum a
1997;42(2):279284
21. Hu rlber t RJ, Hadley MN, Walters BC, et al. Ph arm acological th erapy for acu te sp in al cord inju r y in gu idelin es for th e m an agem en t

15 Classi cation and Treatm ent of Thoracic Fractures


of acute cer vical spin e an d spin al cord injuries. Neurosurger y
2013;72[suppl 2]:93105
22. McAfee PC, Yu an HA, Fredrickson BE, Lu bicky JP. Th e valu e of
com pu ted tom ography in th oracolum bar fract ures. An an alysis
of on e h un dred con secut ive cases an d a n ew classi cat ion .
J Bon e Join t Su rg Am 1983;65(4):461473

23. Rein h old M, Kn op C, Beisse R, et al. Operat ive t reat m en t


of 733 pat ien t s w ith acute th oracolum bar spin al injuries:
com preh en sive result s from th e secon d, prospect ive, In tern etbased m ult icen ter st udy of the Spin e St udy Group of th e Germ an Associat ion of Traum a Surger y. Eur Spin e J 2010;19(10):
16571676

265

16

Thoracolumbar Fractures
Michael Y. W ang and Brian Hood

Introduction
Th e t ran sit ion zon e at th e th oracolum bar jun ct ion di ers bio m ech an ically from th e st i th oracic spin e to th e m obile lu m bar spin e. Th is zon e of t ran sit ion is related to th e loss of th e
rib cage as w ell as th e ch anging orien tat ion of th e facet join ts.
Becau se of th ese factors th is area is p ron e to t rau m at ic inju r y
an d accou n t s for ap proxim ately u p to 50% of all vertebral body
fract u res an d u p to 40% of all spin al cord inju ries.1,2
Man agem en t of th oracolu m bar fract u res is a con t roversial
topic in con tem porar y spin e su rger y. Early su rger y for decom p ression an d st abilizat ion is gen erally accepted for pat ien t s
w ith clear in st abilit y an d an in com plete n eu rologic inju r y. Advan t ages of su rger y in clu de a bet ter correct ion of deform it y
th an closed redu ct ion an d bracing, an opport un it y to perform
d irect or in d irect decom p ression of th e n eural elem en t s, decreased requ irem en t for extern al im m obilizat ion , an d few er
com plicat ion s du e to prolonged recu m ben cy. Th e su rgical
t reat m en t is m ore con t roversial for pat ien t s w ith m ild to m oderate d eform it y, w ith ou t n eu rologic de cit , an d residu al sp in al can al com p rom ise, an d th e ideal solu t ion rem ain s largely
u n kn ow n .1,39

Classi cation
Th e m ost com m on fract ure pat tern s at th e th oracolum bar jun ct ion in clude com pression fract ures, burst fract ures, exion -dist ract ion injuries, an d fract ure-dislocat ion s.

Denis Classi cation


Compression Fractures
Failu re of th e an terior colum n in exion /com pression
A: Failure of th e superior an d in ferior en dplates
B: Su p erior ver tebral en d plate failu re (m ost com m on t yp e of
com pression fract ure)
C: In ferior ver tebral en dplate failure
D: Failu re of th e cen t ral vertebral body w ith less involvem en t
of th e en dplate

Burst Fractures
Com pression failure of th e an terior an d m iddle spin al colum n s
A: Failure of both superior an d in ferior en dplates
B: Su p erior en dp late failu re on ly (m ost com m on t ype of bu rst
fract u re)
C: In ferior en dplate failu re on ly

266

D: Axial loading an d rot at ion al inju r y


E: Axial loading an d lateral exion

Flexion-Distraction
(Ch an ce): Prim ar y an terior force vector act ing along an axis of
rotat ion located an terior to m iddle colum n . Th e p osterior an d
m iddle colu m n s fail in ten sion an d th e an terior colu m n fails in
ten sion or com pression depen ding on th e axis of rot at ion .

Fracture -Dislocation
Results from violen t com plex sh earing force an d by de n it ion
involves all th ree spin al colum n s. High est rate of com plete n eu rologic inju r y.

AO Thoracolumbar System
(of Magerl)
De n es th e m ajor m ech an ism of sp in al inju r y com p ression (A),
dist ract ion (B), an d torsion (C) to in dicate in creasing inju r y severit y occu rring w ith in creasing grade of inju r y. Th ree grou p s
exist w ith in each t ype (A1, A2, A3) an d each grou p is divided
in to subgrou ps (A1.1, A1.2, A1.3). Th e classi cat ion is based on
m orp h ological criteria. Th e categories are est ablish ed according to th e m ain m ech an ism of injur y, an d take in to con siderat ion th e progn ost ic aspect s of poten t ial h ealing. Th e t ypes are
determ in ed by th e th ree m ost im por t an t m ech an ism s act ing
on th e spin e: com pression , dist ract ion , an d axial torque. Th e
t ype A is a ver tebral body com pression injur y; t ype B inju ries
involve an terior an d posterior elem en t inju ries w ith dist ract ion s; an d t ype C lesion s refer to an terior an d posterior elem en t
injuries w ith rot at ion con sisten t w ith axial rot at ion inju ries.
Th e AO system is ver y com preh en sive an d good for describ ing fract ure pat tern s, but it is a vict im of it s com p reh en siven ess; it does n ot con sider n eu rologic st at u s, an d does n ot aid in
decision m aking.10

Thoracolumbar Injury Classi cation


and Severity Score (TCLIS)
Th is system w as developed due to th e n eed for a classi cat ion
system th at cou ld be u sed to p rogn ost icate th e n eed for su rgical
in ter ven t ion . Th e system w as based on a review of th e existing literat u re as w ell as con sen sus opin ion from a m u lt in at ion al
grou p of leading sp in al t rau m a su rgeon s. Th ree m ajor inju r y
ch aracterist ics w ere de n ed: injur y m orph ology, n eurologic

16

Thoracolum bar Fractures

Table 16.1 Thoracolumbar Injury Classi cation and


Severity Score
Injury characteristic

Quali er

Points

Injury morphology
Compression

Burst

1
11

Rotation/translation

Distraction

Intact

Nerve Root

Incomplete

Complete

Intact

Suspected/Indeterm inate

Disrupted

Neurologic status

Spinal cord, conus m edullaris


Cauda equine
Posterior ligam entous complex integrit y

1 5 1 additional point given to morphology

st at u s, an d in tegrit y of th e p osterior ligam en tou s com plex


(PLC) (see Table 16.1).
Severit y score: A score of . 4 suggests a n eed for surgical
t reat m en t becau se of sign i can t in st abilit y, w h ereas a score ,
4 suggests n on surgical m an agem en t . A pat ien t w ith a score of 4
m ay be t reated su rgically or n on su rgically.5,1113

Indications
Grossly u n st able inju ries w ith or w ith ou t n eurologic de cit
To facilit ate n eurologic recover y via direct decom pression or

in direct decom pression th rough ligam en totaxis


To correct deform it y
To provide im m ediate st abilizat ion
To decrease requirem en t s for extern al im m obilizat ion , an d
com plicat ion s due to prolonged im m obilizat ion

Preprocedure Considerations
Radiographic Imaging
An teroposterior (AP) an d lateral radiograph s of th e cer vical,

th oracic, an d lum bar spin e are stan dard im aging st udies follow ing spin al t rau m a. In som e cen ters th is h as been largely
rep laced for su r vey purposes by w h ole body com puted tom ograp hy (CT) scan n ing.
Becau se th ere is a h igh p ercen t age of n on con t igu ou s associated sp in al fract u res, en t ire n euraxis im aging m ay be w arran ted if clin ical su spicion is h igh .

Fig. 16.1 Sagit tal reconstruction of trauma CT scan showing fractures


of T12 and L1 in a 55-year-old man who had fallen from a height.

CT is gen erally th e n ext step after p lain lm s. Axial n e cu ts

an d sagit t al recon st ru ct ion h elp de n e fract u re p at tern s an d


determ in e th e degree of can al com pression (Fig. 16.1).
Magn et ic reson an ce im aging (MRI): Gen erally n ot requ ired
in a n eurologically in t act pat ien t in th e acu te set t ing, bu t
can h elp evaluate th e PLC. With a n eurologic de cit , MRI is
recom m en ded to iden t ify any ongoing spin al com p ression ,
evalu ate cord an atom y, an d ru le ou t ep idu ral h em atom a.

Medication (Neuroprotection and


Nonoperative Management)
According to th e secon d NASCIS t rial, in p at ien t s w ith con rm ed spin al cord inju r y, p at ien ts st ar ted on m ethylp redn isolon e w ith in 3 h ou rs of inju r y h ad a su bstan t ial ben e t in

267

II Spinal Em ergency Procedures

term s of ult im ate n eurologic recover y. We do n ot use steroids


at ou r in st it u t ion . Recen t pu blish ed gu idelin es do n ot recom m en d steroid u sage.14
In t raven ous uid, colloid, an d vasopressors are u sed as n eeded
to m ain tain a m ean arterial pressu re of 85 m m Hg or greater.15

Surgical Management
Th e goals of surgical t reat m en t in clude: (1) decom pression of
th e spin al can al an d n er ve root s to facilit ate n eurologic recover y, (2) restorat ion an d m ain ten an ce of ver tebral body h eigh t
an d align m en t to m in im ize post t rau m at ic deform it y, (3) ob tain ing rigid xat ion to facilitate n ursing care an d allow early
m obilizat ion , (4) obtain ing a solid ar th rodesis of dam aged
segm en ts or fract u re h ealing, an d (5) lim it ing th e n u m ber of
in st ru m en ted vertebral m ot ion segm en ts. Surgical algorith m s
can gen erally be classi ed in to on e of ve grou ps: (1) posterior
decom pression an d st abilizat ion , (2) costot ran sverse/lateral ext racavitar y/t ran spedicular decom pression an d recon st ruct ion /
stabilizat ion , (3) an terior corp ectom y/st abilizat ion , (4) com bin ed an terior/posterior decom pression /st abilizat ion (360),
an d (5) p ercu t an eou s fract u re xat ion .

268

Post e r ior ap p roach es allow for realign m e n t of t h e sp in e,


d ire ct an d in d ire ct d e com p ression of t h e n e u ral ele m e n t s,
an d p rot e ct ion again st lat e d efor m it y an d in st ab ilit y. Sp in al can al d e com p ression via ligam e n t ot a xis is op t ion ally
ach ieve d w it h in t h e first 2 to 4 d ays p ost in ju r y. We p refe r
to st ab ilize t h oracolu m bar fract u res w it h in 48 h ou rs of p re se n t at ion if m e d ically st able. For t h ora cic inju r ies, a p ost e rolat e ral, e it h e r cost ot ran sve rse ctom y or t ran sp e d icu la r,
ap p roa ch allow s som e d e com p ression of an t e r ior p at h ology
an d allow s a circu m fe re n t ial fu sion t h rou gh a p ost e r ior on ly
ap p roa ch .
Th is ch apter addresses th e posterior approach , both open an d
percut an eous.

Operative Field Preparation


Th e skin is clean sed w ith alcoh ol th en a betadin e scrub is

used.
Altern at ively, alcoh ol an d ch lorh exidin e can be u sed.
Th e au th ors u se van com ycin an d ceft riaxon e for an t ibiot ic
prophylaxis provided th e pat ien t does n ot h ave ren al failure
or oth er con t rain dicat ion s.

16

Thoracolum bar Fractures

Operative Procedure
Open Approach
Positioning (Fig. 16.2)

Figure

Procedural Steps

Pearls

Fig. 16.2

The patient is positioned carefully on a radiolucent


frame to obtain optimal preoperative reduction of
deformity.

A four-posted spinal table is used. Preincision


uoroscopy veri es abilit y to visualize pedicles
radiographically after exposure. One can conduct an
awake turn or perform neurom onitoring with pre and
post turn electromyography (EMG)/som atosensory
evoke potentials (SSEPs) in patients with incomplete
neurologic injury.

269

II Spinal Em ergency Procedures

Exposure (Fig. 16.3a, b)

270

Figure

Procedural Steps

Pearls

Fig. 16.3

(a) A midline posterior approach is most common for


thoracolumbar instrumentation. (b) Subperiosteal
exposure of the posterior elements is carried out
laterally over the tips of the transverse processes.

Instrum entation requires a wider exposure for optim al


placem ent of instrum entation. Inadequate exposure
risks screw malposition.

16

Thoracolum bar Fractures

Decompression (Fig. 16.4)

Figure

Procedural Steps

Pearls

Fig. 16.4

The lamina is removed w ith a drill and rongeurs. At this point


a costotransversectomy, or a transpedicular vertebrectomy,
can be performed if indicated (see Chapter 15).

Lam inectomy alone as a decompressive

Ligamentotaxis may be used to mobilize anterior fracture


fragments aw ay from the spinal cord. Alternatively, a
dow nw ard directed curette can be used to tamp bone
fragments anteriorly aw ay from the spinal cord (a rrow). This
technique may be facilitated by removing the pedicle on
one or both sides to achieve more exposure of the superior
endplate, w hich is typically the area of greatest impingement.

procedure has been shown to be ine ective in


achieving anterior spinal cord decompression.
The only indication for a standalone
lam inectomy is to evaluate for dural tears or
posterior compression.

271

II Spinal Em ergency Procedures

Facetectomy and Pedicle Cannulation (Fig. 16.5ac)

272

16

Thoracolum bar Fractures

Figure

Procedural Steps

Pearls

Fig. 16.5

(a) The facet joint is stripped of its capsule. The inferior portion of
the inferior facet is removed w ith a rongeur or osteotome. Partial
facetectomy should reveal a pedicle blush.

Rem oving the inferior portion of

(b) At T12 the starting point is the junction of the bisected transverse
process and border of the lateral pars. The starting point trends medially
and cephalad as one moves cranially tow ard the midthoracic region.

A thoracic (blunt, curved) probe is placed in the blush or starting point


as determined by AP uoroscopy. The curve is directed laterally and
advanced 15 to 20 mm letting the probe fall into the pedicle.
(c) After advancing 15 to 20 mm, the probe is removed and replaced
facing medially and advanced to a depth of 30 to 40 mm in the
midthoracic spine. A feeler/sounder probe is then introduced. Only blood
should return from the tract and not cerebrospinal uid. A oor and then
four w alls should be palpated.

the inferior facet allows m ore soft


tissue rem oval and helps to nd the
entrance to the pedicle.
Anatom ic starting points can be
veri ed with AP uoroscopy and
pedicle m arkers can be placed.
Lateral uoroscopy can then be used
for pedicle cannulation.
Any abrupt step o when
cannulating the pedicle should
raise suspicion of a pedicle breach
and should be investigated with a
sounding probe and radiographic
evaluation. Pay at tention to the
medial portion of the tract where
violations of the pedicle are critical.

273

II Spinal Em ergency Procedures

Tapping and Screw Placement (Fig. 16.6)

274

Figure

Procedural Steps

Pearls

Fig. 16.6

The pedicle is then under-tapped 0.5 mm.


Preoperative assessment of pedicular size guides the
appropriate tapping and screw placement (1). After
tapping, the tract is once again sounded w ith a feeler
probe searching for violations. Slow screw placement
allow s utilization of viscoelastic properties of the
pedicle and avoids pedicle fracture (2).

Charting pedicle size and depth preoperatively

facilitates appropriate screw selection.


All screws placed should be veri ed by intraoperative
imaging. In addition, electrodiagnostic testing can be
perform ed with abdom inal leads.

16

Thoracolum bar Fractures

Rod Placement (Fig. 16.7ac)

Figure

Procedural Steps

Pearls

Fig. 16.7

A rod is selected and contoured appropriately.


Distraction and reduction maneuvers can be applied
to aid in reduction of compression via ligamentotaxis.

The rod should be passed approxim ately 5 m m beyond

the m ost cranial and caudal screw. Compression


maneuvers gain lit tle in achieving additional rod length.

275

II Spinal Em ergency Procedures

Bone Grafting (Fig. 16.8)

276

Figure

Procedural Steps

Pearls

Fig. 16.8

Spinous processes and lamina local autograft removed


are morselized. The remaining lamina, transverse
process, and facets are decorticated w ith a high speed
drill (1). The bone graft is then laid on bleeding bone (2).
Iliac crest bone autograft remains the gold standard.

Intraoperative relaxation of retractors periodically


facilitates blood ow and preservation of extensor
m usculature. Careful preservation of regional blood
supply supports rapid graft incorporation and focuses
on fusion versus construct failure.

16

Thoracolum bar Fractures

Percutaneous Approach
Positioning and Pedicle Targeting (Fig. 16.9ac)

Figure

Procedural Steps

Pearls

Fig. 16.9

(a) The patient is carefully positioned prone on a


radiolucent table, as in Fig. 16.2, in order to obtain
the best preoperative reduction of deformity.
(b) Prior to prepping and draping, the pedicles are
targeted using AP uoroscopy. (c) K w ires are placed
at the 9 oclock position on the left sided pedicles and
the 3 oclock position of the right pedicles. These lines
are marked on the patient. We also mark the mid
pedicle levels in the horizontal plane at each level.

A good AP im age is imperative. The endplates must be


absolutely parallel, and the spinous process equidistant
bet ween the pedicles. At each level, it is helpful to m ark
the degree of rotation of the C-arm needed to obtain
the view. This help to decrease uoroscopy tim e, as well
as operative tim e.

277

II Spinal Em ergency Procedures

Jam Shidi Placement (Fig. 16.10ac)

278

16

Thoracolum bar Fractures

c
b

Figure

Procedural Steps

Pearls

Fig. 16.10

(a) The bone trephine needle is started in the skin


just lateral to the marked pedicle and advanced to
the starting point (3 oclock on the right, 9 oclock
on the left). Once bone is encountered, an image is
obtained. The needle is lightly malleted to engage
the tip into the cortical bone (1). A mark is made
on the needle approximately 25 mm from the skin
surface (2). The needle is then advanced into the
pedicle approximately 15 mm. An image is taken. (b) If
the needle has traversed less than 50%the w idth of
the pedicle, it can be safely advanced the remained of
the distance w ithout fear of medial w all breech.

We use AP im ages to place the bone trephine needles.


Alternatively, the needles can be advanced to 20 m m
under AP im aging, and then switched into a lateral
view to advance the rem ainder of the distance into the
vertebral body (c).

279

II Spinal Em ergency Procedures

Guidew ire Placement (Fig. 16.11a, b)

280

Figure

Procedural Steps

Pearls

Fig. 16.11

(a, b) The stylet is removed from the bone trephine


needle and a K w ire is placed (1). The K w ire is
advanced several mm beyond the bone trephine
needle and then the needle is removed (2).

The K wire can be used as a exible feeler probe to


ensure that bone is encountered when advancing.

16

Thoracolum bar Fractures

Facet Fusion (Optional) (Fig. 16.12)

Figure

Procedural Steps

Pearls

Fig. 16.12

If a long-term fusion is required, dilators are then placed over the K w ire
and docked on the pedicle screw starting point. A tubular retractor is then
placed (1). The facet is superior and medial to the starting point. The soft
tissue is then removed w ith electrocautery, and the facet decorticated
w ith a high speed bur (2). Bone graft is then laid on the facet.

The necessit y for fusion is


decided on an individual basis.

281

II Spinal Em ergency Procedures

Screw Placement (Fig. 16.13a, b)

Figure

Procedural Steps

Pearls

Fig. 16.13

If a facet fusion is not performed, next make a 15 mm skin incision


about the K w ires. (a) A dilator is passed to open the fascia, and
docked at the starting point. The inner cannula of the dilator is
removed (1). An aw l is placed over the K w ire to enhance the starting
point for the tap (2). Next, the C-arm is brought into lateral position.

It is imperative to m aintain control of

(b) We tap the pedicle under lateral imaging (1). At this point, the
tap can be stimulated to assess for a medial pedicle breach. The tap
is removed w ith care to not dislodge the K w ire. A cannulated screw
w ith a screw extension is then advanced (2). Several images are
taken as the screw is advanced. It is important to not advance the K
w ire w ith the screw. The K w ire is then removed.

282

the K wire at all tim es. If the K wire is


inadvertently rem oved, it is best to switch
back to AP im aging to try to replace the
wire. If unable, it is possible to try to
replace the bone trephine needle without
the st ylet.
We t ypically under tap for traum a cases.
Try to keep the position of the screw
heads the sam e for all screws to facilitate
passage of the rod.

16

Thoracolum bar Fractures

Rod Placement and Deformity Correction (Fig. 16.14a, b)

Figure

Procedural Steps

Pearls

Fig. 16.14

(a) A rod is measured and cut. It is extremely important that the


rod is passed subfascially w hen inserted into the rst screw head.
(b) Through a cantilever approach, deformity correction occurs
as the rod is locked into place (1). A derotation device is used
and the screw caps are nal tightened (2). The extended tabs are
then removed (3). If the tabs are inadvertently removed prior
to passing the rod, a rod can still be placed, but it makes rod
placement very di cult.

It is important to leave the rods on


the rod holders until all the caps have
been applied. Minim al distraction and
compression can be perform ed with the
m inim ally invasive system ; therefore,
positioning is imperative.

283

II Spinal Em ergency Procedures

Closing
Open Approach
For th e open approach , m et iculous h an dling of th e exten sor
m u scu lat u re follow ed by a t igh t fascial closu re im proves th e
m u scles abilit y to p rom ote sagit t al balan ce an d ap prop riate
skelet al loading. Th e w ou n d is closed in su ccessive layers (deep
fascia, su p er cial fascia, th en skin ) u sing resorbable su t u re.

Percutaneous Approach
For th e percut an eou s approach , th e in dividual st ab w ou n ds

are irrigated w ith an t ibiot ic im p regn ated salin e. Lit tle bleeding is en cou n tered due to a t am p on ade e ect from th e dilators an d screw exten sion s.
Th e fascia is reapproxim ated w ith in terrupted 2-0 resorbable
su t u res.
Th e skin is closed w ith a 3-0 m ono lam ent , resorbable sut ure.
Fin al AP an d lateral im ages are obtain ed w ith C-arm u oroscopy before th e w oun d is closed.

Postoperative Management
Monitoring

Fig. 16.15 Lateral X-ray of patient depicted in Fig. 16.1 showing posterior
rod construct and vertebroplasties at T12 and L1 to add structural support.

Th e level o f ca re is d ict at e d by t h e com or b id co n d it ion s of


t h e p at ie n t s. For p at ie n t s w it h a p a u cit y of ot h e r in ju r ie s,
w e t yp ica lly obse r ve t h e m ove r n igh t in a st e p d ow n u n it .

Medication
It is ou r pract ice to place p at ien t s on a p at ien t-con t rolled

an algesia device w ith eith er m orp h in e or hydrom orp h on e in


th e in it ial postoperat ive period.
Pat ien t s are gradu ally t ran sit ion ed to oral m edicat ion on th e
secon d or th ird p ostop erat ive day.
We continue antibiotic prophylaxis for approxim ately 24 hours
after surgery.
We rout in ely start pat ien t s on deep vein th rom bosis prophylaxis w ith low m olecular w eigh t h ep arin on th e rst postop erat ive day if th ere are n o oth er bleeding con t rain dicat ion s.

Radiographic Imaging
We t ypically obtain uprigh t AP an d lateral im ages prior to

disch arge (Fig. 16.15).


Im aging is th en p erform ed at 3, 6, an d 9 m on th s
postoperat ively.

Special Considerations
The optim al surgical approach and treatm ent of unstable thoracolum bar spine injures are poorly de ned because of a lack
of w idely accepted level I clinical literature. When treating

284

patients w ith thoracolum bar fractures, the surgeon m ust rst


decide if the injury requires an operation. If an operation is required, a decision m ust be m ade w hether a decom pression is
warranted in addition to stabilization. A decision m ust be m ade
as to w hether the surgical goals can best be accom plished via
an anterior, posterior, or com bined approach.
We gauge the length of our construct based on the degree of
instabilit y. In m ost instances we xate two levels above and t wo
below. For burst fractures it is possible to perform a cem ent augm entation of the fractured level (vertebroplast y or kyphoplast y;
see Fig. 16.15). Short pedicle screw s can also be placed into the
fractured level, thus allow ing som e cases to be instrum ented
only one level above and below the fracture. The thoracic segm ents are relatively im m obile so sacri cing m otion segm ents is
biom echanically irrelevant. Lengthening the construct distally
into the lum bar spine has di erent biom echanical considerations and should be individualized on a per patient basis.
Rem oval of percut an eou s in st rum en tat ion m ay be required if
an in tersegm en t al fu sion is n ot perform ed as th e su ccess of
th e surger y w ill require fusion of th e prim ar y fract u re. Based
on literat ure from th e AO Fixateu r In tern e, rem oval is perform ed t ypically 12 m on th s p ostop erat ive an d after radiograp h ic eviden ce of fu sion .1621

References
1. Vaccaro AR, Leh m an RA Jr, Hu rlber t RJ, et al. A n ew classi cat ion
of th oracolum bar injuries: th e im por t an ce of injur y m orph ology,
th e in tegrit y of th e posterior ligam en tou s com p lex, an d n eu rologic st at us. Spin e 2005;30(20):23252333

16
2. Dai LY, Jiang SD, Wang XY, Jiang LS. A review of th e m an agem en t of th oracolum bar bu rst fract ures. Surg Neurol 2007;67(3):
221231, discussion 231
3. Th om as KC, Bailey CS, Dvorak MF, Kw on B, Fish er C. Com parison of operat ive an d n on operat ive t reat m en t for th oracolum bar
burst fract ures in pat ien t s w ith ou t neurological de cit: a system at ic review. J Neurosurg Spin e 2006;4(5):351358
4. Verlaan JJ, On er FC. Operat ive com pared w ith n on op erat ive
t reat m en t of a th oracolum bar burst fract ure w ith out n eurological de cit . J Bon e Join t Surg Am 2004;86-A(3):649650, auth or
reply 650651
5. Vaccaro AR, Lim MR, Hu rlber t RJ, et al; Sp in e Trau m a St u dy
Grou p . Su rgical d ecision m akin g for u n st able t h oracolu m bar sp in e inju r ies: resu lt s of a con sen su s p an el review by t h e
Sp in e Trau m a St u dy Grou p . J Sp in al Disord Tech 2006;19(1):
110
6. Siebenga J, Leferin k VJ, Segers MJ, et al. Treat m en t of t rau m at ic
th oracolu m bar sp in e fract u res: a m u lt icen ter p rospect ive ran dom ized st u dy of op erat ive versu s n on su rgical t reat m en t . Sp in e
2006;31(25):28812890
7. Hear y RF, Salas S, Bon o CM, Ku m ar S. Com p licat ion avoidan ce:
th oracolu m bar an d lu m bar bu rst fract u res. Neu rosu rg Clin N Am
2006;17(3):377388, viii
8. Harris MB, Sh i LL, Vacarro AR, Zd eblick TA, Sasso RC. Non su rgical
t reat m en t of th oracolum bar spin al fract ures. In st r Course Lect
2009;58:629637
9. Dai LY, Jiang LS, Jiang SD. Con ser vat ive t reat m en t of th oracolu m bar bu rst fract ures: a long-term follow -up result s w ith special
referen ce to th e load sh aring classi cat ion . Spin e 2008;33(23):
25362544
10. Magerl F, Aebi M, Gert zbein SD, Harm s J, Nazarian S. A com preh en sive classi cat ion of th oracic an d lum bar injuries. Eu r Spin e J
1994;3(4):184201
11. Patel AA, Vaccaro AR. Th oracolu m bar sp in e t rau m a classi cat ion .
J Am Acad Or th op Su rg 2010;18(2):6371

Thoracolum bar Fractures

12. Joaquim AF, Fernandes YB, Cavalcante RA, Fragoso RM, Honorato
DC, Patel AA. Evaluation of the Thoracolum bar Injury Classi cation
System in Thoracic and Lum bar Spinal Traum a. Spine 2011;36:
3336
13. Alan ay A, Acaroglu E, Yazici M, Surat A. Th oracolum bar spin e
fract u res. Sp in e 2001;26(7):840841
14. Hurlbert RJ, Hadley MN, Walters BC, et al. Ph arm acological
th erapy for acute spin al cord injur y. Neurosu rger y 2013;72
(Su p pl 2):93105
15. Vale FL, Burn s J, Jackson AB, Hadley MN. Com bin ed m edical an d
surgical t reat m en t after acute spin al cord injur y: result s of a
prospect ive pilot st udy to assess th e m erit s of aggressive m edical resuscit at ion an d blood pressu re m an agem en t . J Neurosurg
1997;87(2):239246
16. Faun dez AA, Taylor S, Kaelin AJ. In st r um en ted fusion of th oracolum bar fract ure w ith t ype I m in eralized collagen m at rix com bin ed w ith autogen ous bon e m arrow as a bon e graft su bst it ute:
a four-case report . Eu r Spin e J 2006;15(Suppl 5):630635
17. Dick W, Kluger P, Magerl F, Woersdrfer O, Zch G. A n ew device
for in tern al xat ion of th oracolu m bar an d lu m bar sp in e fract u res: th e xateu r in tern e. Parap legia 1985;23(4):225232
18. Ben ce T, Sch reiber U, Grupp T, Stein h auser E, Mit telm eier W. Tw o
colum n lesions in the th oracolum bar jun ct ion : an terior, posterior or com bin ed approach ? A com parat ive biom ech an ical in vit ro
invest igat ion . Eur Spin e J 2007;16(6):813820
19. Dai LY, Jiang LS, Jiang SD. Posterior sh or t-segm en t xat ion w ith
or w ith out fusion for th oracolum bar burst fract ures. a ve to
seven -year prospect ive ran dom ized st udy. J Bon e Join t Surg Am
2009;91(5):10331041
20. Haiyun Y, Rui G, Sh u cai D, et al. Th ree-colum n recon st r uct ion
th rough single p osterior app roach for th e t reat m en t of u n st able
th oracolu m bar fract u re. Sp in e 2010;35(8):E295E302
21. Katonis P, Pasku D, Alpan taki K, et al. Com binat ion of the AOMagerl an d load-sh aring classi cat ion s for th e m an agem en t of
th oracolu m bar burst fract ures. Or th opedics 2010;33(3):158163

285

17

Spinal Epidural Compression


Asha Iyer and Arthur Jenk ins

Introduction
Non t rau m at ic spin al epidu ral com p ression can resu lt from several di eren t en t it ies, bu t acu te deteriorat ion alm ost alw ays
occurs as a result of a few con dit ion s, th ree of w h ich are h igh ligh ted in th is ch apter: spon t an eou s epidural h em atom a, spin al
ep idu ral abscess, an d m et astat ic ep idu ral spin al cord com p ression syn drom e.

Incidence
Spontaneous Spinal Epidural Hematoma
Sp in al ep idu ral h em atom as (SEHs) are a rare cau se of sp in al
cord com pression . How ever, th ey con st it ute th e m ajorit y (u p
to 75%) of spin al h em atom as. Th e peak in ciden ce occurs in pat ien ts in th eir sixth decade of life, th ough a secon d peak is seen
in adolescen ts bet w een 15 an d 20 years of age. A m ale predom in an ce h as frequ en tly been docu m en ted.

Spinal Epidural Abscess


Sp in al ep idu ral abscesses (SEAs) are an in frequ en t cau se of spin al cord com p ression , rep resen t ing 0.2 to 2 p er 10,000 h osp it al
adm ission s. Th e m ajorit y of a ected pat ien t s are bet w een 30
an d 60 years old, th ough th ey span a w ide range from n eon ates to geriat ric. A m ale p red om in an ceap p roxim ately t w ice
as com m on as in w om en exists. Risk factors in clu d e diabetes m ellit us, en d-stage ren al disease, HIV or oth er im m un ecom prom ised st ates, in t raven ou s (IV) drug use, an d alcoh olism .
Local factors addit ion ally in clu de sp in e su rger y or t rau m a, an d
cath eter placem en t in to th e ver tebral can al.
W h ile n early on e-th ird of a ected pat ien t s died at th e begin n ing of th e t w en t ieth cen t u r y, th e m ort alit y is n ow less th an
h alf of th at n u m ber given im p rovem en t s in an t ibiot ic th erapy
an d su rgical tech n iqu e. Corresp on dingly, th e p ercen t age of
p at ien t s w ith eith er com plete recover y or on ly m in or residu al
n eu rologic de cit h as m ore th an dou bled.1

Metastatic Epidural Spinal Cord


Compression
In th e Un ited St ates, th ere are 1.4 m illion n ew cases of can cer
an n u ally an d ever y year over h alf a m illion can cer p at ien ts su ccum b to m et astat ic disease. Th e skelet al system ser ves as th e
th ird m ost com m on site of m et ast at ic spread (after pu lm on ar y
an d h epat ic), an d w ith in th e skelet al system th e sp in al colu m n
is m ost frequ en tly a ected.

286

Cu rren t est im ates based on p ost m or tem st u d ies im ply 30


90% of can cer pat ien t s (large variabilit y depen ding on prim ar y)
w ill h ave m etast at ic spin al disease. A tot al of 5 to 10% of can cer pat ien t s have m et astat ic epidural spin al cord com pression
(MESCC), w ith th is propor t ion in creasing to 40% in th ose w ith
other, n on spin al bony m et ast ases. Th ese n um bers t ran slate in to
25,000 cases of sym ptom at ic MESCC per year, an in ciden ce
th at is rising as an t in eoplast ic th erapies evolve an d life expect ancies in crease. MESCC is an epidural lesion causing t ru e displacem en t of th e spin al cord from it s n orm al p osit ion in th e
spin al can al.

Etiologies
Spinal Epidural Hematoma
Sp on t an eou s SEH can be divided in to t rau m at ic an d n on t rau m at ic. Cau ses of t rau m at ic SEH in clu de lu m bar p u n ct u re or
ep idu ral an esth esia, fract u re, spin al su rger y, p hysical exert ion ,
bir th t raum a, an d ch iropract ic m an ipu lat ion . Causes of spon t an eous SEH in clu de h em orrh age from an arterioven ous m alform at ion (AVM), h em angiom a, or t u m or. In u p to 30% of cases,
n o et iology is discern ed .2 Follow ing th ese idiopath ic cases, an t icoagulan t th erapy an d vascular m alform at ion s are m ost often
im plicated. An t icoagulat ion or any bleeding diath esis is a risk
factor for SEH.3

Spinal Epidural Abscess


In fect ion can sp read h em atogen ou sly or con t igu ou sly. Any dist an t site of in fect ion can spread h em atogen ou sly; h ow ever, skin
an d soft t issu e in fect ion s rep resen t th e m ost com m on sou rces.
SEAs arising in th is fash ion gen erally d evelop in th e p osterior
ep idu ral sp ace. SEAs th at sp read by direct exten sion pred om in an tly origin ate from a vertebral body focu s, or less com m on ly
from adjacen t soft t issu e. Th is vector of sp read u su ally involves
th e an terior aspect of th e spin al can al.
In ocu lat ion can also occu r iat rogen ically. In a large m et aan alysis of over 900 cases, ep id u ral an est h esia or an algesia w ere associated w it h a 6% rate of in fect ion , an d invasive
p roced u res, eit h er sp in al or ext ra-sp in al, w it h 1422%.4 Usu ally a severe pyogen ic in fect ion w it h Staphylococcus aureus is
t h e m ost com m on cau sat ive agen t . St reptococcus sp ecies an d
coagu lase-n egat ive Staphylococcus follow in frequ en cy. Gram n egat ive rod s su ch as Pseudom onas an d Escherichia coli, accou n t for a sm all fract ion , being m ore p revalen t w it h IV d r ug
u se. Fin ally, Mycobacterium t uberculosis, fu n gal sp ecies, an d
p arasit ic organ ism s are rare except for im m u n e-com p rom ised
st ates.

17

MESCC
Met a st at ic d isease sp read s to e p id u ral sp ace in t w o w ays:
(1) d ire ct ly in t o t h e sp in a l can al t h rough in t e r ve r t ebral fo ram e n from a p arave r t eb ral m ass (1 5 % of m et ast at ic cord
com p ression ); an d (2 ) t h e re m ain in g 8 5% from h e m at oge n ou s sp read (h ist or ica lly t h ough t via Bat son s p lexu s, n ow
b elieve d t o be m ore likely a r t e r ia l) t o t h e ve r t ebral bod y,
from w h e re t h e lesion grow s p ost e r iorly in to t h e e p id u ral
sp a ce. Th ese m et ast at ic lesion s can cau se b on e e rosion ,
p at h ologic fra ct u res, a n d ext r u sion of b on y fragm e n t s in t o
can al, w h ich can all fu r t h e r com p ou n d can a l n a r row in g or
cord com p ression .

Pathophysiology

Spinal Epidural Com pression

t ien t s of t h e 46- to 75-year-old year age grou p , t h e low er t h o racic an d lu m bar region s are m ost com m on , w it h a sm aller
frequ en cy m a xim u m in t h e cer vical levels.8 A p ain -free in terval m ay occu r, bu t t h en is ge n erally follow ed by p rogression
of n e u rologic d e cit ove r h ou rs to days tow ard accid p aresis
or p legia.

Spinal Epidural Abscess


Seven t y-on e p ercen t of p at ien t s p resen t w ith back pain as th e
in it ial sym ptom ; 66% h ave fevers. Th is proceeds to radicular irrit at ion , w ith su bsequ en t n eu rologic d e cit s, in clu d ing m u scle
w eakn ess, sen sor y dist u rban ces, an d sph in cter in con t in en ce.
Progression to fran k paralysis occurred on ly in on e-th ird of
p at ien ts.9

Spinal Epidural Hematoma

MESCC

Bleeding is gen erally th e resu lt of tearing of epidu ral vein s,


alth ough tearing of epidu ral arteries or h em orrh age from a
m alform at ion is also p ossible. Even in circu m st an ces involving
an t icoagu lan t th erapy, oth er factors are posited to con t ribu te,
in clu ding in creased pressure in th e in terior ver tebral ven ous
p lexu s an d foci of vascular decreased resist an ce.

Pain (8395%) is a com m on p resen t at ion . Local pain is th ough t


to be related to periosteal st retch ing or local n eoplast ic in am m ator y p rocess. Th is p ain respon ds w ell to steroid s an d is w orse
w ith recum ben cy. Mech an ical pain is pain th at is exacerbated
by m ovem en t/act ivit y an d is often caused by path ologic fract ure or ver tebral body collapse, an d in dicat ive of spin al in stabilit y. Th is pain is recalcit ran t to steroids/n arcot ics; radicular
p ain is th at w h ich involves n er ve root com pression an d usu ally
con form s to a derm atom al dist ribut ion .
Motor dysfu n ct ion is p resen t in 6085% of p at ien ts an d is
ch aracterized by w eakn ess an d long t ract sign s. Th ere are correlat ion s bet w een n eu rologic st at us at t im e of diagn osis (part icularly w ith respect to m otor fun ct ion ) an d progn osis from
MESCC. Sen sor y loss is in close proxim it y to m otor n dings an d
au ton om ic/sph in cter dysfu n ct ion is a later n ding, w ith bladder dysfun ct ion being th e m ost com m on . Th ough th e rate varies, p at ien t s w ith th ese de cits in evit ably progress to p aralysis
w ith out in ter ven t ion .

Spinal Epidural Abscess


As w ith any form of com pression , vascular com prom ise w ith
con sequen t hypoxia h as been on e favored path ogen et ic exp lan at ion . How ever, in an im al m odels of S. aureus ep idu ral
abscesses, even w h en SEAs cau sed para- or qu adrip legia, n o
com pression of spin al arteries w as n oted,5 th u s su p port ing a
p aram ou n t role for direct m ech an ical com pression .

MESCC
Hyp ot h esized m ech an ism s by w h ich dam age occu rs in clu d e
(1) direct com p ression t h at lead s to dem yelin at ion an d a xon al dam age; (2) vascu lar com p rom ise, w h ere occlu sion of ven ou s p lexu s p rom otes breakd ow n of cordblood barr ier an d
t h u s vasogen ic ed em a; an d (3) ter m in al ar ter ial occlu sion
w it h isch em ia/in farct ion m ay follow lead ing to ir reversible
dam age. Cer t ain au t h ors h ave hyp oth esized th at in p at ien t s
rap id ly d eteriorat in g ar terial in farct ion m ay u n d erlie d eclin e
w h ereas ven ou s congest ion m ay in it ially be m ore relevan t in
p at ien t s w it h slow d eclin e.6 Th is disp ar it y m ay exp lain t h e
w orse ou tcom e associated w it h a m ore rap id evolu t ion of m o tor w eakn ess.7

Presentation
Spinal Epidural Hematoma
SEH is u su ally acu te an d p rogressive, lead in g to p e r m an e n t
n eu rologic d e cit if n ot m an aged im m ed iately. Sym p tom s
con sisten t ly begin w it h severe back p ain in t h e locat ion of
t h e h em or rh age, w it h or w it h ou t a rad icu lar com p on en t . Th e
com m on segm en t al levels involve d var y by age; in t h e p a-

Indications
Spinal Epidural Hematoma
Most SEHs are located d orsal to t h e sp in al cord , w it h a large
m et a-an alysis qu ot in g
75% in t h is sagit t al locat ion .8 Em ergen t or u rgen t d ecom p ression w it h in h ou rs is associated w it h
bet ter ou tcom es. In t h e sam e m et a-an alysis, for p at ien t s w h o
received t reat m en t w it h in 12 h ou rs of on set of sym ptom s,
66% recovered com p letely, 13% recovered w it h m ild resid u al
n eu rologic d e cit , an d 13% con t in u ed to h ave severe im p air m en t or sh ow n o im p rovem en t . In con t rast , for p at ien t s
w h ose t reat m en t w as in it iated 1324 h ou rs after sym ptom
on set , 64% h ad severe d e cit s or n o im p rovem en t , versu s 36%
w it h su bst an t ial recover y. Th erefore, t h e t reat m en t of ch oice
is im m ed iate d ecom p ression in t h ose p at ien t s t h at can tolerate su rger y. Asym ptom at ic p at ien t s w it h ou t n eu rologic d e cit
can be con sid ered for obser vat ion , esp ecially in ch ild ren an d
teen agers in w h ich a lam in ectom y m ay d est abilize t h e p oster ior colu m n .

287

II Spinal Em ergency Procedures

Spinal Epidural Abscess


Th e rst operat ive in ter ven t ion a lam in ectom yfor SEA w as
perform ed in 1892; after in creasing report s of successes, surger y becam e th e m ain stay of t reat m en t by th e 1930s. An early
series 10 n oted th at SEA pat ien t s w ith out paralysis or w h ose
p aralysis h ad developed less th an 36 h ours before th e operat ion h ad bet ter postoperat ive ou tcom es w ith respect to sur vival
an d fu n ct ion . In con t rast , in p at ien ts w h ose p aralysis develop ed
m ore than 48 h ou rs before su rger y, n on e recovered n eu rologic
fu n ct ion ; all m ort alit ies in th e series w ere rep or ted in th is latter group. Th is correlat ion of outcom e w ith t im e to in ter ven t ion
h as been rep eatedly con rm ed.11,12 Con ser vat ive t reat m en t is
rarely in dicated: eith er for th ose w h o can n ot tolerate surger y,
or w h o h ave large abscesses exten ding a con siderable length of
th e spin al cord.

MESCC
Con sen su s an d exper t opin ion s regarding in dicat ion s for surger y largely d erive from st u dies invest igat ing th e p rogn ost ic value of surgical in ter ven t ion given variou s pat ien t group
at t ribu tes. Th e eviden ce dictat ing th e app ropriate approach to
t um or decom pression h as evolved sign i can tly over th e past
50 years. Early t reat m en t un derscored in direct decom pression of th e ep idu ral sp ace via st raigh t lam in ectom y, follow ed
by radiat ion th erapy (RT).13,14 How ever, later st u dies 15,16 dem on st rated n o advan t age for lam in ectom y, ren dering radiat ion
alon e th e p referred th erap eu t ic st rategy for a p eriod of years.
More recen t st u dies w ith m odern an esth et ic an d im aging tech n iqu es h ave led to a resu rgen ce of su rgical decom pression as
p ar t of th e t reat m en t st rategy.6,17 A large ran dom ized con t rol
t rial6 assessed decom pressive resect ion in conjun ct ion w ith RT
versu s RT alon e. Criteria for st u dy in clu sion requ ired MESCC
rest ricted to a single area; accept able surgical can didates w ith
life expect an cy . 3 m on th s; on e n eurologic sym ptom (in clu ding pain ); n ot tot ally p araplegic for . 48 h ou rs. Radiosen sit ive
t um ors an d sole root com pression or cau da equin a syn drom es
w ere exclu ded; 84% of th e su rger y grou p versu s 52% of th e RT
group w ere able to w alk after t reat m en t , 62% versus 19% regain ed am bu lat ion w h en ce lost , an d 94% versu s 74% rem ain ed
am bulator y. Ad dit ion ally, th e st u dy revealed sign i can t d ifferen ces bet w een t reat m en t grou p s w ith resp ect to m ain ten an ce of con t in en ce; m u scle st rength ; fu n ct ion al abilit y; an d
in creased sur vival (126 versu s 100 days), w ith am bulat ion an d
con t in en ce persist ing for th e lifet im e of th e surger y group.
Spin al in stabilit y can in depen den tly con tribu te to sym ptom s,
by directly causing m echan ical injur y to the spinal cord. As RT
is un likely to am eliorate spinal in st abilit y, su rger y m ay be m ore
ap prop riate in th ese circu m stan ces. An an alysis focu sing on
form s of com pression for patien ts w h o w ere, at th e on set , eith er
in depen den tly am bulator y, assisted am bulator y, paraparet ic,
an d paraplegic: w ith ou t bony com pression , post -RT am bulat ion rates w ere 100%, 94%, 60%, 11%, respectively. These rates
dropped to 92%, 65%, 43%, and 14%, respectively, w hen all pat ients (w ith bony an d non bony com pression ) w ere considered.18
A com preh en sive literat ure review 19 suggested that w ith RT
alon e, 36%subjects im proved w h ile 17%w orsen ed; w ith decom pressive lam inectom y 6 RT, 42%im proved w h ile 13%w orsen ed;

288

w ith posterior decom pression w ith stabilizat ion, 64%im proved;


an d n ally w ith an an terior approach , 75%im proved w ith 10%
m ortalit y.
Prevailing convict ion h olds th at if com pression is of sh ort du rat ion , n eurologic de cit s m ay be reversible, as re-m yelin at ion
an d recover y of fu n ct ion are p ossible. How ever, w ith prolonged
com pression , secon dar y vascu lar injur y w ith in farct ion of th e
spin al cord m ay occu r w ith irreversible con sequ en ce.
Based on th ese an d sim ilar st u dies, gen erally accepted in d icat ion s for surger y in clude: th e n eed for t issue for diagn osis; spinal in stabilit y; cord com pression w ith dysfun ct ion from bon e
or t um or n ot radiosen sit ive; an d deteriorat ion or recurren ce
during/despite RT. Surgical decom pression to preven t irreversible dam age sh ou ld be im m ediate. Conversely, RT is a reason able altern at ive for p at ien ts w ith radiosen sit ive t u m ors, st able
neurologic st at us, n o spin al in stabilit y, n o sign i can t bony com prom ise of can al, or life expectan cy less th an 3 m on th s.
The location of the origin of the tum or (isolated epidural disease versus arising from osseous lesion w ith extension) as well
as considerations of spinal stabilit y should dictate choice of
operative procedure. A thorough description of all surgical ap proaches is beyond the scope of this chapter. However, a sim ple
lam inectom y should be reserved for dorsally located disease, and
a posterolateral or ventral approach should be utilized w henever
ventral disease is present, as tum ors m ay continue to grow or
swell and thus w ithout a direct rem oval of the o ending pathology, an indirect decom pression w ill result in further deform ation
of the spinal cord. At the spinal cord level (occiput to bottom of
conus m edullaris), the cord should never be retracted to gain
access to ventral tum or; the approach should be selected that
obtains the m ost advantageous angle to access the tum or instead.

Preprocedure Consideration
Radiographic Imaging
Com pu ted tom ography (CT) m yelography w as on ce th e diagn ost ic tool of ch oice for evalu at ion of SEH. CT m yelogram also
is m ore invasive an d carries th e risk of seeding in fect ion . It is
th erefore n o longer recom m en ded in th e con text of spin al
ep idu ral abscess. Magn et ic reson an ce im aging (MRI) w ith or
w ith out CT h as em erged as th e less invasive an d m ore available
m eth od of ch oice. MRI also o ers th e advan t age of di eren t iating bet w een t um or, in fect ion , h ern iated disk, an d h em atom a 20
(Figs. 17.1 an d 17.2). CT is also n ecessar y to evaluate for bony
invasion an d st abilit y (Fig. 17.3).

Medication
For SEH, in pat ien t s w h o cann ot tolerate surger y, an t icoagu lat ion sh ould be stopped an d possibly reversed; h igh dose steroids sh ould be con sidered alth ough th eir u se is con t roversial.21
For SEA, broad-sp ect rum IV an t ibiot ics sh ould be in it iated
im m ediately, in cluding coverage for Gram -posit ive cocci an d
Gram -n egat ive rods.
For MESCC, steroids decrease edem a and m ay have an oncolytic e ect on som e t um ors such as lym phom a and breast cancer.

17

Spinal Epidural Com pression

Fig. 17.1a, b Spinal epidural hem atoma. (a) Axial and (b) sagit tal MRI in a patient with focal spontaneous hematoma around the central herniated
disk located ventral to the cord.

Operative Management
Anesthesia
For all cases, gen eral en dot rach eal an esth esia is th e preferred
tech nique, assum ing favorable an atom y an d th e pat ien ts con dit ion . In t ubat ion -related m an ipulat ion of th e n eck con cern s
in pat ien t s w ith cer vical spin al cord com pression n eed to be
w eigh ed again st th e u rgen cy of obt ain ing a reliable air w ay.
W h ere possible, a m in im ally m an ipulat ion tech n iquesu ch as

aw ake beropt ic, lar yngeal in t ubat ion w ith an illum in ated lar yngoscope w ith cam era, or n asal in t u bat ion in a pat ien t w ith
n o risk factors for cribriform fract u re or in com p eten cesh ou ld
be used.
W h en em ergen t air w ay com prom ise is presen t an d in t ubat ion is n ot likely to be able to be perform ed in a t im ely fash ion ,
th en em ergen t cricothyroid or t rach eostom y in t u bat ion w ill
n eed to be p erform ed , an d it w ou ld be pru den t to h ave a t rach eostom y kit at th e side of any pat ien t w ith em ergen t spin al cord
com pression in case th ey deteriorate on th eir w ay to or from

Fig. 17.2a, b Spinal epidural abscess. (a) Axial T2-weighted MRI of the cervical spine in a patient who presented with acute rapidly progressive
paraplegia and respiratory failure. There is a large dorsal epidural abscess collection with cord compression. (b) Sagit tal postcontrast image of a
posterior thoracolumbar spine abscess associated with multiple areas of vertebral body osteomyelitis including T11, L2 through L5, and diskitis at L23.

289

II Spinal Em ergency Procedures

any procedu re, or even in th e op erat ing room d u ring stan dard
en dot rach eal in t u bat ion .
For those cases w here the opportunit y presents and the surgeon w ishes, if intraoperative m onitoring is to be used, then
the anesthetic should take into account any potential e ects on
electrom yography or m otor evoked potential (MEP) m onitoring
by focusing on a total intravenous anesthetic (TIVA) technique to
prevent the detrim ental im pact of inhalational anesthetic. TIVA
also includes the absence or m inim al use of paralytics to prevent
their im pact upon the m uscle activit y being m onitored by electrom yography (EMG) or MEP. Som atosensory evoke potentials
(SSEPs) are used to avoid potential peripheral nerve com plications such as arm positioning apraxias, or even in ltration of an
IV leading to com partm ent syndrom e, w hich if caught intraoperatively instead of identi ed postoperatively m ay result in im m ediate treatm ent of the problem and prevent perm anent m orbidit y.
W here practical and feasible, m ean arterial pressures (MAP)
sh ould be m ain tain ed as h igh as can be tolerated (u p to 100 m m
Hg), an d w h en a n eu rologic de cit is presen t , if th e pat ien t can
tolerate, MAPs in th e 901 m m Hg range sh ould be th e goal, to
m ain tain spin al cord perfusion given th e presum ably edem atou s
state of th e spin al cord. Th is can be correlated w ith in t raoperative evoked potent ial m onitoring, and m any tim es a decrem ent
in evoked poten tials can be corrected w ith elevat ion of the MAP.

Surgical Approach
General Principles
Posit ion select ion d ep en ds on several factors, in clu ding th e locat ion of th e prim ar y path ology (an terior, posterior, or lateral
w ith in th e can al), n um ber of levels, an d di cult y approach ing

290

Fig. 17.3a, b Metastatic epidural spinal cord compression.


(a) Sagit tal CT reconstruction and (b) axial CT image in a
patient with known m etastatic breast cancer with sudden
paraplegia and incontinence after a fall. A large destructive
L1 vertebral body lesion is also invading both pedicles,
left more than right, with signi cant ventrolateral cord
compression. There is a resultant kyphotic deformit y at T12.

th e path ology directly, su ch as w h en a t rach eostom y, an terior


scar, sp in al deform it y, or oth er con dit ion m akes th e app roach
m ore ch allenging or h as h igh er risks of com p licat ion . W h ere
possible, th e m ost direct approach leads to th e best resu lt ing
t reat m en t , but on e or m ore factors m ay ch ange th at decision
process, in cluding availabilit y of an access surgeon , result ing
postoperat ive in stabilit y, an d pat ien t appropriaten ess for stabilizat ion tech n iques, am ong oth ers. W h en th e disease process or
th e approach to th e disease causes spin al in st abilit y, fu sion of
th e u n stable levels is addit ion ally recom m en ded. Several t reatm en t opt ion s exist (allograft bon e, p olym ethyl m eth acr ylate
[PMMA] cem en t w ith Stein m an pin s, t it an ium cages, carbon ber cages, an terior t it an ium plate/rod xat ion devices, etc.), th e
discussion of w h ich is beyon d th e scope of th is ch apter.
A dedicated spin al t able can h elp to posit ion properly an d
possibly preven t di eren t posit ion ing com plicat ion s, as w ell
as being radiolu cen t to opt im ize im aging. Kn ee-elbow p osit ion
on a stan dard n on spin al operat ing room t able can be used for
dorsal th oracic or lum bar procedures. W h ile an on -call n eurom on itoring team m ay be desirable, on e sh ou ld n ot d elay th e
case to w ait for a team to be available.
For dorsal/dorsolateral path ology, a un ilateral approach is
often su cien t . For sh ort-segm en t path ologies, such as focal
abscess or lateral an d d orsal ep idu ral sp in al m etast ases, a m icrosurgical in t ralam in ar approach can be used as is don e for
h ern iated disks. Ven t ral lu m bar path ology, located ven t rolaterally or below th e con u s m edu llaris, can be app roach ed in a
sim ilar w ay w ith gen tle ret ract ion of th e th ecal sac.
Soft (i.e., n ot calci ed, bon e, or h ard brou s lesion s) lesion s
at th e cord level, su ch as in th e cer vical or th oracic sp in e, can
be approach ed via several approach es, depen ding on th e surgeons com fort level an d th e facilit ys resou rces (in clu ding th e
exp erien ce of th e even ing or on -call st a ). On e app roach is via

17
u n ilateral h em ilam in ectom y w ith part ial t ran spedicular decom pression to gain access to th e ven t ral locu s of purulen ce,
leaving th e posterior m idlin e an d con t ralateral st ru ct ures in t act
to m in im ize delayed in st abilit y, reduce th e size of th e w oun d
an d cavit y to be closed, an d redu ce in t raoperat ive bleeding. Th e
less p ed icle rem oved, th e m ore st able th e sp in e w ill be over
t im e. Should a m ore exten sive exposure n eed to be perform ed
(com plete pedicle rem oval, bilateral decom pression plus t ran sp edicu lar, or rem oval of th e pars in terart icu laris), a fusion of
th e poten t ially un stable segm en ts m ay be n ecessar y, an d w h ere
app ropriate, in st ru m en tat ion sh ou ld be u sed. In st ru m en tat ion
sh ou ld n ot be forgon e ju st becau se th e p rim ar y p ath ology is in fect ion . W h ere ap p rop riate, a bilateral p osterolateral m in im ally
invasive approach from a part ial t ran sp edicu lar or costot ran sverse ap proach on eith er side can be p erform ed as w ell, w ith
angled in st ru m en ts pu sh ing p ath ology dow n an d aw ay from
th e cord. W h en th e path ology is liquid (acute abscess or relat ively lique ed h em atom a), an angled in ser t ion tech n ique can
allow for placem en t of a sm all-caliber d rain (like a ven t ricu lostom y cath eter) th at can be used to rem ove ven t ral path ology
an d facilit ate irrigat ion in th e abscess plan e.
In gen eral, w e do n ot recom m en d a st raigh t lam in ectom y for
p redom in ately ven t rally located in fect ion s at cord-level cases,
u n less th ere is en ough room to reach th rough laterally located
p u ru len t collect ion s an d p ass a righ t-angled in st ru m en t ven t ral to th e th eca in to th e ven t ral pus w ith out pressure on th e
already ten u ou s sp in al cord .
In acu te cases, th ere is rarely m u ch ep idu ral bleed ing, bu t in
m ore ch ron ically in fected cases, th ere m ay be an in am m ator y
rin d th at h as sign i can t vascu lar inp u t . Ep idu ral d rain s sh ou ld
be left beh in d, an d drain age con t in ued longer th an st an dard
durat ion to preven t any furth er collect ion or con t am in at ion of
in fected m aterial in th e epid ural space.22
For m et ast at ic epidural disease, th e locat ion of th e origin of
th e t u m or (isolated epidural disease versus arising from osseou s lesion w ith exten sion ) as w ell as con sid erat ion s of sp in al st abilit y sh ou ld dict ate ch oice of op erat ive p rocedu re.23
A th orough descript ion of all surgical approach es is beyon d th e
scop e of th is ch apter. How ever, a sim p le lam in ectom y sh ou ld
be reser ved for dorsally located disease, an d a posterolateral or
ven t ral ap proach sh ou ld be u t ilized w h en ever ven t ral d isease
is presen t , as t u m ors m ay con t in u e to grow or sw ell an d th u s
w ith out a direct rem oval of th e o en ding path ology, an in direct decom p ression w ill resu lt in fu rth er deform at ion of th e
sp in al cord. At th e spin al cord level (occip u t to bot tom of con u s
m edu llaris), th e cord sh ou ld n ever be ret racted to gain access to
ven t ral t u m or; th e ap proach sh ou ld be selected th at obtain s th e
m ost advan t ageou s angle to access th e t u m or in stead.

Posterior Approaches
Lam in ectom y alon e is to be u sed at th e spin al cord level on ly
w h en th e disease is w h olly dorsal or ju st posterior to th e n er ve
root if lateral. Any m ass ven t ral to th e n er ve root , u n less prim arily liqu id an d able to be drain ed w ith a cath eter p assed in
an exist ing m ass ch an n el (e.g., an abscess th at w raps arou n d
th e lateral aspect of th e dura), sh ould be resected or drain ed
via a posterolateral ap p roach , an d th e m ore ven t ral an d m ed ial
th e locat ion , th e m ore lateral th e approach sh ould be. Th e posterolateral approach es, in order of successively m ore lateral

Spinal Epidural Com pression

(an d th erefore m ore ven t ral access) locat ion , in clude: lam in ectom y, t ran spedicular, costot ran sversectom y (in th oracic spin e
on ly), an d lateral ext racavitar y. Th e parascapular approach is a
varian t of th e costot ran sversectom y or lateral ext racavit ar y at
th e levels of T27 w h ere th e m uscles of th e scapu la n eed to be
carefully separated an d th e scapula m obilized for th e exposu re,
an d recon n ected carefu lly after w ard to p reven t m orbidit y.

Anterior Approaches
Cervical
Tran soral, w h ich gives good access from th e clivus to C3
St an dard ven t rom edial an terior cer vical, w h ich gives good
access from C2 to T1 or T2

Cervicothoracic and Thoracic


Su p raclavicu lar, w h ich gives access at th e cer vicoth oracic

ju n ct ion (dow n to T3) via an ap p roach th at is sim ilar to th e


t radit ion al ven t rom edial an terior cer vical approach , but uses
a m ore acu te angle to ap p roach th e th oracic vertebrae.
Transsternal, w hich gives good access to the T3-T10 region, but
there is an association w ith an increased risk of m ediastinit is.
Tran sm an u brial, w h ich can be com bin ed w ith ven t rom edial
to give access to C5-6 dow n to T2-3, alth ough th ere is a risk of
injur y to m ajor vascular or chylou s st ruct ures.
Tran sth oracic, w h ich gives excellen t ven t ral access to th e
T4-T11 region s an d can be used to expose m ult iple levels, but
in creased pulm on ar y m orbidit y lim it s it s u se today.
Th oracoscopic approach es, w h ich give sim ilar access as th e
t ran sth oracic w ith less pu lm on ar y m orbidit y, in clude a sign i can t learn ing cu r ve an d th e p or t size lim it s som e of th e
access an d procedu res th at can be perform ed.
Th oracoabdom in al, w h ich gives a w ide exposure to th e vertebral bodies an d ven t ral cord at th e region of T10 to L2, bu t
requires split t ing of th e diap h ragm , an d h as a h eigh ten ed risk
of injur y to abdom in al an d th oracic viscera.

Lumbar
Ret rop eriton eal or direct lateral exposu res from L1-S1. Varia-

t ion s of th ese can be used at di eren t levels, w ith good exposu re of th e vertebral bodies w ith less risk to in t rap eriton eal
organ s, alth ough th e t ran spsoas tech n iques do h ave greater
risks to th e n er ves, an d th e m ore ven t ral ap p roach es h ave a
greater risk of inju r y to u reters an d great vessels.
Tran speriton eal, w h ich gives good exposu re from L1/2 to th e
u pper sacrum ; th is can give good exp osu re to th e bodies an d
th ecal sac, but lim itat ion s in clude w orking arou n d th e aort a
an d in ferior ven a cava (IVC); risk to bow el, bladder, or u reter;
an d in m ales a risk of sexu al dysfu n ct ion d u e to ret rograde
ejacu lat ion , believed by som e to be related to injur y to th e
sym path et ic p lexu s.

The follow ing illustrations dem onstrate som e of the m ore


com m on em ergency procedures for epidural com pression. W hile
open approaches are dem onstrated here, m inim ally invasive ap proaches can be chosen depending on the surgeons judgm ent
and experience as n oted in th e case exam ples. Som e of the oth er
approaches m en tion ed are addressed in detail in oth er ch apters.

291

II Spinal Em ergency Procedures

Operative Procedure
Positioning for Posterior and Posterolateral Procedures
Positioning and Incision (Fig. 17.4a, b)

292

Figure

Procedural Steps

Fig. 17.4

(a) The patient is placed prone on a spinal table and/or Wilson frame
(b) w ith an incision marked as diagrammed.

17

Spinal Epidural Com pression

Thoracic Laminectomy for Dorsal Spinal Epidural Hematoma


Laminectomy (Fig. 17.5)

Figure

Procedural Steps

Fig. 17.5

After incising the fascia and dissecting the muscle o of the spinous processes and laminae, the laminae are
removed w ith a drill/ Leksell rongeur exposing the epidural hematoma. It is important to remove as much of
the laminae at consecutive levels until the superior and inferior limits of the hematoma have been reached.

293

II Spinal Em ergency Procedures

Hematoma Removal (Fig. 17.6)

294

Figure

Procedural Steps

Fig. 17.6

A Woodson or Pen eld dissector is used in conjunction w ith suction to removed congealed hematoma taking
care not to put undue pressure on the thecal sac and spinal cord. Irrigation is helpful in assisting hematoma
removal.

17

Spinal Epidural Com pression

Lumbar Laminectomy for Epidural Abscess


Laminectomy (Fig. 17.7)

Figure

Procedural Steps

Fig. 17.7

After incising the fascia and dissecting the muscle o of the spinous processes and laminae, the laminae are
removed w ith a drill/ Leksell rongeur and Kerrison rongeurs.

295

II Spinal Em ergency Procedures

Nerve Root Retraction and Abscess Removal (Fig. 17.8a, b)

Figure

Procedural Steps

Pearls

Fig. 17.8

For ventral and ventrolateral disease related to a diskitis or


mycobacterium infection, the nerve root is retracted gently w ith a
Pen eld no. 4.

It is important to send m ultiple

(a) In the case of liquid purulent material, the abscess is evacuated


w ith suction and a small catheter can be placed to ush out material
from the epidural space ventrally and under adjacent laminae.
(b) For chronic infections consisting of granulation tissue or
granuloma, abnormal material is removed w ith small pituitary
rongeurs, Woodson and Pen eld dissectors, along w ith suction.

296

cultures for bacterial (anaerobic and


aerobic), fungal, and acid fast bacilli in
addition to pathology.

17

Spinal Epidural Com pression

Transpedicular Approach for Metastatic Disease


Laminectomy (Fig. 17.9)

Figure

Procedural Steps

Fig. 17.9

After incising the fascia and dissecting the muscle o of the spinous processes and laminae, the laminae are
removed w ith a drill/ Leksell rongeur exposing the epidural tumor. It is important to remove as much of the
laminae at consecutive levels until the superior and inferior limits of the epidural mass have been reached.

297

II Spinal Em ergency Procedures

Pediculectomy (Fig. 17.10)

Figure

Procedural Steps

Pearls

Fig. 17.10

If not already disrupted by tumor a bur is used


to perform a partial facetectomy at the location
of the pedicle and neural foramen. The pedicle
is drilled dow n to the level of the posterior
vertebral body. A Kerrison rongeur can be used
to remove more of the facet to expose the
neural foramen if tumor is occupying this area.

Many tum ors arising from the vertebrae have eroded the

298

pedicles. If there is lateral and ventral tum or without pedicle


erosion, it will be necessary to drill the pedicle down to the
posterior aspect of the vertebral body to rem ove tum or
without retracting the thecal sac and spinal cord. Unilateral
pediculectomy in the thoracic spine does not necessarily
require stabilization, while bilateral pediculectom ies do.
A costotransversectomy can be perform ed if substantial
vertebral body erosion has occurred and instrum entation in
planned to improve anterior colum n support (see Chapter 15).

17

Spinal Epidural Com pression

Lateral and Ventral Tumor Removal (Fig. 17.11)

Figure

Procedural Steps

Fig. 17.11

Without retracting the thecal sac and spinal cord, lateral and ventral tumor is removed w ith Pen eld and
Woodson dissectors. Dow n-going spinal curettes can be used to push ventral tumor aw ay from the thecal sac.
The tumor is collected by suction and small pituitary rongeurs.

299

II Spinal Em ergency Procedures

Special Considerations

Closing
Th e w oun ds are irrigated copiou sly w ith n orm al salin e.
All e p id u ral ble e d in g sh ou ld b e coagu lat e d an d h e m ost at ic
8

m at e r ial ca n b e left , as lon g as t h e h e m ost at ic su bst a n ce


is n ot left in a w ay t h at w ill cau se im m e d iat e or d elaye d
(d u e to sw ellin g of t h e m at e r ial ove r t im e ) sp in a l cord
com p ression .
A su ct ion drain age device m ay be left in th e su bfacial p lan e in
th e postoperat ive period.
Th e m uscle an d facial layers are closed w ith n o. 0 absorbable
su t u re. Th e facia is closed t igh tly w ith n o gap s.
Th e subcut an eous layer is closed w ith 20 or 30 absorbable
sut u re an d th e skin is closed w ith st aples.

Postoperative Management
Monitoring
Close n eu rologic m on itoring sh ou ld be p erform ed in all cases

after su rger y.
SEH: if a coagu lop athy w ere presen t p reop erat ively, it sh ou ld
be follow ed w ith h em atology laboratories an d t reated to n orm al valu es for at least 1 to 2 days after w ard su rger y. Treatm en t beyon d th at rarely h as ben e t , as th e p at ien t w ill revert
to th eir n orm al state even t u ally.
SEA: W h ile single valu es of er yth rocyte sedim en t at ion rate
(ESR)/C-react ive protein (CRP) are m in im ally in form at ive, serial ESR an d CRP levels can be t ren ded to re ect th e cou rse
of in fect ion .

Medication
SEA: An t ibiot ics are con t in u ed u p to 12 w eeks p ostoperat ively,

th ough th e usu al cou rse is 46 w eeks. Th erapy sh ould be


in it iated w ith IV an t ibiot ics, an d can be t ran sit ion ed to oral
an t ibiot ics at a later t im e. As cu lt ures yield a causat ive agen t ,
coverage can be n arrow ed accordingly.
MESCC: Ch em oth erapy is lim ited except for a few ch em osen sit ive en t it ies su ch as Ew ing sarcom a an d n eu roblastom a.
Dep en d ing on th e exten t of decom p ression , steroids m ay be
con t in ued or t apered.

Radiographic Imaging
MESCC: Recu r ren ce sh ou ld be w atch ed for via p osit ron
em ission tom ograp hy (PET)/CT, MRI, or CT scan . Progressive sp in al d eform it y m ay suggest eith er t u m or recu r ren ce
or p rogression , or develop m en t of late rad iat ion -in du ced
osteon ecrosis.

Adjuvant Treatments
MESCC: Radiat ion th erapy is u su ally an app rop riate adju n ct to
t reat m en t postoperat ively after rem oval of epidural t um ors.

300

Spinal Epidural Hematoma


Sp in al an esth esia is u sed for su rgeries of th e low er ext rem it ies, su ch as h ip ar th roplast y an d am pu t at ion s, an d in obstetrics. Risk of an SEH is 1:150,000 to 1:190,000 in th is con text .
Th e prim ar y predisposing factors are t rau m at ic in ser t ion an d/
or rem oval of th e cath eter an d coagulopathy. How ever, given
th e h igh risk of deep vein th rom bosis (DVT) in both h ip arth roplast y an d low er ext rem it y am pu t at ion s, cu rren t recom m en dat ion s en dorse in it iat ion of th erap eu t ic an t icoagu lat ion
2 h ours after th e spin al n eedle is in ser ted or epidural cath eter
is rem oved. An t icoagu lat ion sh ou ld be fu r th er delayed if th ere
is a h em orrh age.2
Postop erat ive SEH su rfaces as a p ar t icu larly p er t in en t topic
in th e set t ing of postoperat ive DVT/pulm on ar y em bolism prophyla xis. Postoperat ive SEH sh ou ld be su spected in any pat ien t
w ho develops n ew n eu rologic de cit s after surger y. In ciden ce
across m any st u dies is 1% or less. Preop erat ive coagu lop athy is
th e m ost im por tan t risk factor. Oth er risk factors in clude age
greater th an 60; u se of n on steroidal an t i-in am m ator y drugs
(NSAIDs); Rh 1 blood group; greater th an 5-level procedure;
h em oglobin level less th an 10; blood loss greater th an 1 L; an d
in tern at ion al n orm alized rat io (INR) greater th an 2.0 in th e rst
48 h ou rs. Curren tly th ere is in su cien t eviden ce to o er precise recom m en dat ion s of w h en to st ar t postoperat ive ch em oprophylaxis for DVTs.3
Traum at ic SEH h as been associated w ith spin al fract ures. In
one series, approxim ately h alf of pat ien t s w ith a t raum at ic spin al fract u re also su ered from an SEH. In th is series, t reat m en t
focu sed exclu sively on th e fract u re. Th e ou tcom e in p at ien ts
w ith n eurologic de cits w ere equivalen t in both th e group w ith
a t rau m at ic SEH an d th e grou p w ith ou t .24

Spinal Epidural Abscess


Th e un derlying con dit ion th at predisposed the pat ien t to developing a sp in al abscess sh ou ld be invest igated, if n ot im m ediately kn ow n . W h ile perfectly h ealthy pat ien t s can develop a
spin al abscess w ith ou t oth er risk factors, th is is ext rem ely rare
an d a search for a p redisposing factor sh ou ld be u n der taken
at th e sam e t im e as th e t reat m en t itself. An t ibiot ics sh ould be
con t in ued for several w eeks after drain age, if un der t aken , an d
th e du rat ion w ill depen d on th e in fect ious agen t an d local sen sit ivit ies. Th e in am m at ion su rrou n ding th e sp in al cord from
th e in fect ion can cause local th rom bosis an d isch em ia, an d th e
associated hyp oten sion th at can n orm ally d evelop from any spin al cord inju r y or sh ock m ay w orsen th is e ect . If th e pat ien t
h as any sign s of hyp oten sion , at least acu tely, th is sh ou ld be
m an aged, p ossibly in an in ten sive care environ m en t , u n t il th e
pat ien t is st abilized or at least for th e rst 48 h ours or so.

MESCC
Em erging technologies becom ing increasingly relevant, especially
for those w ho cannot tolerate surgery, include stereotactic radiosurgery, proton beam , radiofrequency ablation, and cryotherapy.

17
Minim ally invasive surgical treatm ents m ay lower the bar for
surgical intervention, especially if it facilitates reoperation or
reim aging w ith less artifact If postoperative radiation is anticipated, incision placem ent m ay be m odi ed in a m anner that w ill
m inim ize exposure to the eld of radiation and m axim ize potential for wound healing.

References
1. Reih sau s E, Wald bau r H, Seeling W. Spin al ep idu ral abscess:
a m et a-an alysis of 915 pat ien t s. Neurosurg Rev 2000;23(4):
175204, discussion 205
2. Al-Mu t air A, Bedn ar DA. Spin al epid u ral h em atom a. J Am Acad
Or th op Su rg 2010;18(8):494502
3. Glot zbecker MP, Bon o CM, Wood KB, Harris MB. Postoperat ive
spin al ep idu ral h em atom a: a system at ic review. Sp in e 2010;
35(10):E413E420
4. Tom p kin s M, Pan u n cialm an I, Lu cas P, Palu m bo M. Sp in al Ep idu ral Abscess. Jou r Em er Med . 2010;39(3):384390
5. Felden zer JA, McKeever PE, Sch aberg DR, Cam p bell JA, Ho JT.
The p ath ogen esis of spin al epidural abscess: m icroangiograph ic
st udies in an experim en t al m odel. J Neurosurg 1988;69(1):
110114
6. Patch ell RA, Tibbs PA, Regin e W F, et al. Direct decom pressive
surgical resect ion in th e t reat m ent of spin al cord com pression caused by m et ast at ic can cer: a ran dom ised t rial. Lan cet
2005;366(9486):643648
7. Rad es D, Heiden reich F, Karsten s JH. Fin al resu lt s of a p rospect ive st udy of th e progn ost ic value of th e t im e to develop m otor
de cit s before irrad iat ion in m et ast at ic sp in al cord com p ression .
In t J Radiat On col Biol Phys 2002;53(4):975979
8. Krep p el D, An ton iadis G, Seeling W. Sp in al h em atom a: a literat ure sur vey w ith m et a-an alysis of 613 pat ien t s. Neurosu rg Rev
2003;26(1):149
9. Joh n son KG. Sp in al ep idu ral abscess. Crit Care Nu rs Clin Nor th
Am 2013;25(3):389397
10. Heusn er AP. Non t uberculous spinal epidural infect ion s. N Engl J
Med 1948;239(23):845854
11. Yang SY. Spin al ep idu ral abscess. N Z Med J 1982;95(707):
302304

Spinal Epidural Com pression

12. Rigam on t i D, Liem L, Sam path P, et al. Spin al epidural abscess:


con tem porar y t ren ds in et iology, evaluat ion , an d m an agem en t .
Surg Neurol 1999;52(2):189196, discussion 197
13. Byrn e TN, Borges LF, Loe er JS. Met ast at ic epidural spin al cord
com pression : update on m an agem en t . Sem in On col 2006;
33(3):307311 Review
14. Cole JS, Patch ell RA. Met ast at ic epidural spinal cord com pression .
Lan cet Neu rol 2008;7(5):459466
15. Gilbert RW, Kim JH, Posn er JB. Epidural spin al cord com pression
from m et ast at ic t u m or: diagn osis an d t reat m en t . An n Neu rol
1978;3(1):4051
16. Rodriguez M, Din apoli RP. Spinal cord com pression : w ith special referen ce to m et ast at ic epidural t um ors. Mayo Clin Proc
1980;55(7):442448
17. Fessler RG, Steck JC, Giovan in i MA. Anterior cer vical corpectom y for cer vical spondylot ic m yelopathy. Neurosurger y
1998;43(2):257265, discussion 265267
18. Loblaw DA, Perr y J, Ch am bers A, Laperriere NJ. System at ic review of th e diagn osis an d m an agem en t of m align an t ext radu ral spin al cord com pression : th e Can cer Care On t ario Pract ice
Guidelines In it iat ives Neuro- On cology Disease Site Group. J Clin
On col 2005;23(9):20282037 Review
19. With am TF, Kh avkin YA, Gallia GL, Wolin sky JP, Gokaslan ZL. Surger y in sigh t: cu rren t m an agem en t of ep idu ral sp in al cord com pression from m et ast at ic spin e disease. Nat Clin Pract Neurol
2006;2(2):8794, quiz 116
20. Braun P, Kazm i K, Nogus-Meln dez P, Mas-Estells F, ApariciRobles F. MRI n dings in spin al subdural an d epidural h em atom as. Eur J Radiol 2007;64(1):119125
21. Sh ort DJ. El Masr y WS, Jon es PW. High dose m ethylpredn isolon e
in th e m an agem en t of acute spin al cord injur ya system at ic
review from a clin ical perspect ive. Midlan ds Cen t re for Spin al
Inju ries, Rober t Jon es & Agn es Hu n t Or th op aedic & Dist rict Hospit al NHS Tr ust , Osw est r y, Sh ropsh ire, SY109DP, UK.
22. Recinas P, Pradilla G, Crom pton P, Th ai Q, Rigam ont i D. Spin al
Epidural Abscess: Diagn osis an d Treat m en t . Operat ive Tech n iques in Neurosu rger y 2004;7:188192
23. Quraish i NA, Gokaslan ZL, Borian i S. Th e surgical m an agem en t of
m et ast at ic epidural com pression of th e spin al cord. J Bon e Join t
Surg Br 2010;92(8):10541060
24. Benn et t DL, George MJ, Oh ash i K, El-Khour y GY, Lucas JJ, Peterson
MC. Acu te t rau m at ic sp in al ep idu ral h em atom a: im aging an d
n eurologic outcom e. Em erg Radiol 2005;11(3):136144

301

18

Treatment of Acute Cauda


Equina Syndrome
Harel Deut sch

Introduction
Acu te cau da equ in a syn drom e is th e su dden com p ression of th e
n er ves in th e lu m bar cistern resu lt ing in p ain an d n eu rologic
im p airm en t . Th e spin al cord en d s at approxim ately th e L1 to
L2 levels an d, th erefore, cau da equin a com pression involves th e
n er ve roots rath er th e spin al cord. Clin ically it m ay n ot be p ossible to di eren t iate bet w een a con u s m edu llaris inju r y versu s
a cau da equ in a syn drom e. Neu rologic m an ifestat ion s in clu de
bilateral leg w eakn ess, loss of sen sat ion , an d bladder an d bow el
p roblem s. True cau da equ in a syn drom e is rare because th e
n er ve root s are m ore resist an t to com p ression th an th e spin al
cord. Acute cau da equin a syn drom e th erefore requires severe
com pression an d a rapid on set of com pression . Causes in clude
an acu te lu m bar disk h ern iat ion or a lu m bar fract u re/dislocat ion . Ch ron ic com pression is an ext rem ely rare cau se of cauda
equ in a sym ptom s. Treat m en t involves gen erally a w ide lu m bar
lam in ectom y an d rem oval of th e com p ression . In cases w h ere
th ere is a fract u re or dislocat ion , spin al redu ct ion an d in st ru m en tat ion m ay be n ecessar y. Oth er cau ses of cau da equ in a
syn drom e in clu de h em atom as, t u m ors, an d in fect ion s su ch as
ep idu ral abscesses.

Indications
Pat ien t s w ith acu te cau da equ in a syn drom e h ave leg w eak-

302

n ess, decreased low er ext rem it y sen sat ion , an d bladd er


reten t ion . Im aging st udies sh ow severe lum bar acute com p ression . Pat ien t s also gen erally h ave severe low er back an d
bilateral leg pain.
Som e lu m bar sten osis is a com m on n ding on m agn et ic
reson an ce im aging (MRI) scan s. Cau da equin a syn drom e is
n ot p ossible u n less th e sten osis is ver y severe. Add it ion ally,
m ost pat ien t s w ith ver y severe lu m bar sten osis do n ot h ave
cauda equin a syn drom e. For a cau da equin a syn drom e to occur th ere usu ally is an acute w orsen ing of th e baselin e sten osis. Som et im es a sm all acu te disk m ay be su p erim p osed on
ch ron ic severe sten osis.
Pat ien t s w ith acu te cau da equ in a syn drom e h ave u rin ar y reten t ion . Bladder cath eterizat ion after th e pat ien t t ries to void

allow s docu m en t at ion of th e post void residu al. A p ost void


residual over 100 m L suggests a n eurogen ic bladder.
Bow el function is not usually apparently disturbed in acute
cauda equina syndrom e. Patients m ay have severe constipation
and im pacted stool. Diarrhea or loss of bowel issues are not
com m on ndings in acute cauda equina syndrom e.
For pat ien ts w ith a t raum at ic lu m bar fract u re as th e cau se of
an acu te cau da equ in a syn drom e, su rger y m ay be requ ired to
address n eu rologic issu es as w ell as sp in al colu m n stabilit y.
Th is ch apter depicts decom pression for an acu tely h erniated
lum bar disk causing sign i can t sp in al can al com p rom ise.

Preprocedure Considerations
Radiographic Imaging
MRI is th e p referred im aging st u dy to evalu ate for severe

lum bar com pression . T2-w eigh ted MRI is excellen t in sh ow ing th e absen ce h igh in ten sit y cerebrospin al uid sign al at
th e level of th e com pression (Fig. 18.1).
If MRI in u n available or pat ien t factors p reclu d e get t ing an
MRI, th en a com p u ted tom ograp hy (CT) m yelogram m ay
dem on st rate severe sten osis or a com plete block to con t rast
ow at th e level of com p ression .
For pat ien ts w ith t raum at ic lu m bar fract ures, X-rays an d CT
scan s are essen t ial to evalu ate align m en t an d fract u res.

Medication
An t ibiot ics are adm in istered prior to in cision .
Updated guidelines released in 2013 recom m end against the
use of steroids in spinal cord injur y. The guidelines conclude,
In su m m ar y, th ere is n o con sisten t or com pelling m edical evidence of any class to just ify the adm inistration of MP
[m ethylprednisolone 1,2 ] for acu te SCI [spin al cord injur y]. Both
consistent and com pelling Class I, II, and III m edical evidence
exists suggest ing th at high -dose MP adm in ist rat ion is associated w ith a variet y of com plicat ions including infection , respirator y com prom ise, GI hem orrhage, and death. MP sh ould not
be routinely used in the t reatm ent of patients w ith acute SCI.3

18

Treatm ent of Acute Cauda Equina Sym drom e

Foley Catheter Placement

Operative Field Preparation

Pat ien t s m ay h ave sign i can t u rin ar y reten t ion leading to hy-

Alcoh ol prep is perform ed before povidon e iodine or chlorh ex-

p oten sion because of blad der disten sion .

idin e application .
Th e in cision s are m arked an d in lt rated w ith 1% lidocain e
w ith epin eph rin e 1:100,000.

Fig. 18.1 Lumbar T2-weighted MRI sagit tal and axial images with severe stenosis at L5-S1.

303

II Spinal Em ergency Procedures

Operative Procedure
Positioning (Fig. 18.2)

304

Figure

Procedural Steps

Pearls

Fig. 18.2

Patient positioning. The


patient is positioned
prone. X-ray or uoroscopy
is used to localize the level
and plan the incision.

There are several options for beds. Bolsters can be used for the chest. A Wilson fram e
allows for opening up of the lum bar spine. A spinal table with hip and chest pads avoids
abdom inal compression and m ay reduce bleeding due to venous congestion. In patients
undergoing a fusion, a Wilson fram e should be used carefully to avoid an iatrogenic at
back syndrom e.

18

Treatm ent of Acute Cauda Equina Sym drom e

Skin Incision (Fig. 18.3)

Figure

Procedural Steps

Fig. 18.3

(a) The incision is made w ith a no. 10 blade and extends about 5 cm.
(b) A monopolar is used to extend the incision through the posterior lumbar fascia.

305

II Spinal Em ergency Procedures

Subperiosteal Dissection (Fig. 18.4)

306

Figure

Procedural Steps

Pearls

Fig. 18.4

The monopolar is used to strip


the paraspinal muscles from the
spinous process and lamina. The
medial facet joint is exposed.

Staying in the subperiosteal space helps reduce bleeding. Constant bleeding from
the m uscle m ay interfere with subsequent steps. Preserving the facet capsule rather
may prevent future facet arthropathy. Fluoroscopy or X-ray im aging is used to
con rm the level.

18

Treatm ent of Acute Cauda Equina Sym drom e

Lumbar Laminectomy (Fig. 18.5)

Figure

Procedural Steps

Pearls

Fig. 18.5

The spinous process is removed and the lamina is removed using a


high-speed drill, Kerrison, and/or Leksell rongeurs. A high-speed drill is
helpful for performing a partial medial facetectomy.

The pars articularis is preserved to


m aintain lum bar stabilit y.

307

II Spinal Em ergency Procedures

Lumbar Diskectomy (Fig. 18.6a, b)

308

Figure

Procedural Steps

Pearls

Fig. 18.6

(a) The dura is retracted and if there is a


signif cant disk herniation component, the
disk fragment is removed. The disk space
is often incised and disk material removed
w ith pituitary rongeurs under magnif cation.
(b) The nerve root and thecal sac are inspected
for any remaining fragments or compression.

With a large ventral disk herniation, dural retraction m ay be very


di cult or impossible initially. More bone m ay need to be rem oved
laterally. As the decompression progresses, dural retraction is easier.

18

Closing
Lumbar Incision
Th e w oun d is h eavily irrigated.
A m edium suct ion drain age device is placed deep an d brough t

out th rough a separate skin in cision .


Th e posterior lum bar fascia is reapproxim ated using 0 ab sorbable su t u re in an in terru pted fash ion . In terru pted loose
m u scle su t u res to obliterate dead sp ace are opt ion al.
Th e subcut an eous t issue is closed using several in terrupted
2-0 Vicr yl sut ures.
The skin is closed w ith staples or a m ono lam ent nylon sut ure.

Postoperative Management
Medication
Tw o to th ree doses of prophylact ic an t ibiot ics in th e im m ediate postoperat ive period are opt ion al. Longer term an t ibiot ics
or an t ibiot ics for drain m an agem en t are discouraged.

Further Management
Drain s are rem oved w h en drain age is m in im al (less th an

50 m L per sh ift).
Skin su t u res or st aples are rem oved after 2 w eeks.

Special Considerations
Timing of Surgery
The tim ing of surgery and in uence on outcom e in cases of
cauda equina surgery is the subject of m ultiple investigations.4
The literat ure indicates outcom e is m ore related to preoperative
con dition th an th e speci c tim ing of inter vention . Studies sh ow
people w ith com plete urinary incontinence have a poor outcom e
an d patients w ith a w eak stream or decreased sensation having
a bet ter outcom e. Sh apiro et al reported an im provem ent for
patients operated on w ithin 48 hours 5 after review ing 14 patients
w ith cauda equina syndrom e. All patients had bilateral sciatica
an d leg w eakness. Of the 14 patien ts, 13 had urinar y in contin ence, 9 m assive disk h erniations, and 5 sm all disk herniations
superim posed on stenosis. All patients were am bulatory. Sh apiro
foun d 7/10 patients w ith no in continence had surgery w ith in
48 hours. The four patients w ith incontinence after surger y all
h ad surgery after 48 hours. Shapiro et al concluded surgery w ithin 48 hours is w arranted in cauda equina patients.
Tator et al u sed a sur vey to determ in e curren t pract ices in
t im ing of surger y for spin al cord injur y. Of th e 585 cases th ey
su r veyed, 5.6%w ere cau da equ in a cases.6 In gen eral 23.5%of pat ien ts h ad su rger y w ith in 24 h ours of injur y. In an other st udy,
Tator et al fou n d n o im provem en t w ith acute surger y for spin al
cord injur y.7 Th e coh or t of 208 pat ien t s in clu ded som e pat ien t s
w ith cauda equ in a injur y. In a review of th e literat ure, Feh lings
et al con clu ded an im al st u dies sh ow bet ter ou tcom e w ith early

Treatm ent of Acute Cauda Equina Sym drom e

decom pression for spin al cord injur y.8 Th e literat u re review ed


w as m ain ly sp in al cord inju r y dat a rath er th an cau da equ in a in ju ries. Feh lings et al con clu d ed th at early decom p ression w ith in
24 h ou rs is recom m en ded for spin al cord injuries.9 Gleave et al,
Qu resh i et al, an d Olivero et al sh ow ed su rgical t im ing did n ot
a ect pat ien t ou tcom e in cau da equ in a syn drom e.1012 Rath er,
outcom e w as depen den t on th e pat ien ts preoperat ive n eurologic stat us. Cases of cau da equ in a syn drom e sh ould be t reated
expedit iou sly.13 W h ile absolu te t im ing m ay n ot m ake a d i eren ce, earlier su rgical in ter ven t ion s seem s to p reven t fu r th er
deteriorat ion .
Cau da equ in a syn drom e inju ries sh ou ld be dist ingu ish able
from inju ries to th e con u s m ed u llaris. Th e con u s m edu llaris is
th e term in al port ion of th e spin al cord an d represen t s a cen t ral
n er vou s system st ru ct u re. Ou tcom es m ay be di eren t w ith con u s inju ries.

References
1. Bracken MB, Sh ep ard MJ, Holford TR, et al. Adm in ist rat ion of
m ethylpredn isolon e for 24 or 48 h ours or t irilazad m esylate for
48 h ou rs in th e t reat m en t of acute spin al cord injur y: result s of
th e th ird n at ion al acu te sp in al cord inju r y ran dom ized con t rolled
t rial. JAMA 1997;277:15971604
2. Bracken MB, Shepard MJ, Holford TR, et al. Methylprednisolone or
tirilazad m esylate adm inistration after acute spinal cord injury:
1-year follow up. Results of the third National Acute Spinal Cord
Injury random ized controlled trial. J Neurosurg 1998;89(5):699706
3. Hurlbert RJ, Hadley MN, Walters BC, et al. Pharm acological therapy
for acute spinal cord injury. Neurosurgery 2013;72(Suppl 2):93105
4. Kingw ell SP, Cu r t A, Dvorak MF. Factors a ect ing n eu rological outcom e in t raum at ic con us m edullaris an d cauda equin a
inju ries. Neurosurg Focus 2008;25:E7
5. Sh apiro S. Cau da equ in a syn drom e secon dar y to lu m bar d isc
h ern iat ion . Neurosu rger y 1993;32(5):743747
6. Tator CH, Feh ling M, Th orp e K, Math M, Taylor W. Cu rren t u se
an d t im ing of spin al surger y for m an agem en t of acute spin al
cord injur y in Nor th Am erica: result s of a ret rospect ive m ult icen ter st udy. J Neurosurg 1999;91(1):1218
7. Tator CH, Du n can eG, Edm on ds VE. Com p arison of su rgical an d
con ser vat ive m an agem en t in 208 pat ien t s w ith acu te spin al cord
inju r y. Can J Neurol Sci 1987;14:6069
8. Feh lings M, Perrin RG. Th e t im ing of su rgical in ter ven t ion in th e
t reat m ent of spin al cord injur y: a system at ic review of recen t
clin ical eviden ce. Spin e 2006;31:S32S35
9. Feh lings MG, Vaccaro A, Wilson JR, et al. Early versu s d elayed d ecom pression for t raum at ic cer vical spinal cord injur y: result s of
th e su rgical t im ing in acu te spin al cord inju r y st u dy (STASCIS).
PLoS On e 2012;7:e32037
10. Gleave JRW, Macfarlan e R. Cauda equin a syn drom e: w h at is
th e relat ion sh ip bet w een t im ing of su rger y an d ou tcom e? Br J
Neurosurg 2002;16:325328
11. Olivero W, Wang H, Han igan W, et al. Cauda equin a syndrom e
(CES) from lu m bar disc h ern iat ion s. J Spin al Disord Tech
2009;22(3):202206
12. Quresh i A, Sell P. Cauda equin a syndrom e t reated by surgical
decom pression : th e in u ence of t im ing on surgical outcom e.
Eur Spin e J 2007;6(12):21432151
13. DeLong W B, Polissar N, Neradilek B. Tim ing of su rger y in cauda
equin a syn drom e w ith urinar y retent ion : m et a-an alysis of
obser vat ion al st udies. J Neurosurg Spine 2008;8(4):305320

309

III

Nontraumatic Emergencies

19

Removal of Spontaneous
Intracerebral Hemorrhages
Just in Mascitelli, Yakov Gologorsk y, and Joshua Bederson

Introduction

Preprocedure Considerations

Sp on t an eou s in t racerebral h em orrh age (ICH) accou n t s for 10


30% of all st rokes an d is a sign i can t cause of m orbidit y an d
m ort alit y arou n d th e w orld. Alth ough it is th e secon d m ost
com m on form of st roke after isch em ic in farct , spon tan eous ICH
is th e m ost deadly t yp e of st roke w ith a 30-day m ort alit y as
h igh as 50%. Un like isch em ic in farct s, spon t an eou s ICH u su ally
p rogresses over m in utes to h ou rs often w ith w orsen ing h ead ach e, n au sea, vom it ing, alterat ion s of con sciou s, an d deteriorating n eu rologic stat u s. Th e m ost com m on locat ion for a spon t an eou s ICH is deep (in clu ding th e basal ganglia, th alam u s, an d
in tern al capsu le) follow ed by lobar, cerebellar, an d brainstem .
Rapid diagn osis an d m an agem en t is cru cial as early deteriorat ion is com m on w ith in th e rst few h ours after on set .1,2

Radiographic Imaging
Com puted tom ography (CT) can be obtained rapidly and clearly

Indications
Supratentorial ICH

dem onstrates high density blood w ithin brain parenchym a. In


addition, the ellipsoid m ethod (diam eter of the clot in each dim ension: anteroposterior [AP], lateral [LAT], and height [HT]) can
be used to calculate ICH volum e and has prognostic signi cance.6
Ellip soid volu m e 2 AP 3 LAT 3 HT / 2
Magn et ic reson an ce im aging (MRI) is n ot th e in it ial diagn ost ic im aging m odalit y of ch oice du e to th e t im e n eeded to
com plete the st udy as w ell as th e com plicated appearan ce of
acu te blood on MRI.7
CT angiograp hy (CTA) is recom m en ded for all pat ien t s except th ose older th an 45 years of age w ith preexist ing hyp erten sion an d ICH in th e th alam u s, pu tam en , or cerebellum
(Fig. 19.1).8 CTA h as low er yield for cerebellar ICH in com p arison to su p raten torial ICH.
Preoperat ive im aging (Fig. 19.2).

Precise in dicat ion s for su rger y are con t roversial14 an d sh ou ld

be based on th e in dividual pat ien ts n eu rologic condit ion , th e


size an d locat ion of th e h em atom a, th e p at ien ts age, an d th e
fam ilys w ish es.
The 2010 Am erican Stroke Association/Am erican Heart Association (ASA/AHA) guidelines recom m end standard craniotom y
for lobar clots greater than 30 m L and w ithin 1 cm of surface.
In gen eral, factors th at favor su rgical m an agem en t 5 in clu de:
Lesion s w ith m arked m ass e ect , edem a, or m idlin e sh ift;
Lesion s w ith sym ptom s th at ap pear to be secon dar y to in creased in t racran ial pressure (ICP) or m ass e ect;
Moderate clot volu m e;
Persisten tly elevated ICP desp ite m axim al m edical
m an agem en t;
Rapid n eu rologic deteriorat ion ;
Favorable locat ion s: lobar, cerebellar, extern al cap su le,
n on dom in an t h em isp h ere;
You ng age;
On set of sym ptom s less th an 24 h ou rs old.

Infratentorial ICH
2010 ASA/AHA in dicat ion s for surgical evacuat ion of cerebellar ICH1
Pat ien t s w h o are deteriorat ing n eu rologically
Brain stem com p ression
Hydrocep h alu s from ven t ricu lar obst ru ct ion

312

Fig. 19.1 CTA demonstrating right cerebellar arteriovenous malformation


with associated intracranial hemorrhage and intraventricular hemorrhage
(IVH).

19

Rem oval of Spontaneous Int racerebral Hem orrhages

Fig. 19.2 Case example: frontal craniotomy. CT head demonstrating


large right frontal intracranial hem orrhage with mild mass e ect and
midline shift and no hydrocephalus.

Initial Management and


Medication 1,2

In it ial m on itoring sh ou ld t ake place in an in ten sive care u n it

or oth er m on itored set t ing.


Blood pressu re sh ou ld be p rom ptly bu t n ot over-aggressively
con t rolled. In pat ien ts presen t ing w ith systolic blood pressure
(SBP) of 160220 m m Hg, th e auth ors prefer n icardipin e in fu sion w ith a goal SBP of 140160 m m Hg.
For p at ien ts w ith clin ical seizu res or elect roen ceph alography
(EEG) eviden ce of seizure act ivit y, th e auth ors prefer ph enytoin . Alth ough seizure prophylaxis is debated in th e set t ing of
ICH, th e au th ors also p refer ph enytoin for th e preven t ion of

early seizu res in p at ien t s w ith lobar ICH.


Glucose sh ould be m on itored an d n orm oglycem ia m ain t ain ed .
Platelet t ran sfu sion an d factor rep lacem en t sh ou ld be given
to all pat ien t s w ith severe th rom bocytopen ia or coagulat ion
factor de cien cy, respect ively. For p at ien t s w ith a coagulopathy, con siderat ion sh ould be given to giving p rot am in e
su lfate, vitam in K, fresh frozen p lasm a, cr yop recip it ate, or
oth er clot t ing factors. For pat ien ts w ith a h istor y of an t iplatelet m edicat ion use, th e auth ors prefer desm op ressin acetate
alon e for th ose u n dergoing con ser vat ive m an agem en t an d
desm opressin plus platelet t ran sfu sion for th ose u ndergoing surgical m an agem en t . Curren tly recom bin an t factor VIIa
(rFVIIa) is n ot recom m en ded given it s th rom boem bolic risk.9
Regarding th e preven t ion of deep ven ous th rom bosis an d
p ulm on ar y em bolism , all pat ien ts sh ould h ave in term it ten t
p n eum at ic com pression , an d ph arm acological prophylaxis
sh ou ld be con sidered on ce cessat ion of bleeding h as been
docum en ted.
Treat m en t of elevated ICP sh ould begin w ith sim ple m easu res
su ch as h ead of bed elevat ion , an algesia, an d sedat ion . More
aggressive m easu res to reduce ICP in clu de osm ot ic diu resis,
cerebrospin al uid (CSF) drain age, paralysis, hyper ven t ilat ion , hypoth erm ia, an d barbit urate com a.
Pat ien t s w ith obst ru ct ive hyd rocep h alu s sh ou ld u n dergo
em ergen t placem en t of an extern al ven t ricu lar drain (EVD) in
th e in ten sive care un it prior to surger y. Altern at ively, an EVD
m ay be placed in th e op erat ing room at th e t im e of su rger y as
long as th is is don e expedit iously.
In th e au th ors exp erien ce, u pw ard cerebellar h ern iat ion d u e
to EVD over-drain age is ext rem ely rare. Non eth eless, EVD
drain age sh ould be lim ited by set t ing a gradien t n o less th an
10 cm H2 O p rior to su rger y.

Operative Field Preparation


Th e exposed skin is sterilized w ith povidon e iodin e or

ch lorh exidin e applicat ion .


Th e in cision is m arked an d in lt rated w ith 1% lidocain e w ith
ep in ep h rin e 1:100,000.

313

III Nontraum atic Em ergencies

Operative Procedure
Frontal Craniotomy10
Positioning and Skin Incision (Fig. 19.3)

Figure

Procedural Steps

Pearls

Fig. 19.3

The patient is placed supine on the operating table.

A frontal craniotomy is described here. Of

The May eld skull clamp is placed w ith the single pin at the equator
in contralateral frontal bone above the orbit and the paired pins
placed at the equator in the ipsilateral occipital lobe.

Alternatively, the patients head may be placed on a horseshoe or a


donut w ithout a May eld clamp.

The head is rotated as far as possible to the contralateral side w ithout


obstructing the airw ay or venous drainage.

The super cial temporal artery (STA) should be palpated at the level
of the zygoma and the vertical limb of the incision should be placed
betw een the artery and the tragus.

The incision begins at the zygoma and then curves posteriorly to the
parietal eminence and upw ard from the auricle to reach 2 cm from
the midline.

The incision is then carried forw ard to the frontal region and curved
across the midline just behind the hairline.

314

course, the exact craniotomy should always


be tailored to the location of the ICH.
Su cient tim e should be devoted for ICH
localization before the incision is m arked. The
patients head position should be correlated
with the CT scan. It is often helpful to draw
the planned craniotomy on the scalp.
If tim e perm its, a volum etric CT scan m ay be
obtained and intraoperative navigation m ay
be used for precise localization of the ICH.
When applying the May eld clamp, the
frontal sinus and m astoid air cells should be
avoided.
Care should be taken to avoid the frontal
branch of facial nerve that originates just
below the root of the zygom a and travels in
the super cial temporal facia to the orbital
rim .11
Care should also be taken when dissecting
adjacent to the auricle to not violate the
external auditory canal.

19

Rem oval of Spontaneous Int racerebral Hem orrhages

Subcutaneous Dissection (Fig. 19.4)

Figure

Procedural Steps

Pearls

Fig. 19.4

The skull is then exposed by incising the temporalis muscle


posteriorly and superiorly and elevating the muscle anteriorly
and inferiorly w ith a periosteal elevator.

Use of electrocautery to elevate the temporalis


m uscle m ay result in injury to the trigem inal
nerve m otor bers. Mechanical elevation with
a periosteal elevator is preferred.

The approach of Spetzler and Lee 12 involves leaving a cu of


temporalis superiorly that can be used during the closure.

315

III Nontraum atic Em ergencies

Craniotomy (Fig. 19.5)

Figure

Procedural Steps

Pearls

Fig. 19.5

The craniotomy should be started w ith a single bur


hole, the location of w hich is tailored to the planned
craniotomy (in this case, it is placed at the posterior
superior temporal line).

It is helpful to again re-correlate with the

The craniotomy is then w idened using the craniotome.


A high speed drill can be used to atten the orbital
roof and remove the inner table of the frontal bone if
needed.

316

CT scan prior to m aking the craniotomy.


While drilling the inner table of the
frontal bone, care should be taken not
to enter the orbit or frontal sinus. If this
were to occur, the orbit can be packed
with oxidized cellulose and the sinus with
m uscle/fascia.
If the temporal air cells are entered, they
should be thoroughly waxed.

19

Rem oval of Spontaneous Int racerebral Hem orrhages

Dural Opening (Fig. 19.6)

Figure

Procedural Steps

Pearls

Fig. 19.6

Before opening the dura, tack up sutures should be placed


along the entire craniotomy to prevent postoperative
epidural hematoma formation.

Placem ent of dural tack ups m ay be


delayed until after ICH evacuation if
the patient is actively herniating and
im m ediate ICH evacuation is necessary.

There are many fashions in w hich the dura may be opened.


The authors prefer a C-shaped opening w ith the dura
re ected anterior/inferiorly in the same direction as the
scalp/muscle.

317

III Nontraum atic Em ergencies

Hematoma Evacuation (1) 13 (Fig. 19.7a, b)

Figure

Procedural Steps

Pearls

Fig. 19.7

(a) A corticotomy is then performed w here the


hematoma comes closest to the surface (a).

Eloquent tissue should be avoided when choosing the

Bipolar cautery should be used along the planned


cortical incision to prevent bleeding.
The cortical incision is then made using a no. 11
blade.

318

location for the corticotomy.


Intraoperative ultrasound m ay be used if the ICH does
not com e to the cortical surface. (b) Intraoperative
ultrasound im age of a large frontal basal ganglia
hem atom a (arrow).

19

Rem oval of Spontaneous Int racerebral Hem orrhages

Hematoma Evacuation (2) (Fig. 19.8)

Figure

Procedural Steps

Pearls

Fig. 19.8

A malleable can be used to gently retract the cortical opening.

Self-retaining retractors are not advised as they

The hematoma is then evacuated from w ithin the cavity. The


center of the hematoma is evacuated rst follow ed by the
peripheral blood.

Bipolar cautery is used to stop bleeding from the cavity w alls.


Gelatin sponge and oxidized cellulose available in various forms
may also be used for nal hemostasis.

can dam age norm al parenchym a.


The operating m icroscope m ay be used for this
part of the case for increased illum ination and
m agni cation, if needed.
Special at tention should be paid for sm all
tum ors, cryptic arteriovenous m alform ations
(AVMs), and cavernous angiom as.

319

III Nontraum atic Em ergencies

Closing

Th e w oun d is copiously irrigated.


A m ediu m su ct ion drain age device is placed in th e subgaleal

On ce adequ ate h em ost asis h as been ach ieved, th e du ra is

closed using run n ing or in terrupted 4-0 braided nylon sut ures (th e dura m ay be left open if in creased ICP is a poten t ial
con cern ).
Th e bon e ap is placed an d secured w ith plates an d screw s
(th e bon e plate m ay be m arsupialized in th e abdom en if in creased ICP is a poten t ial con cern ).

plan e.
Th e tem poralis m uscle is reapproxim ated w ith 2-0 braided
absorbable su t u res.
Th e galea is approxim ated w ith 3-0 braided absorbable su t ure in an inverted, in terrupted fash ion .
Th e skin is closed w ith 3-0 nylon sut ure in a run n ing fash ion
or st aples.

Midline Suboccipital Craniectomy10 (Fig. 19.9a, b)

b
Fig. 19.9a, b Case example: midline suboccipital craniectomy. (a) Large cerebellar intracranial hemorrhage causing e acement of the fourth
ventricle and brainstem compression. (b) Hydrocephalus secondary to fourth ventricular compression.

320

19

Rem oval of Spontaneous Int racerebral Hem orrhages

Positioning (Fig. 19.10)

Figure

Procedural Steps

Pearls

Fig. 19.10

The head is xed in a May eld skull clamp w ith the


single pin on the linea temporalis anterior to one
external auditory meatus (EAM) and the paired
pins on the opposite linea temporalis (one pin over
the EAM and one pin anterior to the EAM).

The m idline suboccipital craniectomy is described

The patient is placed in the prone position on the


operating table on bolsters.

here. The lateral suboccipital craniectomy can


also be used for m ore lateral cerebellar ICHs.
Care should be taken to not hyper ex the neck
and com prom ise the airway as well as to inspect
and pad all pressure points.
If not done already, an EVD should be placed rst.
Once it has been secured, the patient should be
turned to the prone position for the craniectomy.

The head should be in exion w ith as much


distraction as possible.

321

III Nontraum atic Em ergencies

Skin Incision and Subcutaneous Dissection (Fig. 19.11)

322

Figure

Procedural Steps

Pearls

Fig. 19.11

A linear midline skin incision is made from the


inion to the upper cervical vertebrae.

The inferior extent of the incision should

The subcutaneous musculature is divided along the


midline raphe. The muscle is re ected laterally.

be determ ined by the size of the planned


craniectomy and need for C1 or C2 lam inectomy.
The m idline raphe is avascular and blood loss can
be m inim ized by remaining along that plane.

19

Rem oval of Spontaneous Int racerebral Hem orrhages

Craniectomy (Fig. 19.12a, b)

Figure

Procedural Steps

Pearls

Fig. 19.12

The craniectomy is made from just below the inion/torcula and


carried dow nw ard tow ard the foramen magnum.

The location and size of the lesion will

There are a number of w ays to perform the craniectomy; (a) the


authors prefer to thin the bone w ith a high speed drill and then
(b) complete the bone removal w ith rongeurs and punches.

determ ine the extent of the craniectomy;


occasionally the posterior arch of C1 will
need to be rem oved.

323

III Nontraum atic Em ergencies

324

19

Rem oval of Spontaneous Int racerebral Hem orrhages

Dural Opening and Hematoma Evacuation (Fig. 19.13)

Figure

Procedural Steps

Fig. 19.13

There are a number of w ays to perform the dural opening ; the authors prefer a Y-shaped opening w ith
the superior dural ap re ected over the transverse sinus.

325

III Nontraum atic Em ergencies

Hematoma Evacuation (Fig. 19.14)

326

Figure

Procedural Steps

Pearls

Fig. 19.14

A cerebellar hematoma should be


evacuated using the same techniques as
a supratentorial hematoma.

If the cerebellum is noted to be signi cantly swollen or


irritated, consideration should be given to resection of a
portion of the cerebellar hem isphere.

19

Rem oval of Spontaneous Int racerebral Hem orrhages


Con sider keep ing p at ien t in t u bated for 24 to 48 h ou rs as

Closing
On ce adequ ate h em ostasis h as been ach ieved, th e d u ra is

closed using ru n ning or in terrupted 4-0 braided nylon sut ures (Valsalva m an euver sh ou ld be used to assure a w atert igh t dural closure).
If th e cerebellu m is sw ollen , con sid erat ion sh ou ld be given to
a du ral p atch graft .
Th e w oun d is h eavily irrigated.
A m edium suct ion drain age device is placed in th e epidural/
su bfacial p lan e.
Th e m uscle an d fascia sh ould be approxim ated in layers using 2-0 braided absorbable su t ure (again , a w ater t igh t fascial
closure sh ould be obt ain ed to preven t CSF leakage th rough
th e w oun d).
Th e derm is is approxim ated w ith 3-0 braided absorbable su t ure in an inver ted, in terrupted fash ion .
Th e skin is closed w ith 3-0 nylon su t ure in a run n ing fash ion
or staples.

Postoperative Management

Pat ien t s sh ou ld be m on itored in an in ten sive care u n it .


Com plete postoperat ive labs sh ou ld be obt ain ed an d th e pa

t ien t sh ould be kept NPO (n oth ing by m outh ).


A CT scan of th e h ead sh ould be obtain ed to evaluate th e decom pression an d ven t ricular size (Figs. 19.15 an d 19.16).
It is opt ion al to give t w o to th ree doses of p rophylact ic an t ibiot ics in th e im m ediate p ostop erat ive p eriod.
Sp eci cally for cerebellar ICH
Du ring th e p ostop erat ive evalu at ion , ch eck for respirator y
rate an d p at ter, hyp er ten sion , an d evid en ce of CSF leak.

a p recau t ion ar y m easu re as resp irator y arrest can occu r


su dden ly.
Hyp erten sion sh ou ld be avoided.
Postop erat ive edem a or h em atom a are com p licat ion s th at
can be seen in th e im m ediate postoperat ive period an d be
rap idly fat al.
St an dard EVD m an agem en t sh ou ld be u sed an d is n ot described in detail h ere.
Drain s sh ou ld be rem oved on p ostoperat ive day 1 or 2.
Su t u res or stap les sh ou ld be rem oved 1 to 2 w eeks after
su rger y dep en d ing on su rgeon p referen ce.

Special Considerations
Other Surgical Considerations
In addit ion to stan dard cran iotom y, m ore m in im ally invasive
tech n iques h ave been con sidered in cluding en doscopic aspirat ion an d stereot act ic in fu sion of th rom bolyt ics in to th e clot cavit y. En doscopic asp irat ion via a single bu r h ole h as been sh ow n
to im prove ou tcom e.14 Alth ough in fu sion of th rom bolyt ics h as
been sh ow n to reduce clot bu rden an d risk of death , rebleeding
is a greater con cern an d fun ct ion al outcom e is n ot n ecessarily
im proved.15 Both m inim ally invasive techn iques are st ill un der
invest igat ion. Curren tly th ere is too lit tle dat a to com m en t on
th e role of decom pressive h em icran iectom y as a t reat m en t
opt ion for spon tan eous ICH alth ough it h as been sh ow n to be
ben e cial for deep ICH in an im al m odels.16 Su rgical t im ing rem ain s con t roversial as w ell as th e de n it ion of early su rger y.
Cu rren tly th ere is n o clear eviden ce th at th ere is a ben e t from
eith er u lt ra early or delayed evacu at ion . In fact , u lt ra early
cran iotom y h as been associated w ith recu rren t bleeding.1

Arteriovenous MalformationAssociated ICH

Fig. 19.15 Postoperative CT following evacuation of right frontal


hematoma shown in Fig. 19.2.

Sp on t an eou s ICH can be secon dar y to AVM, an eu r ysm , or ven ou s angiom a ru pt u re. AVM h em orrh age p rod u ces ICH in
82% of cases an d less com m on ly in t raven t ricular h em orrh age
(IVH), subarach n oid h em orrh age (SAH), or subdural h em orrh age (SDH). AVM resect ion is gen erally an elect ive p rocedu re.
Many recom m en d, if p ossible, delaying AVM su rger y w eeks to
m on th s after h em orrh age th u s allow ing th e p at ien t to st abilize
an d th e clot to liqu efy.1719 It h as been suggested th at if an AVM
associated ICH is m an aged op erat ively, th e h em atom a sh ou ld
be addressed rst as w ell as aggressive m an agem en t of in t raop erat ive ICP20 an d th at th e AVM sh ou ld on ly be addressed at th e
sam e t im e if it is su per cial w ith easily elu cidated an atom y.21
As a caut ion , if AVM bleeding occurs, h em ostasis in th ese
cases can be ext rem ely di cult . Gen tle an d prolonged t am pon ade is often ver y h elp ful an d h em ost at ic adjun ct s su ch as
gelat in sp onge or p ow der are im p ort an t tools. Occasion ally
persisten t bleeding an d can be m it igated w ith in d u ced hypotension . Cerebral perfusion pressure (CPP) sh ould alw ays be
kept in m in d, h ow ever, esp ecially in p at ien t s w ith elevated ICP.

327

III Nontraum atic Em ergencies

b
Fig. 19.16a, b (a) Postoperative CT following evacuation of cerebellar hematoma shown in Fig. 19.9. (b) Hydrocephalus has also
improved (without an EVD in this particular case).

Rarely, AVM re-ru pt u re du ring ICH rem oval leads to bleeding


th at can n ot be con t rolled w ith th e above m en t ion ed m an eu vers. In th ese desp erate circu m stan ces, u rgen t resect ion of th e
AVM m ay be th e on ly life-saving m easure available to th e surgeon . If AVM resect ion is u n dert aken at th e t im e of h em orrh age,
th e basic ten et s of AVM surger y sh ould st ill be m ain tain ed:
w ide exposure, occlusion of large feeding arteries rst , circum feren t ial dissect ion of th e AVM n idu s, system at ic separat ion of
th e AVM from w h ite m at ter, an d preser vat ion of drain ing vein s
u n t il th e en d of th e procedure.19 W h en ever blood loss is sign i can t en ough to requ ire m ajor in fu sion of u ids an d t ran sfu sion of p acked red blood cells, con siderat ion sh ou ld be given to
rep len ish ing fresh frozen p lasm a, platelet s, an d oth er clot t ing
factors to avoid a dilu t ion al coagulop athy.

Aneurysmal ICH
An eu r ysm ru pt u re t yp ically resu lt s in SAH bu t can also p rod u ce
ICH an d u su ally involves an eu r ysm s distal to th e circle of Willis su ch as th e m id dle cerebral ar ter y (MCA) or an eu r ysm s th at
h ave becom e adh eren t to th e brain . Pat ien t s w ith an eur ysm al
ICH in gen eral h ave p oorer ou tcom es du e to m ass e ect an d in creased ICP.22 Un like th e t reat m en t for AVM associated ICH, ult ra
early h em atom a evacu at ion an d an eu r ysm clipp ing in p at ien t s
w ith poor clin ical grade h as been advocated for an eur ysm al
ICH.23 Th ere is a m u ch greater im p or tan ce in secu ring th e an eu r ysm given th e prop en sit y for an d devastat ing con sequ en ces
of an eur ysm re-rupt ure. Alth ough cath eter angiography is th e
gold stan dard for an eu r ysm diagn osis an d p reop erat ive evalu at ion , som e advocate operat ing based on CTA alon e as th e delay
could lead to w orse outcom e.24 If t im e p erm it s, h ow ever, con siderat ion sh ou ld be given to p reop erat ive angiography an d coil
em bolizat ion to p rotect th e an eu r ysm from re-ru pt u re an d , in

328

t urn , allow for a m uch safer ICH evacuat ion .25 If preoperat ive
em bolizat ion is n ot an opt ion du e to t im e con strain t s, th e su rgeon sh ou ld be fu lly p repared to clip th e an eu r ysm .
Prior to en tering or evacu at ing th e ICH, th e operat ing room
an d p erson n el sh ou ld be p rep ared for poten t ial an eu r ysm ru p t ure. Ideally, a discussion of the follow ing steps sh ould occur
before th e skin in cision is even m ade. Th e operat ing m icroscop e sh ou ld be d raped an d ready. A fu ll select ion of tem p orar y
an d perm an en t clip s sh ou ld be open on th e surgical eld. Th e
an esth esiologist sh ou ld be p rep ared to adju st blood p ressu re
rapidly. At least t w o (possibly th ree) large suction s sh ou ld be
prepared an d ready. On ce th e h em atom a is en tered, a con ser vat ive evacuat ion is w arran ted. Part icular care sh ou ld be t aken
n ear th e bot tom of th e ICH (n ear th e an eu r ysm ) to avoid u n du e
m an ipu lat ion . If ru pt u re occu rs, su ct ion an d p recise tam p on ade
are perform ed w h ile p roxim al arterial con t rol is obt ain ed. Th e
an eu r ysm an atom y is de n ed su rgically an d th e an eu r ysm n eck
is recon st ructed. After clipping an d ICH evacuation , th e pat ient
sh ou ld h ave im m ediate angiograp hy, ideally in th e operat ing
room . Fin ally, a th ird reason able opt ion in clu des cran iectom y
w ith out ICH evacuat ion to im m ediately address ICP follow ed by
im m ediate coil em bolizat ion .

External Ventricular Drainage


Placem en t of an EVD sh ou ld be con sidered in all pat ien ts w ith
IVH especially th ose w ith blood in th e th ird ven t ricle, th e cerebral aqueduct , or fourth vent ricle. Generally, th e EVD should be
placed in th e lateral vent ricle cont ralateral to th e hem orrhage
to avoid clogging th e cath eter. Alth ough in traven tricular t issue
plasm in ogen act ivator (rt-PA) m ay h elp lyse clot and m aintain
cath eter patency,26 it is still con sidered invest igat ion al an d sh ould
not be used if th ere is a suspected vascular lesion . Im portan tly,

19
ven t ricu lar drain age alon e is n ot an acceptable treatm en t for
cerebellar h em orrhage w ith associated hydroceph alus. Th ese
patien ts should undergo surgical decom pression.1

References
1. Morgen stern LB, Hem p h ill JC 3rd, An d erson C, et al. Gu id elin es
for th e m an agem ent of spon t an eous int racerebral h em orrh age:
a guidelin e for h ealth care profession als from th e Am erican
Hear t Associat ion /Am erican St roke Associat ion . St roke 2010;
41(9):21082129
2. Broderick J, Connolly S, Feldm ann E, et al; Am erican Heart
Association/Am erican Stroke Association Stroke Council; Am erican
Heart Association/Am erican Stroke Association High Blood Pressure Research Council; Qualit y of Care and Outcom es in Research
Interdisciplinary Working Group. Guidelines for the m anagem ent
of spontaneous intracerebral hem orrhage in adults: 2007 update:
a guideline from the Am erican Heart Association/Am erican Stroke
Association Stroke Council, High Blood Pressure Research Council,
and the Qualit y of Care and Outcom es in Research Interdisciplinary Working Group. Circulation 2007;116(16):e391413
3. Men delow AD, Gregson BA, Fern an d es HM, et al. Early su rger y
versu s in it ial con ser vat ive t reat m en t in p at ien t s w ith sp on t an eous su praten torial in t racerebral h aem atom as in th e In tern at ion al Surgical Trial in In t racerebral Haem orrh age (STICH): a
ran dom ised t rial. Lan cet 2005;365(9457):387397
4. Teern st ra OP, Evers SM, Kessels AH. Met a an alyses in t reat m en t
of spont an eous supraten torial in t racerebral h aem atom a. Act a
Neuroch ir (Wien ) 2006;148(5):521528
5. Green berg, Mark S. Han dbook of Neurosurger y. New York:
Th iem e; 2010
6. Broderick JP, Brot t TG, Du ldn er JE, Tom sick T, Hu ster G. Volu m e of
in t racerebral h em orrh age. A pow erful an d easy-to-use predictor
of 30-day m or t alit y. St roke 1993;24(7):987993
7. Bradley WG Jr. MR ap p earan ce of h em orrh age in th e brain . Radiology 1993;189(1):1526
8. Zh u XL, Ch an MS, Poon WS. Sp on t an eou s in t racran ial h em orrh age: w hich pat ien t s n eed diagn ost ic cerebral angiography?
A prospect ive st udy of 206 cases and review of th e literat u re.
St roke 1997;28(7):14061409
9. Diringer MN, Skoln ick BE, Mayer SA, et al. Th rom boem bolic
even t s w ith recom bin an t act ivated factor VII in Spon t an eous In t racerebral h em orrh age: result s from the factor seven for acute
h em orrh agic st roke (FAST) t rial. St roke 2010;41:4853
10. Clat terbuck RE, Tam argo RJ. Surgical posit ion ing and exposures
for cran ial procedures. In : Win n HR, ed. Youm ans Neurological
Surger y. 5th ed. Ph iladelphia: Saun ders; 2004
11. Yasargil MG, Reich m an MV, Ku bik S. Preser vat ion of th e fron totem poral bran ch of th e facial n er ve using th e in terfacial tem poralis ap for pterion al craniotom y. Tech n ical ar t icle. J Neurosurg
1987;67:463466

Rem oval of Spontaneous Int racerebral Hem orrhages


12. Spet zler RF, Lee KS. Recon st ru ct ion of th e tem poralis m uscle for th e pterion al cran iotom y: Tech n ical n ote. J Neu rosurg
1990;73:636637
13. Singh RV, Pru sm ack CJ, Morcos JJ. Spon t an eous in t racerebral
h em orrh age: non -ar terioven ous m alform at ion , n on an eu r ysm . In : Win n HR, ed. You m an s Neurological Surger y. 5th ed.
Ph iladelp h ia: Sau n d ers; 2004
14. Auer LM, Dein sberger W, Niederkorn K, et al. En doscopic surger y
versus m edical t reat m en t for spon t an eous in t racerebral h em atom a: a ran dom ized st udy. J Neurosurg 1989;70(4):530535
15. Teern st ra OP, Evers SM, Lodder J, Le ers P, Fran ke CL, Blaauw G.
Mu lt icen ter ran dom ized con t rolled t rial (SICHPA). Stereot act ic
t reat m ent of in t racerebral h em atom a by m ean s of a plasm in ogen
act ivator: a m ult icen ter random ized con t rolled t rial (SICHPA).
St roke 2003;34(4):968974
16. Marin kovic I, St rbian D, Pedron o E, et al. Decom pressive cran iectom y for in t racerebral hem orrh age. Neurosu rger y 2009
Oct;65(4):780786
17. Mart in NA, Wilson CB. Preoperat ive an d postop erat ive care:
Man agem en t of in t racran ial h em orrh age. In : Wilson CB, Stein
BM, eds. In t racran ial Ar terioven ous Malform at ion s. Balt im ore:
William s & Wilkin s; 1984: 121129
18. Solom on RA, Stein BM. Managem en t of deep supraten torial an d
brain stem arterioven ous m alform at ions. In : Barrow DL, ed. In t racran ial Vascular Malform at ion s. Park Ridge, IL: Am erican Associat ion of Neurological Surgeon s; 1990: 125141
19. Yasargil MG. Micron eurosurger y. Vol 3B. AVM of th e Brain : Clinical Con siderat ion s, Gen eral an d Special Operat ive Tech n iques,
Surgical Result s, Non operat ive Cases, Cavern ous an d Ven ous An giom as, Neuroan esth esia. New York: Th iem e; 1987
20. Jafar JJ, Rezai AR. Acute surgical m an agem ent of in t racran ial arterioven ou s m alform at ion s. Neurosurger y 1994;34(1):812
21. St arke RM, Kom ot ar RJ, Hw ang BY, et al. Treat m en t guidelin es for
cerebral ar terioven ou s m alform at ion m icrosurger y. Br J Neurosurg 2009;23(4):376386
22. Hau erberg J, Eskesen V, Rosen orn J. Th e progn ost ic signi can ce of in t racerebral h aem atom a as sh ow n on CT scann ing
after an eur ysm al subarach n oid h em orrh age. Br J Neurosurg
1994;8(3):333339
23. Gueresir E, Beck J, Vat ter H, et al. Subarach n oid h em orrh age an d
in t racerebral h em atom a: in cidence, progn ost ic factors, an d outcom e. Neurosurger y 2008;63(6):10881093
24. de los Reyes K, Patel A, Bederson JB, Fron tera JA. Man agem en t
of subarach n oid h em orrh age w ith in t racerebral h em atom a: clip ping an d clot evacuat ion versus coil em bolizat ion follow ed by
clot evacuat ion . J Neuroin ter v Surg 2013;5(2):99103
25. Bergdal O, Springborg J, Hauerberg J, Eskesen V, Poulsgaard L,
Rom n er B. Outcom e after em ergen cy surger y w ith out angiography in pat ien t s w ith in t racerebral h aem orrhage after an eur ysm
r u pt u re. Act a Neu roch ir (Wien ) 2009;151(8):911915
26. Engelh ard HH, An drew s CO, Slavin KV, Ch arbel FT. Curren t m an agem en t of in t raven t ricular h em orrh age. Surg Neurol 2003
Ju l;60(1):1521

329

20

Surgery for Acute


Intracranial Infection
P. B. Rak sin

Introduction
Sp ace-occu pying in t racran ial in fect ion m ay arise via con t iguous spread from adjacen t st ruct ures, th rough h em atogen ous
dissem in at ion , follow ing operat ive n eurosurgical procedures,
or after h ead t raum a. Th e sam e st ruct ural elem en ts th at den e th e variou s in t racran ial com p ar t m en tsep id u ral, su bdu ral, p aren chym al, an d ven t ricu laralso dictate th e p ath w ays
for sp read of in fect ion across th ose n at u ral barriers. Man agem en t t yp ically involves a com bin at ion of m edical an d su rgical
m odalit ies.

Epidural Abscess
In fect ion w ith in th e space bet w een th e in n er t able of th e calvariu m an d d u ra occu rs m ost com m on ly as a com plicat ion of
p aran asal sin u sit is, orbit al cellu lit is, m astoidit is, or ch ronic
ot it is m edia. It m ay also occu r follow ing t rau m at ic fract u re of
th e calvarium or follow ing cran iotom y. Rarely, epidural abscess
m ay follow from fetal scalp m on itoring or th e ap p licat ion of
h alo p in s to th e sku ll.1 Clin ical p resen t at ion is often in sidiou s.
Headach e m ay be accom pan ied by a relat ive p au cit y of oth er
sym ptom s u n less m ass e ect is p resen t or th e in fect iou s p rocess exten ds to th e subdu ral space as w ell. Periorbit al edem a
occurs in conjun ct ion w ith bon e osteom yelit is or orbital cellulit is. (Pot ts pu y t um or is th e h istorical term applied to th e clin ical n ding of foreh ead soft t issue sw elling du e to th e presen ce
of subgaleal uid.2 ) An in fect ious n idus adjacen t to th e pet rous
ap ex m ay p resen t as Graden igo syn drom e. St reptococci (St reptococcus m illeri grou p) p redom in ate, th ough p ost t rau m at ic an d
p ostcran iotom y in fect ion s are m ore com m on ly associated w ith
st ap hylococci.3

Subdural Empyema
In fect ion w ith in th e p oten t ial sp ace bet w een du ra an d arach n oid m ater arises eith er from th e sp read of in fect ion via valveless em issar y vein s (in associat ion w ith th rom bop h lebit is) or
via exten sion of an osteom yelit is of th e sku ll w ith an accom panying epidural abscess. Oth er predisposing con dit ion s in clude
sku ll t rau m a, in fect ion of a p reexist ing su bd u ral h em atom a,
or prior n eurosurgical procedu re. A sm all n um ber are m et ast at ic (often from a p u lm on ar y sou rce). Su bd u ral em pyem a
m ay also occu r in u p to 10% of in fan t s w ith bacterial m en ingit is, presum ably as th e result of in fect ion of a previously sterile

330

su bdu ral e u sion .4 Fever is p resen t in m ost cases. Headach e


an d vom it ing are t yp ical early n dings. Th ese sym ptom s m ay
be accom pan ied by con fusion , seizure, an d focal n eurologic deficit s (m ost com m only h em iparesis). Neurologic declin e m ay be
rap id follow ing sym ptom on set . On th e oth er h an d, p ost su rgical su bdural em pyem a m ay presen t in a delayed fash ion up to
8 w eeks follow ing in it ial in ter ven t ion .3 A less fulm inan t course
m ay be seen w ith p rior an t im icrobial th erapy, as w ell as in th e
set t ing of m et ast at ic sp read to th e su bdu ral sp ace or in fect ion
of an exist ing subdu ral h em atom a. Bacterial isolates are sim ilar
to th ose fou n d in epidu ral abscess cases. Polym icrobial in fect ion is com m on . Th e in ciden ce of cult ure-n egat ive (2729% in
on e series) cases is greater in subdural em pyem a 5 ; th is m ay reect th e fast id iou s n at u re of m any an aerobic organ ism s.

Intracerebral Abscess
Focal, en capsulated in fect ion w ith in th e brain t issu e m ay be
single or m u lt ifocal. A single abscess t yp ically arises by d irect
exten sion of a paran asal sin u s, m astoid, or m iddle ear in fect ion ;
a solitar y focu s m ay also arise follow ing p en et rat ing t rau m a.
Mu lt ifocal d isease m ore com m on ly resu lt s from h em atogen ou s
dissem in at ion of prim ar y cardiac, pulm on ar y, periodon t al, ab dom in al, or derm atologic in fect ion . Less th an 50% of pat ien t s
w ill presen t w ith th e classic t riad of h eadach e, fever, an d focal
n eu rologic de cit .6 In fact , pat ien t s m ay p resen t w ith h eadach e
or n ausea alon e. Fever, w h en presen t , is t ypically low -grade;
a tem perat ure of greater th an 101.5 F (38.6 C) sh ou ld raise
su sp icion for a system ic in fect ion . Focal n eu rologic sym ptom s
re ect th e locat ion of th e path ology. Hem iparesis is com m on .7
New on set of m en ingism u s, associated w ith su dd en n eu rologic
w orsen ing, m ay in dicate ru pt u re in to th e ven t ricu lar sp ace.
Mort alit y in su ch cases is h igh .8 Isolated p ath ogen s are p redom in an tly bacterial, com m on ly polym icrobial, an d re ect th e
site of origin . St reptococci are isolated in u p to 70% of cases.
Bacteroides an d Prevotella are presen t in 2040% of cases an d
often occur in m ixed cult ure. Staphylococcus aureus is p resen t
in 1015% of brain abscessesusually p ost t raum a or in th e
set t ing of en docardit isan d is u su ally m on om icrobial. En teric
Gram -n egat ive bacilli are presen t in up to 2233% of cases, often in associat ion w ith ot ic foci, bacterem ia, or prior n eurosu rgical p rocedu re.9 Diagn ost ic con siderat ion s m u st be exp an ded
in cases of im m unocom prom ise. Gram -n egat ive organ ism s an d
fu ngal isolates are com m on in cases of n eu t rop h il de cien cy,
w h ile Listeria, Nocardia, Cryptococcus, an d Toxoplasm a are en coun tered in th e set t ing of T-cell de cien cy.

20

Indications
Th e in dicat ion s for surgical in ter ven t ion are dict ated by size,
an atom ic locat ion , an d accessibilit y, as w ell as by kn ow n or
p resu m ed p ath ogen . In all cases, su rgical in ter ven t ion m ust be
cou pled w ith appropriate in t raven ou s (an d, in cert ain cases,
in t rath ecal) an t im icrobial th erapy.

Epidural Abscess
Most cases requ ire op en n eu rosu rgical debrid em en t . Bu r h ole
drain age gen erally is in e ect ive given th e ten acit y of th e pu ru len t m aterial; h ow ever, in select cases w h ere a ver y sm all
collect ion is presen t , t rial bur h ole drain age m ay be at tem pted.
Th e par t icipat ion of Otolar yngology m ay be n ecessar y for sim u ltan eou s debridem en t of th e a ected sin u s(es).

Surgery for Acute Intracranial Infection

coexisten t hydroceph alus w h ere sh un t placem en t risks con t am in at ion, or w h ere m edical con t rain dicat ion s to invasive in ter ven t ion m ay exist .13
In a p at ien t w ith docu m en ted bacterem ia an d a posit ive
cult ure, con siderat ion m ay be given to a t rial of system ic an t im icrobial th erapy, provided th e ch osen agen t(s) o ers good
cent ral n er vous system pen et rat ion . If th e diagn osis is in quest ion an d/or th ere is a quest ion of a polym icrobial in fect ion in
an im m u n ocom p rom ised h ost , con sid erat ion sh ou ld be given
to early biopsy to perm it t ailoring of m edical th erapy.

Preprocedure Considerations
Radiographic Imaging
CT h ead p re- an d p ost-con t rast w ill provid e basic in form a-

Subdural Empyema
Th e vast m ajorit y of cases requ ire open n eurosurgical debridem en t . More lim ited bu r h ole drain age m ay be con sidered in cases of p arafalcin e em pyem a, crit ically ill p at ien ts in sept ic sh ock,
an d ch ildren p resen t ing w ith em pyem a secon dar y to m en ingit is.10 Repeated drain age an d/or conversion to cran iotom y m ay
be n ecessar y in such cases.

Intracerebral Abscess
Several factors dictate th e in dication s for an d exten t of n eu rosurgical in ter ven tion . Prim ar y con siderat ion s in clu de th e m at urit y of th e capsule, size, an d location . Brit t an d En zm an n sough t
to de n e stages in th e m at u ration of th e abscess capsule.11 Cort ical in am m ationor, cerebritisalone is not a surgical disease.
Dem arcation of an abscess cavit y w ith respect to th e surroun ding parenchym a begins abou t 10 days after the onset of infection. The capsule w all, how ever, rem ain s thin and discontinuous
at this t im e. Abscesses m ay be am enable to cannulation and
drain agew ithout at tem pted resection of the w allduring this
early en capsulat ion ph ase. Th is strategy m ay also be appropriate
in th e set t ing of a m ore m at ure lesion in a less accessible location. With further m at urit y com es greater collagen deposition
an d, con sequen tly, a capsule m ore con sisten t w ith th at of a m etastat ic lesion . Con siderat ion m ay be given to drain agew ith resect ion of capsulein th e case of a m at ure an d accessible lesion .
This is generally feasible after 2 w eeks.
Th e size of th e lesion also m ay in uen ce t reat m en t st rategies. It h as been suggested th at abscesses of a cert ain size
(1.7 cm or less) m ay be t reated by m edicat ion alon e, w hereas
lesion s of greater th an 2.5 cm rarely resolve w ith ou t surgical
in ter ven t ion .9,12
Medical th erapy alon e m ay be con sidered in cases of m u lt ifocal disease, lesion s in eloquen t areas, con com it an t m en ingit is,

t ion regarding lesion locat ion , th e degree of associated edem a/m ass e ect , an d bony involvem en t . Cerebrit is w ill ap pear
as a n on sp eci c region of hypoden sit y. A m ore m at u re ab scess w ill d em on st rate ring-en h an cem en t w ith associated
p erilesion al edem a. CT of th e sin u ses (w ith coron al an d sagit t al recon st ruct ion s) m ay be a n ecessar y adju n ct if con t iguous
exten sion is su sp ected.
MRI brain pre- an d p ost-gadolin iu m m ay provide add it ion al
in form at ion to assist diagn osis an d th erap eut ic in ter ven t ion s. MRI m ay de n e th e st age of abscess or cerebrit is. In
cases of epidural or subdural em pyem a, m agn et ic reson an ce
ven ograp hy (MRV) w ill de n e th e exten t of sin u s th rom bosis,
if presen t . Magn et ic reson an ce di usion im ages are u seful in
diagn osing subdural em pyem a, w h ich often sh ow s hyperin ten se sign al in dicat ing di usion rest rict ion .14
Magn et ic reson an ce spect roscopy or posit ron em ission tom ograp hy m ay h elp dist ingu ish an in fect iou s from a n eoplast ic process.
Lum bar pun ct ure gen erally is n ot n ecessar y an d, w h en a
m ass lesion is p resen t , m ay be con t rain dicated. Given p hysical separat ion from th e subarach n oid space, cerebrospin al
u id sh ou ld be sterile (perh ap s w ith n on sp eci c in am m ator y ch anges) in th e set t ing of epidural em pyem a.
Blood cu lt u res sh ou ld be draw n (p referably p rior to in it iat ion
of an t im icrobial th erapy).
In th e set t ing of bacterem ia, an ech ocardiogram is in d icated
to exclu de en docardit is as th e et iology for in t racran ial
in fect ion .
HIV test ing sh ou ld be u n dert aken as th e spect ru m of in fect ious path ology (an d th e approach to t reat m en t) in th e im m u n ocom prom ised p opu lat ion m ay di er.
A ch est X-ray sh ould be com pleted. A puri ed protein derivat ive skin test sh ould be placed if t ubercu losis is suspected.
A pan oram ic X-ray m ay de n e an odon tologic et iology for in t racran ial in fect ion .
Preoperat ive im aging (Fig 20.1af).

331

III Nontraum atic Em ergencies

Fig 20.1af Axial CT (a) soft tissue and (b) bone windows, as well as (c) sagit tal MRI post-gadolinium T1-weighted image demonstrating a Pot ts
pu y tumor. Note the extracranial soft tissue collection in communication with the epidural space, via the frontal air sinus. (d) Axial MRI postgadolinium T1-weighted image demonstrating a right frontal subdural empyema. (e) The di usion-weighted imaging sequence, in this set ting,
demonstrates hyperintense signal, indicating di usion restriction. (f) Axial MRI post-gadolinium T1-weighted image demonstrating an intracerebral
abscess with loculations and peripheral enhancem ent, extending to the local meninges.

332

20

Medication
Em piric, broad-spect rum an t im icrobial th erapy sh ould be

in it iated at th e t im e of presen t at ion . Th e source, an d th erefore


likely path ogen s, sh ou ld be con sidered. Th e au th or prefers a
regim en of van com ycin , ceft riaxon e (cefep im e if a n osocom ial in fect ion is su sp ected), an d m et ron idazole, bearing in
m in d th at th e sp eci c clin ical circu m stan ces of a given case
m ay dictate m odi cat ion of th is regim en an d /or th e addit ion
of an t ifungal or an t it uberculous coverage.
In cases w h ere th e p ath ogen is kn ow n , t argeted an t im icrobial
th erapy is th e goal.
Corticosteroid therapy m ay be considered on an individual
case basis for m anagem ent of accom panying vasogenic edem a.
W hile the use of corticosteroids has been show n to be of som e

Surgery for Acute Intracranial Infection

bene t in the set ting of m eningitis,15 there exists no sim ilar


established role for steroids in th e prim ar y m edical m an agem en t of abscess.
Seizu res are com m on in th e set t ing of in t racran ial in fect ion . An t iepilept ic drug prophyla xis sh ould be in it iated upon
p resen t at ion .

Operative Field Preparation


Th e h air is cropped (n ot sh aved) w ith an elect ric razor at th e

p lan n ed surgical site.


Th e skin is prepared in it ially w ith alcoh ol, follow ed eith er
w ith a st an dard povidon e iodin e or ch lorh exidin e scru b.
Th e plan n ed in cision site is in lt rated w ith 1%lidocain e w ith
1:100,000 epin eph rin e.

333

III Nontraum atic Em ergencies

Operative Procedure
Positioning (Fig. 20.2a, b)

334

20

Surgery for Acute Intracranial Infection

Figure

Procedural Steps

Pearls

Fig. 20.2

(a) Patient positioning w ill depend upon the ultimate surgical


target. In the majority of cases, a supine positionw ith varying
degrees of head turnw ill be appropriate. Posterior fossa pathology
may be approached in the prone position. The head should be
clamped in three -point pin xation. All pressure points should be
padded.

Infectious processes arising in the frontal


sinus often extend contiguously to the
frontal lobe. Mastoid-related processes
generally track to the adjacent temporal
fossa or posterior fossa.

(b) The surgical target w ill dictate the planned incision. (A) For
pathology involving the frontal lobes, anterior skull base, and/or
anterior falx, a bicoronal incision is appropriate. (B) For temporal
lobe pathology, a pterional or rocking chair-type incision is
appropriate. (C) Posterior fossa, petrous-associated pathology may
be approached via a paramedian linear or hockey stick incision. For
simplicity, the subsequent steps w ill assume a bicoronal approach.

335

III Nontraum atic Em ergencies

Incision (Fig. 20.3a, b)

Figure

Procedural Steps

Fig. 20.3

(a) An incision is planned extending from tragus to tragus, just posterior to the hair line.
(b) A no. 10 blade is used to initiate the skin opening. The incision initially is carried dow n to the level of
pericranium centrally and temporalis fascia laterally. Hemostatic scalp clips are applied to the skin edges. The
scalp ap is re ected forw ard until the orbital rim and root of zygoma are palpable bilaterally.

336

20

Surgery for Acute Intracranial Infection

Pericranial Flap Harvest (Fig. 20.4)

Figure

Procedural Steps

Fig. 20.4

A no. 15 blade is used to open the pericranium bilaterally just superior and parallel to superior temporal line ;
a third, transverse cut is made at the level of coronal suture. A periosteal elevator is used to advance the ap
forw ard to the level of the superior orbital rim. The vascularized ap is w rapped in a saline moistened sponge
and secured temporarily w ith 4-0 braided nylon sutures under minimal tension.

337

III Nontraum atic Em ergencies

Division of the Temporalis and Bur Holes (Fig. 20.5)

Figure

Procedural Steps

Pearls

Fig. 20.5

Division of the temporalis muscle and fascia generally is not necessary


for an approach to the frontal lobe/frontal air sinus. The author does
create a cu in the fascia and muscle just inferior and parallel to superior
temporal line, allow ing for placement of bur holes at the key hole and
most posteriorly, at the level of the coronal suture.

If access to the temporal fossa is

The position of the bone ap, too, will depend on the location of the target
pathology. A rectangular frontal bone ap will address frontal lobe and
unilateral frontal sinus pathology. If pathology is present along the bilateral
falx, a mirror image bone ap may be necessary over the contralateral
frontal lobe, leaving a strip of bone along the midline sagittal sinus.
For a unilateral frontal bone ap, holes may be placed w ith a high
speed drill at three points: (1) the keyhole, (2) at the level of coronal
suture and just inferior to superior temporal line, and (3) just anterior
to coronal suture and lateral to midline. Bone w ax is applied to the bony
edges. A Pen eld no. 3 is used to strip the dural attachments from the
undersurface of the calvarium betw een each set of bur holes.

338

necessary, an additional vertical


opening can be m ade from the
midpoint of the cu to the root of
zygom a (creating a T). The resultant
aps m ay be re ected anteriorly and
posteriorly, respectively.
The strategic placem ent of t wo bur
holes and subsequent ushing of the
epidural space with antibiotic irrigation
bet ween the holes m ay be considered
in the case of a very sm all epidural
collection.

20

Surgery for Acute Intracranial Infection

Elevation of the Bone Flap (Fig. 20.6)

Figure

Procedural Steps

Fig. 20.6

The craniotome is used to create a roughly rectangular bone ap. A periosteal elevator or Pen eld no. 3 is used
to elevate the bone ap aw ay from the underlying dura. The dural surface is irrigated w ith saline. Hemostasis is
attained w ith bipolar electrocautery. Bleeding attributable to the midline sinus may be controlled w ith brillar
hemostatic material and/or gelatin foam soaked in thrombin. Epidural tacking stitches may be used to augment
these techniques. If epidural abscess is present, proceed to the next step. If not, proceed to Dural Opening and
Addressing Subdural Empyema (Fig. 20.8).

339

III Nontraum atic Em ergencies

Addressing Epidural Abscess (Fig. 20.7)

340

Figure

Procedural Steps

Pearls

Fig. 20.7

Epidural abscess, if present, w ill be evident immediately


upon elevation of the bone ap (if not at the time of bur
hole placement). Direct communication w ith an adjacent
air sinus and/or the orbit may be observed via gross
erosion of bone. Liquid purulent material may be captured
in a suction trap. Often, there is a friable, in ammatory
pannus adherent to the dural surface. A Pen eld no. 2 or
Oberhill periosteal may be used (gently) to scrape this
layer aw ay from the underlying dura. A drain may be left
in the epidural space and brought out through one of the
posterior bur holes to a skin exit site, posterior to the scalp
incision. Here, the drain is secured w ith a 3-0 nylon stitch.
If no deeper infection is suspected, proceed to Dural
Closure and Cranialization of Frontal Sinus (Fig. 20.11).

Specim ens should be obtained for stat Gram stain,

aerobic, anaerobic, acid-fast bacilli, and fungal


culture. Where feasible, collect tissue and/or uid as
the diagnostic yield m ay exceed that of swabs alone.
Great care must be taken to avoid perforating
otherwise intact dura. Bleeding is best controlled with
bipolar electrocautery. The epidural space should be
irrigated with large volumes of antibiotic solution.
The dura should be inspected but not opened unless
there is a strong suspicion for a subdural component
to the infectious process. Intentional or unintentional
breach of the dura m ay result in seeding the deeper
compartm ents with infection.

20

Surgery for Acute Intracranial Infection

Dural Opening (Fig. 20.8)

Figure

Procedural Steps

Fig. 20.8

The dural opening w ill depend on the position of the bony defect. In the setting of a frontal craniotomy, a no. 15
blade is used to initiate a trap doortype opening that may be apped tow ard the midline sagittal sinus. A mirror
image opening is made if a bifrontal craniotomy is present.

341

III Nontraum atic Em ergencies

Addressing Subdural Empyema (Fig. 20.9)

342

Figure

Procedural Steps

Pearls

Fig. 20.9

Subdural empyema, if present, w ill be visualized upon


elevation of the dural ap. Once again, liquid purulent
material may be collected in a suction trap. Gentle
retraction of the frontal pole w ill permit access to the
frontal oor. Gentle depression/retraction of the superior
frontal gyrus w ill permit access to the falx. The subdural
space should be explored in all directions under direct
visualization and irrigated w ith antibiotic solution to ush
out any remaining purulent material. An in ammatory
pannus may be adherent to the pia. If no deeper infection
is suspected, proceed to Dural Closure and Cranialization
of Frontal Sinus (Fig. 20.11).

The developm ent of brain swelling m ust be

anticipated upon evacuation of subdural empyem a.


If subdural empyem a is suspected, a large bone
ap should be planned. Likewise, the dura m ay
be opened initially via multiple linear radiations
from a central point. In cases of parafalcine
empyema, Nathoo advocates an initial drainage via
parasagit tal craniectomyprior to craniotomyto
help prevent acute, m assive swelling.16
The exudative m embrane should not be disturbed
as at tempted debridement m ay result in cortical
injury and/or hem orrhage.

20

Surgery for Acute Intracranial Infection

Approaching Intraparenchymal AbscessOpen Craniotomy (Fig. 20.10)

Figure

Procedural Steps

Pearls

Fig. 20.10

To approach an intraparenchymal abscess, the sulcus


overlying the abscess is opened; the abscess cavity
typically lies at the base of the sulcus. A blunt brain
needle may be introduced under ultrasound or image
guidance into the abscess cavity for immediate
drainage. The blunt needle may be exchanged for
an external ventricular drain catheter, allow ing for
continued drainage and/or instillation of antibiotic
agents. The capsule may be dissected aw ay from
the surrounding w hite matter. The capsular plane is
follow ed circumferentially until the lesion has been
shelled out. The site then is irrigated w ith antibiotic
solution and hemostasis attained w ith bipolar
electrocautery as w ell as various hemostatic agents.

An open approach is indicated for an easily accessible

lesion with a well-developed capsule, in a noneloquent


area. Abscesses secondary to fungal infection and/or
foreign body may be m edically refractory.
If the abscess is not visible along the cortical surface,
ultrasound or im age guidance m ay be used to
determine the best trajectory for approach.
The surrounding tissue is often friable and bleeds easily.
Particular care m ust be taken with periventricular
lesions where the capsule wall m ay be thinner.
Consideration should be given to aspiration alone,
given the risk of intraventricular rupture with
at tempted resection.

343

III Nontraum atic Em ergencies

Dural Closure and Cranialization of Frontal Sinus (Fig. 20.11)

Figure

Procedural Steps

Pearls

Fig. 20.11

If feasible, primary closure may be accomplished w ith interrupted


4-0 braided nylon stitches. If grafting is necessary, it is preferable
to incorporate autologous materials in the setting of infection.
Pericranium, temporalis fascia, or fascia lata (the latter requiring the
foresight to prepare the lateral thigh preoperatively) are good options.

Prim ary dural closure m ay not be

In cases of contiguous extension of infection from the frontal air sinus


to the epidural and/or subdural space, it is necessary to cranialize the
frontal sinus prior to closure. The dura should be dissected from the roof
of the orbit and posterior w all of the frontal sinus (if not already done
by the abscess itself). The posterior table should be drilled ushed w ith
the frontal fossa oor. Mucosa should be stripped from the sinus and the
inner surface of the sinus, in turn, decorticated w ith a diamond bur. The
sinus then is packed. The nasofrontal duct is obliterated. The previously
harvested, vascularized pericranial ap then is folded dow n over the sinus
opening and secured to the native dura at multiple points w ith 4-0 braided
nylon stitches. A layer of brin glue is applied to the suture line.

344

feasible in the set ting of m alignant


cerebral edem a. Autologous graft
material m ay be tacked loosely at the
edges to accom m odate swelling. In
extrem e circum stances, a large piece
of dural substitute m aterial m ay be laid
over the dural defect.
The author uses dry pieces of gelatin
sponge coated with bacitracin powder
for packing of the frontal sinus.
Alternately, adipose tissue (from a
peripheral site) or m uscle (temporalis)
may be used.
See Chapter 27 for additional discussion
of techniques for frontal sinus
reconstruction.

20

Surgery for Acute Intracranial Infection

Approaching Intraparenchymal AbscessStereotactic (Fig. 20.12ac)

345

III Nontraum atic Em ergencies

346

Figure

Procedural Steps

Pearls

Fig. 20.12

(a) Using framed or frameless stereotaxy, a small skin


opening is planned to allow for access to the abscess cavity
along a de ned trajectory. A single bur hole is placed at
the planned entry site. The underlying dura is coagulated
w ith bipolar electrocautery and opened in a cruciate
fashion w ith a no. 11 blade. The dural lea ets again are
coagulated. The underlying arachnoid-pia is coagulated
and opened sharply. (b) Frameless stereotactic planning for
needle aspiration of a right frontal deep intraparenchymal
abscess. (c) An external ventricular drain or blunt brain
needle is passed along the predetermined image guidance
trajectory until the abscess cavity is entered. Liquid
purulent material is collected by gravity drainage and
gentle aspiration. The catheter may be irrigated gently,
taking care that the amount of uid entering is observed
to drain by gravity. The catheter may be left in place and
brought out to a skin exit site, remote from the scalp
incision. Here, the drain is secured w ith a 3-0 nylon stitch.
The bur hole site is irrigated w ith antibiotic solution. The
scalp is closed in tw o layers (see Closing).

A stereotactic approach is indicated for aspiration

of less m ature lesions, deep lesions, and lesions


adjacent to eloquent areas.
If im age guidance is not available, ultrasound m ay
be used in conjunction with a slightly larger bony
opening.
Multiple lesions or m ultiple loculations within
an abscess m ay require m ultiple entry point s for
aspiration.
Passage of a needle through thickened
leptom eninges, without opening of the arachnoidpia, may result in subdural bleeding as cortex is
pushed away from the calvarium .
The best trajectory is de ned as the shortest
route to the pathology that bypasses eloquent areas
and vital structures.

20

Closing

Surgery for Acute Intracranial Infection

out put s becom e m in im al an d/or serial im aging dem on st rates


resolu t ion of th e t argeted collect ion .

If th ere is rad iograp h ic an d/or gross eviden ce of osteom yelit is

involving th e bon e ap, it sh ou ld n ot be reim plan ted.


Likew ise, if m align an t cerebral ed em a is presen t , th e bon e
ap sh ou ld n ot be reim p lan ted.
In oth er circu m st an ces, th e bon e ap m ay be reapp roxim ated
u sing a p late an d screw system .
Th e in cision site is irrigated w ith an t ibiot ic solut ion .
Hem ostasis is at t ain ed w ith a com bin at ion of bipolar elect rocauter y an d h em ost at ic agen t(s) of ch oice. Epidural t acking
st itch es are placed circu m feren t ially arou n d th e cran iotom y
defect w ith 4-0 braided nylon sut ure.
A no. 7 Jackson -Prat t drain is laid in th e subgaleal space an d
brough t out to a skin exit site just posterior to th e scalp in cision . Here, th e drain is secu red w ith a 3-0 nylon st itch .
Th e tem poralis cu is reapproxim ated w ith 0-absorbable
braided sut u re in terru pted st itch es.
Th e scalp ap is released from ret ract ion . Hem ostat ic scalp
clips are rem oved from th e skin edges an d h em ost asis att ain ed, w h ere n ecessar y, w ith bipolar elect rocauter y.
Th e galea an d subcutan eous t issue are reapproxim ated w ith
0-absorbable braided su t ure inver ted st itch es.
Th e skin is closed w ith a run n ing 3-0 nylon st itch or staples.

Medication
Em piric, broad-spect rum antim icrobial therapy should be con -

Radiographic Imaging
Early post procedure CT im aging is in dicated to assess th e

Postoperative Management
Monitoring

Pat ien t s sh ou ld be m on itored in th e in ten sive care u n it set

t ing follow ing operat ive in ter ven t ion .


Th e use of invasive n eurologic m onitors (in t raparen chym al or
in t raven t ricu lar) is approp riate for pat ien t s in w h om serial
n eu rologic exam is n ot feasible.
Th e ou t put of epidural an d/or subdural drain s, if presen t ,
sh ou ld be m on itored . Drain rem oval m ay be con sidered w h en

t inued pending cult ure results and then narrow ed accordingly


to provide targeted th erapy for th e iden ti ed path ogen (s).
Generally, a 4- to 6-w eek course of intravenous an t im icrobial
therapy is prescribed. Som e advocate a 6- to 8-w eek course for
intracerebral abscess.16 Longer-term therapy m ay be in dicated
for select organism s (e.g., Mycobacterium tuberculosis).
Steroid th erapy sh ou ld be tapered rap idly in accordan ce w ith
evolving clin ical exam an d eviden ce of resolving edem a/m ass
e ect per serial im aging.
An t iepilept ic drug (AED) prophylaxis sh ould be con t in ued in
cases w h ere docu m en ted seizure act ivit y is presen t . Oth erw ise, AEDs m ay be t apered o in th e postoperat ive period.
Pat ien t s w ith eviden ce of in creased in t racran ial pressu re m ay
require addit ion al m edical th erapies for m an agem en t .

e cacy of debridem en t as w ell as to ru le ou t h em orrh age,


isch em ia, an d hydrocep h alus. Im aging sh ould be repeated at
in ter vals during th e im m ediate postoperat ive cou rse as n eu rologic stat u s w arran ts.
MRI m ay be u sed for longer-term follow -u p , bearing in m in d
th at MRI en h an cem en t m ay persist for m on th s despite clin ical im provem en t an d appropriate an t im icrobial th erapy. MRI
m ay be em p loyed for m ore d etailed ch aracterizat ion of st ru ct ural path ology in th e acute set t ing, as w ell as for serial t racking of respon se to th erapy (bearing in m in d th at radiograph ic
ch ange often lags beh in d clin ical im provem en t).
Postoperat ive im aging (Fig. 20.13a, b). A CT scan is obt ain ed
in th e im m ediate p ostop erat ive period for in ter val assessm en t

Fig. 20.13a, b (a) Non-contrast CT scan demonstrating local craniectomy and debridement of epidural abscess for the patient depicted in Fig. 20.1ac.
(b) Post-gadolinium T1-weighted axial image demonstrating resolution of intracerebral abscess and associated meningeal enhancement for the
patient depicted in Fig. 20.1f.

347

III Nontraum atic Em ergencies


of m ass e ect , edem a pat tern , an d ven t ricular size, as w ell as
to exclu de h em orrh age.

Further Management
Reaccum ulat ion of epidu ral, su bdural, an d in t raparen chym al

collect ion s m ay occur. Pat ien ts m ay require m ult iple operat ive in ter ven t ion s for debridem en t .
In th e set t ing of in t raven t ricu lar ru pt u re of an abscess, p lacem en t of an extern al ven t ricu lar drain is app ropriate to p erm it
con t in uou s drain age of cerebrospin al uid, as w ell as in t rath ecal adm in ist rat ion of ant im icrobial th erapy.

Special Considerations
If in fect ion arises from th e sin u ses or m astoid p rocess, si-

m u ltan eou s m an agem en t of th e in fect iou s p ath ology by


Otolar yngology m ay be in dicated. Otolar yngology sh ou ld be
involved in th e p reoperat ive p lan n ing for such cases.
Form al In fect ious Diseases con sultat ion is appropriate to
gu ide an t im icrobial th erapy.
Suppurative intracranial throm bophlebitis is a feared com plication of central nervous system infection. Suppurative throm bophlebitis m ay begin w ithin the veins or venous sinuses or m ay
occur after infection of the paranasal sinuses, m iddle ear, m astoid, or oropharynx. MRI of the brain, w ith MRV, is the test of
choice. A 3 to 4 week course of intravenous antim icrobial therapy is recom m ended. The use of anticoagulation in this setting
is controversial.17 It is also im portant to note that relapse m ay
occur w ithin 6 weeksafter apparent clinical resolutionand
abscess form ation has been reported up to 8 m onths later.18

References
1. Dill SR, Cobbs CG, McDon ald CK. Su bdu ral em pyem a: an alysis of
32 cases an d review. Clin In fect Dis 1995;20:372386
2. Flam m ES. Percivall Pot t: an 18th cen t u r y n eu rosu rgeon . J Neu rosurg 1992;76:319326
3. Hall WA. Cerebral in fect iou s p rocesses. In : Loft u s CM, ed . Neu rosurgical Em ergen cies. Vol. 1. Park Ridge, IL: Am erican Associat ion of Neurological Surgeon s Publicat ions; 1994: 165182

348

4. Nath oo N, Nadvi SS, van Dellen JR, Gouw s E. In t racran ial su bdu ral em pyem as in th e era of com puted tom ography: a review of
699 cases. Neurosurger y 1999;44:529535
5 . Har t m an BJ, Helfgot t DC, We in gar t e n K. Su b d u ral em pyem a an d su p p u rat ive in t racran ial p h lebit is. In : Sch eld W M,
W h it ley RJ, Mar ra CM, e d s. In fe ct ion s of t h e Cen t ral Ner vou s
Syst e m . Ph ilad elp h ia: Lip p in cot t W illiam s & W ilkin s; 2 0 04 :
52 3 53 6
6. Riech ers RG, Jarell AD, Ling GSF. In fect ion of th e cen t ral n er vou s
system . In : Suarez JI, ed. Crit ical Care Neurology an d Neurosurger y. New York: Hum an a Press; 2004: 515532
7. Yang S-Y. Brain abscess: a review of 400 cases. J Neu rosu rg
1981;55:794799
8. Math isen G, Joh n son JP. Brain abscess. Clin In fect Dis 1997;
25:763779.
9. Tu n kel AR. Brain abscess. In : Man dell GL, Ben n et t JE, Dolin R, eds.
Prin ciples an d Pract ice of In fect ious Diseases. 6th ed. Ph iladelph ia: Elsevier; 2005: 11501163
10. Nath oo N, Nadvi SS, Gouw s E, van Dellen JR. Cran iotom y im proves ou tcom es for cran ial su bd u ral em pyem as: Com p u tedtom ograp hy era experien ce w ith 699 p at ien t s. Neu rosu rger y
2001;49:872878
11. Brit t R, En zm an n D. Clin ical st ages of h u m an brain abscesses
on serial CT scans after con t rast in fusion . J Neurosurg 1998;59:
972989
12. Oban a WG, Rosen blu m ML. Non op erat ive t reat m en t of n eu rosurgical in fect ion s. Neurosurg Clin N Am 1992;3:359373
13. Rosen blu m M, Ho J, Norm an J, Edw ards M, Berg B. Non op erat ive t reat m en t of brain abscesses in select h igh -risk pat ien t s.
J Neu rosu rg 1980;52:217225
14. Wong AM, Zim m erm an RA, Sim on EM, et al. Di u sion -w eigh ted
MR im aging of su bdu ral em pyem as in ch ildren . AJNR Am J Neu roradiol 2004;25:10161021
15. Tu n kel AR, Har t m an BJ, Kaplan SL, et al. Pract ice gu idelin es
for th e m an agem ent of bacterial m en ingit is. Clin In fect Dis
2004;39:12671284
16. Kasten bau er S, P ster H-W, W h isp elw ey B, et al. Brain abscess.
In : Sch eld W M, W h itley RJ, Marra CM, eds. Infect ion s of th e
Cen t ral Ner vou s System . Ph iladelp h ia: Lipp in cot t William s &
Wilkin s; 2004: 479508
17. Bh at ia K, Jon es NS. Sept ic cavern ou s sin u s th rom bosis secon dar y
to sin u sit is: are an t icoagu lan t s in dicated ? A review of th e literat ure. J Lar yngol Otol 2002;116:667676
18. Tu n kel AR. Su bdu ral em pyem a, epid u ral abscess, an d su p purat ive in t racran ial throm boph lebit is. In : Man dell GL, Ben n et t
JE, Dolin R, eds. Prin cip les an d Pract ice of In fect iou s Diseases.
6th ed. Ph iladelph ia: Elsevier; 2005: 11641171

21

Ventricular Shunt Malfunction


Sergey Abeshaus, Sam uel R. Brow d, and Richard G. Ellenbogen

Introduction
A ven t ricu lar sh u n t (VS) m alfu n ct ion is a com m on n eu rosu rgical em ergen cy. In fact , a sh un t revision is on e of th e m ost com m on p roced u res a n eu rosu rgeon m ay perform . It is est im ated
th at up to 50% of sh un t s m ay fail w ith in 2 years. Despite it s
ap paren t sim plicit y, a sh u n t revision requ ires m et icu lou s atten t ion to detail an d vigilan ce in diagn osis an d m an agem en t
to en su re th e pat ien t is t reated in a t im ely an d adequ ate m an n er. Th e w orku p an d su rgical t reat m en t of a VS m alfu n ct ion is
fraugh t w ith risks an d com plicat ion s even in th e m ost exp erien ced h an ds. In th e Un ited St ates, sh u n t revision costs are h igh ,
perh aps over $1 billion a year. Th e h um an costs are st aggering.
Com m on causes of sh un t m alfun ct ion in clude m ech an ical failu re (obst ru ct ion , discon n ect ion , or m igrat ion ), h ardw are failure
(valve), in fect ion , fun ct ion al (u n derdrain age or overdrain age),
or a com bin at ion of th ese aforem en t ion ed issues.1,2
A t ypical clin ical presen t at ion of an acu te VS m alfu n ct ion
in clu des drow sin ess, severe h eadach es, an d vom it ing.3 How ever, th e presen t at ion m ay be qu ite d iverse, from rap id to slow /
su btle an d ch ron ic. Th e com m on sign s an d sym ptom s m ay be
as m od est an d in con sp icu ou s as d eteriorat ion in sch ool perform an ce, irritabilit y, in crease in h ead circu m feren ce over th e
95th percen t ile, in creased leth argy or sleep, clu m sin ess, ch ron ic m alaise, ch ron ic fever, abdom in al pain , or sw elling aroun d
th e sh un t t ract . More im pressive presen tat ion s in clude seizu re,
cran ial n er ve paresis (III, IV, or VI), decrease in visual acuit y,
p aralysis of u pw ard gaze, papilledem a, w eakn ess or paralysis,
st u por, com a, or ch ange in vital sign s (decreased p u lse or in creased m ean arterial pressu re).
Obt ain ing m et icu lou s in form at ion from a p at ien t or h is/h er
caregiver or th e m edical records about th e t ype of sh un t im p lan ted an d previou s sh un t failure presen tat ion is im port an t .
Previou s im aging, especially w h en don e during sym ptom -free
p eriod, is vital in su rgical decision m aking. Kn ow ledge of th e
t yp e of sh u n t an d in form at ion abou t th e set t ing, date, an d sp eci cs of previous operat ion s m ay in u en ce t reat m en t st rategy
in com p lex cases. How ever, th ese det ails m ay often be in com p lete. It is im p or tan t to n ote th at a sh un t can m alfun ct ion w ith out cau sing an obvious ch ange in ven t ricular size, in part , du e
to poor com plian ce of th e brain . How ever, th e in t racran ial pressu re (ICP) can be elevated an d on ly th e h istor y from th e pat ien t
or fam ily m em ber, sym ptom s, or exam m ay be h elpfu l. In th ose
p at ien t s w h ose scan s m ay n ot ch ange during a t yp ical sh u n t
m alfu n ct ion , it is im p erat ive to listen to th e h istor y provided
by a know ledgeable caregiver w h o can accurately com pare th is

presen t at ion w ith th at of a previous sh un t m alfun ct ion . Failure


to do so m ay be cat ast roph ic.
Th e steps in w orking up a ven t ricular sh un t m alfun ct ion :
1. Obtain inform at ion about the underlying et iology of hydrocephalus treated by initial shunt placem ent. In our experience,
over 90%of patien ts h ave hydroceph alus from in t raven t ricular
hem orrhage (IVH) of prem at urit y, infect ion, t raum a, t um or,
norm al pressure hydrocephalus (NPH), past hem orrh age, aqueductal stenosis, or congenital etiology (m yelom eningocele,
craniofacial, or genet ic). In about 10% of patients the et iology
is unclear. This histor y m ay be especially im portant in cases
of aqueductal stenosis, in w hich a patient m ay undergo an
en doscopic th ird ven triculostom y (ETV), in stead of a sh un t
revision.
2. Determ in e th e t ype of th e VS. Th e m ost com m on are ven t riculoperiton eal, ven t ricu loat rial, an d ven t riculopleural sh u n ts;
t yp e of valve (m aker, m odel, xed p ressure or adju st able [n eed
to verify last pressure set t ing]); side of th e sh un t im plan t at ion ; an d date an d t ype of recen t in ter ven t ion s on sh un t system . Th ere are a variet y of sh un t valves currently available at
th e m arket (please refer h t t p://w w w.pedsn eurosurger y.org/
ed u cat ion .asp for fu r th er in form at ion ).

Indications
Clin ical sym ptom s of sh un t m alfun ct ion su ch as th ose listed
in th e in t rodu ct ion
Radiological sym ptom s of sh u n t m alfu n ct ion w ith ven t ricu lar dilatat ion
Posit ive cerebrosp in al u id (CSF) cu lt u res, posit ive eviden ce
of m icroorgan ism or elevated w h ite coun t con sisten t w ith
in fect ion , an d oth er possible clin ical scen arios described
elsew h ere 1,2
Discon t in u it y in sh u n t t u bing or d islodgem en t of t u bing from
ven t ricle or abdom en (VP), pleu ra (Vp leu ral), or h ear t (VA)
Exposure of sh un t t u bing
Sh u n t explorat ion w ith ou t ven t ricu lom egaly in p at ien t w h o
h as poor com plian ce of brain , an d p resen ts w ith sign s an d
sym ptom s of in creased in t racran ial pressu re
Slit-ven t ricle w ith in term it ten t sh u n t m alfu n ct ion
Desire to convert sh u n t p at ien t in to a sh u n t-free p at ien t by
an ETV, in th e face of a sh u n t obst ru ct ion
Th ere is a sim pli ed algorith m for decision m aking in ven t ricular sh un t m alfun ct ion in Fig. 21.1.

349

III Nontraum atic Em ergencies

Evalu ate for


Sh un t Malfu n ct ion

Sh un t Tap

Yes

Fever > 38.4, sh un t


su rger y in past 6
m on th s or p osit ive
blood cu lt ure

Posit ive

Negat ive

No

Sh u n t
Extern alizat ion
+ ABx

Pseu docyst

No

Sh u n t Revision

Yes

Sh u n t
Extern alizat ion
+ ABx

Fig. 21.1 Simpli ed algorithm for decision making in ventricular shunt malfunction.

Preprocedure Considerations
Radiographic Imaging
Head com p u ted tom ograp hy (CT; m ay be com bin ed w ith

ducial m arkers for n avigat ion ) (Fig. 21.2a).


Rap id sequ en ce brain m agn et ic reson an ce im aging (MRI;
Haste T2 protocol) 4 (Fig. 21.2b)fast , gen erally n o n eed
for an esth esia/sedat ion . Th e rat ion ale for u sing a fast T2w eigh ted abbreviated MRI exam is to avoid th e radiat ion risk
from cu m u lat ive CT scan s.
Sh u n t seriesX-ray: Head an d n eck an terop osterior (AP)
an d lateral (Fig. 21.3a, b), ch est AP an d lateral, abdom en
an d p elvis AP (Fig. 21.3c) an d lateral. Abdom en an d pelvis

radiography is n ot n ecessar y in case of ven t ricu loat rial or


ven t ricu lopleu ral sh u n t evalu at ion .5
Sh u n togram (radion u clide) p rovides som e in form at ion regarding op en ing p ressu re an d sh u n t ow. Radion u clide
sh u n togram sh ou ld be con sidered in p at ien ts w h ose h istor y,
CT scan , or exam is n ot de n it ive an d sh u n t ow ch aracterist ics n eed to be evalu ated to decide w h eth er or n ot to operate.
A radion uclide st udy sh ould n ot delay revision in th e set t ing
of an acute, obvious m alfun ct ion .

Diagnostic Procedures
Sh un t tapif th e fever is greater th an 101 F or th ere is a p osit ive blood cult ure in last 48 h ours an d/or sh un t system in ter-

b
Fig. 21.2a, b Preoperative imaging of shunt malfunction of the same patient. (a) Head CT and (b) brain
MR (Haste T2 protocol).

350

21

Ventricular Shunt Malfunction

Fig. 21.3ac Shunt series. (a) Anteroposterior (AP) and (b) lateral
skull showing ventricular catheter disconnection. (c) AP abdom en
showing distal catheter disconnection (arrow).

ven t ion w ith in 612 m on th s, p roceed w ith sh u n t t ap p rior to


revision . Over 95% of all sh u n t in fect ion s occu r w ith in 1 year
of th e last sh un t in st rum en t at ion , w ith th e m ajorit y of th em
occurring w ith in 3 m on th s.

Medication
Antibiotics
Any n ew sh un t placem en t or revision : t w o doses of cefazolin

or any late gen erat ion ceph alosporin ; rst dose is adm in istered during an esth esia in duct ion (45 m in utes to 1 h our prior
to th e in cision ) an d th e secon d dose after th e surger y w ith in
8 h ours. Som e surgeon s cover th e pat ien ts w ith an t ibiot ics
for 24 h ou rs; h ow ever, th e eviden ce m ostly su pp or t s a single
p reoperat ive dose p rior to skin in cision . Con sid er van com ycin 1 h ou r in advan ce of surger y in m eth icillin -resistan t
Staphylococcus aureuscolon ized pat ien t s.
Sh u n t in fect ion : tap sh u n t , th en im m ed iately begin t riple
an t ibiot ics (ceft riaxon e, van com ycin , an d m et ron idazole in

com m u n it y-acquired an d im ipen em /cilast in in stead of ceft riaxon e in h ospit al-acqu ired in fect ion ).6

Operative Field Preparation


Preparat ion is don e according to follow ing th e Hydroceph alus
Clin ical Research Net w ork (HCRN) p rotocol adopted for Seat tle
Ch ild rens Hospit al (Fig. 21.4).7
Position the patient w ith the head away from the door. Wide exposure is im portant. Hair is rem oved w ith clippers. Prelim inarily
prepare the skin w ith chlorhexidine soap, then isopropyl alcohol,
to rem ove any dirt or debris and allow to dry. Mark the incision.
Previous in cision s on th e scalp m ay be exten ded to get ap propriate exposu re of ven t ricular cath eter an d sh u n t valve
( con sider vascular supply to scalp so as n ot to devascularize
th e scalp ap). We use 2% ch lorh exidin e glucon ate/70% isopropyl alcoh ol solu t ion preparat ion for th e surgical eld an d w ait
3 m in utes or longer to dr y. Double gloves are advised. Drape
w ith an t im icrobial in cise lm an d en sure isolat ion of poten t ial
in fect ion sources (t rach eostom y, gast rostom y t ube, etc.).

351

III Nontraum atic Em ergencies

Pat ien t in room

Sign on OR door rest rict ing t raffic

Posit ion head aw ay from th e m ain OR door

Ask for an t ibiot ics

Clip h air as n eeded

Dir t , d ebris, and adh esive m aterial rem oved

Ch lorap rep ap plied to su rgical field an d n ot w ash ed off

Wait 3 m in u tes

Han d scrub w ith betad in e or ch lorh exidin e

# w h o scru bbed
# w h o w ash ed h an ds correctly

Dou ble gloves (n on -latex)

# w h o d ou ble-gloved

Ioban drape used

Yes

An t ibiot ics in ?

No

In cision , sh un t evalu at ion , revision

Wait

Inject ion of van com ycin /gen t am ycin in to shu n t reser voir

Closure

Dressing

Postoperat ive orders in clu de


on e dose of sam e an t ibiot ic
Fig. 21.4 HCRN protocol7 /Seat tle Childrens Hospital (SCH) protocol.

352

21

Ventricular Shunt Malfunction

Operative Procedure
Shunt Revision
Positioning and Preparation (Fig. 21.5)

Figure

Procedural Steps

Pearls

Fig. 21.5

The patient is placed supine w ith the head on a gel donut, head
mildly rotated aw ay from valve site for adequate exposure
of operative eld. A gel roll is placed under the shoulders to
extend and maintain the appropriate plane for tunneling. Ensure
appropriate foam or gel padding to reduce pressure sore risk at
every pressure point.

Som etim es in complex patients wound

preparation and draping m ay be challenging,


such as those patients with chem otherapy
catheters or gastrostomy tubes.
It is important to change gloves before
making the incision.

Alw ays expose w idely so that all parts of the shunt and tract
(abdomen for the VPS, chest for ventriculoatrial or ventriculopleural
shunt) are covered. In noninfected cases, incisions are in ltrated
w ith 1%lidocaine w ith epinephrine 1:100,000.

353

III Nontraum atic Em ergencies

Skin Incision and Wound Dissection (Fig. 21.6a, b)

354

21

Ventricular Shunt Malfunction

Figure

Procedural Steps

Pearls

Fig. 21.6

Evaluate ventricular catheter skull entry site and valve location based on
review of imaging, palpation, and navigation assistance. (a) An incision
is made w ith a no. 10 or no. 15 blade often through a preexisting
incision w ith extension along the valve for appropriate exposure of
distal part of the valve. The incision should not be over the hardw are
to avoid w ound breakdow n. After w e score the skin w ith a blade, w e
use Bovie electrocautery dow n to and around the shunt hardw are
because it does not cause harm to the valve or tubing. (b) The careful
dissection of soft tissue in the galeal-pericranial plane to preserve
pericranium and appropriate exposure of both ventricular catheter and
valve is performed. Wound edges are retracted carefully w ith Weitlaner
retractor(s) or retraction sutures. Wound hemostasis is obtained w ith
monopolar or bipolar electrocautery.

We use the needle tip monopolar

electrocautery.
One can utilize a custom tailored skin
incision or curvilinear incision to provide
adequate scalp coverage and release
tension from the wound. In patients with
a comprom ised scalp, the surgeon m ay
need to perform a Z-plast ya rotational
ap or score the galeal layer to ensure
adequate scalp coverage over the tubing
without tension.

355

III Nontraum atic Em ergencies

Evaluation of Ventricular Catheter Reservoir (Fig. 21.7)

Figure

Procedural Steps

Pearls

Fig. 21.7

Carefully disconnect the ventricular catheter from the valve and assess
CSF ow. If no ow, the catheter is replaced. If partial ow, connect the
ventricular catheter to a manometer and obtain the opening pressure. If
there is partial obstruction, so identi ed due to high ICP or no pulsatility
in the CSF uid column then proceed w ith catheter revision.

It is important to avoid pulling the

When extant, the side arm of the Rickham reservoir and valve are
carefully dissected free. Disconnect the side arm of the Rickham
reservoir from the valve to assess CSF ow. Use above algorithm for
revision if no/reduced ow.

356

Rickham reservoir/ventricular catheter


out (if adherent) to reduce risk of
intraventricular bleeding.

21

Ventricular Shunt Malfunction

Revision of Ventricular Catheter (Fig. 21.8)

Figure

Procedural Steps

Fig. 21.8

During catheter revision, if the ventricular catheter is adherent to the choroid plexus in the ventricle, a monopolar
w ire is used to release the catheter. It takes careful monopolar coagulation, gentle manipulation, or tw isting of the
catheter until a burst of CSF signals the release of the catheter. We use a Jake clamp to hold the catheter during
this maneuver. 8 If there is intraventricular blood, gently irrigate the ventricle via barbotage w ith normal saline or
lactated Ringers until it clears.

357

III Nontraum atic Em ergencies

Placement of Ventricular Catheter (Fig. 21.9)

358

Figure

Procedural Steps

Pearls

Fig. 21.9

After removal of the old ventricular catheter, a new antibiotic


impregnated or dotted ventricular9 catheter is placed w ith
the catheter tip just anterior to ipsilateral foramen of Monro.
We utilize stereotactic navigation to assist placement. 10
Alternatively, one can use anatomic landmarks, such as the
mid-pupillary line and nasion, w ith the catheter insertion and
trajectory perpendicular to the skull.

Place a gloved nger in the hole im m ediately after


rem oval of a ventricular catheter to prevent the
CSF from leaking out which m ight reduce or shift
the ventricle size thereby m aking catheter insertion
challenging. Consider using intrathecal antibiotics
according to HCRN protocol if the catheter is not
antibiotic im pregnated.

21

Ventricular Shunt Malfunction

Evaluation of Valve and Distal Catheter (Fig. 21.10)

Figure

Procedural Steps

Pearls

Fig. 21.10

Follow ing revision of the ventricular catheter (or if it is found to be functioning


and not revised), a manometer is connected to the proximal part of the
valve to test distal run-o . If the pressure is appropriate according to the
performance characteristics of the valve, then the proximal catheter is
reconnected to the valve and secured w ith a 2-0 silk tie. If the pressure is
higher than inspected, the valve is disconnected from distal tubing and the
distal tubing is evaluated again w ith a manometer. The expected pressure
is usually less than 5 cm H2 O. If found to be functional, the distal catheter is
ushed w ith 12 mL of normal saline and the presumed compromised valve is
replaced w ith a new one. The connections to the proximal and distal catheters
are secured w ith 2-0 silk ligatures. If the distal catheter is obstructed, it is
removed by gently pulling out as one piece through the cranial incision. If the
distal catheter is adherent, the abdominal incision w ill need to be opened in an
attempt to free the catheter. In rare cases w hen total removal of shunt in one
piece is not possible, the abdominal incision is opened to remove the rest of
the distal catheter.

While reconnecting the parts


of the shunt, it is important to
ensure that there is no airlock in
any part of the tubing including
the valve.

359

III Nontraum atic Em ergencies

Revision of Distal Catheter (Figs. 21.11 to 21.15)

360

Figure

Procedural Steps

Pearls

Fig. 21.11

Subcostal approach: After removal of the distal


(peritoneal) catheter, a super cial abdominal skin
(linear) incision (usually at the site of the previous
incision) is made by a no. 15 blade or needle tip
cautery. The incision size depends on the patients
age and body mass index. The incision is usually
1020 mm in length but is tailored to the patients
particular anatomic features. The surgeon holds the
skin edges gently distracted so that the incision can
be extended through the subcutaneous fat layer and
deep membranous layer (Scarpas fascia) dow n to the
anterior rectus sheath.

There are several ways to replace the distal catheter in

cases of obstruction. Either a sm all abdom inal opening,


blunt abdom inal trochar, or laparoscopic technique are
perform ed.11,12 For obese patients, we prefer a laparoscopic
approach. For an open approach, som e surgeons prefer a
sub-xiphoid, vertical m idline incision, while others prefer
a right-sided subcostal lateral incision. Both general
approaches work well as long as the surgeon is fam iliar with
the anatomy in the abdom en.
We usually use the preexisting incision. The goal is to avoid
multiple parallel incisions if possible.

21

Ventricular Shunt Malfunction

Figure

Procedural Steps

Fig. 21.12

The anterior rectus sheath is opened along the tissue bers and the rectus muscle is identi ed. Straight clamps are
used to separate along the muscle bers. A self-retaining retractor is placed to keep the anatomic layers spread.
The posterior rectus sheath can be gently elevated w ith an atraumatic toothed forceps and sharply opened w ith
no. 15 blade or cautery. The incision may be extended w ith curved Metzenbaum scissors. After advancement of the
retractor, the transversalis fascia is opened often revealing extraperitoneal fat.

361

III Nontraum atic Em ergencies

362

Figure

Procedural Steps

Pearls

Fig. 21.13

The peritoneum is identi ed and elevated as betw een


tw o Halsted mosquito clamps to avoid trapping the
viscus below. Delicate scissors are used to create a
small 57 mm incision into the peritoneum

A Pen eld no. 4 dissector is gently introduced into the


peritoneal cavit y to con rm entrance into this space. If the
Pen eld no. 4 does not pass with ease, it is possible to be in
a pre-peritoneal space. Once can often see bowel or liver to
con rm presence in the peritoneal cavit y.

21

Ventricular Shunt Malfunction

Figure

Procedural Steps

Pearls

Fig. 21.14

The peritoneal catheter is tunneled


subcutaneously through a passer and
connected to the valve w ith a 2-0 silk tie.

There are m any tricks to passing a shunt through the subcutaneous

The direction of tunneling is of surgeon


preference. We prefer the tunneling from
the peritoneal end tow ard the cranial
direction in the majority of patients
unless it is safer to tunnel from the cranial
direction tow ard the peritoneum. There
is no proven bene t to either tunneling
technique.

track. One technique is to pass the shunt through the hollow end of
the shunt passer while saline is irrigated through the tube from the
other end. Another technique includes using a heavy 72-inch 2-silk
ligature at the end of the shunt passer and pulling the silk through
the subcutaneous track. The new tubing is tied to the silk ligature and
pulled through the subcutaneous track as the silk is pulled toward the
surgeon. Alternatively, a silk ligature could be placed on the old distal
tubing and pulled through the subcutaneous track. The new tubing is
tied to the end of the silk ligature and it is pulled toward the surgeon
with the new tubing which is then laid in its new position. The proxim al
catheter/reservoir and valve can subsequently be sutured to the tubing.

363

III Nontraum atic Em ergencies

364

Figure

Procedural Steps

Pearls

Fig. 21.15

After CSF ow is observed, the distal catheter is


inserted into the peritoneal cavity w ith tw o smooth
forceps (Adson or bayonet). The peritoneum is closed
w ith absorbable suture maintaining the shunt tubing
in the peritoneum and aw ay from the suture loops.

The catheter should sm oothly slide into the peritoneum .


If it form s a tight coil or is ejected, it is possible to be preperitoneal or trapped in adhesions.

21

Ventricular Shunt Malfunction

Placement: Ventricular Catheter and Tunneling for External Drainage (Fig. 21.16)

Figure

Procedural Steps

Pearls

Fig. 21.16

If circumstances require removal of an entire shunt system w ith continued


need for ventricular drainage, then an external drain is placed. Placement
of antibiotic-impregnated ventricular catheter9 occurs w ith ideal placement
of the tip anterior to the ipsilateral foramen Monro. We typically utilize
stereotactic navigation or alternatively use anatomic landmarks.

Prevent CSF from leaking to


improve likelihood of cannulating
the ventricle.

The distal end of the tubing is then tunneled subcutaneously utilizing a


trocar to an exit site at least 5 cm from the edge of incision. The exiting
tubing is securely xed w ith a purse string stitch to prevent CSF leak and
connected to sterile external CSF collection bag (inset).

Closing
After appropriate irrigat ion w oun ds are closed in a m ult ilay-

Th e abdom in al w oun d is also closed in a layered fash ion :

ered fash ion . We u se absorbable braided su t u re su t u res for


su bcu t an eou s an d absorbable m on o lam en t su t u res for skin
closure. Cu rren t sut ures are an t ibiot ic im pregn ated.
If th e w ou n d is of qu est ion able in tegrit y, w e u t ilize nylon su t ures for closure.

t ran sversalis fascia, an terior an d posterior rect u s sh eath s,


Scarpas fascia, an d th e skin . Met icu lou s at ten t ion is paid
th rough ou t th e closing to m atch up th e an atom ic layers an d
avoid kin king or injuring th e sh u n t t ubing.
Glue is placed on th e skin surface after su bcut icu lar closure.

365

III Nontraum atic Em ergencies

Externalizing the Distal Catheter (Fig. 21.17)

366

Figure

Procedural Steps

Pearls

Fig. 21.17

(a) A small incision (1 cm) is marked at a level near


the clavicle and made w ith a no. 10 blade through the
epidermis. Use monopolar cautery to dissect dow n to
the subcutaneous fat. Use blunt dissection w ith small
hemostat to nd the catheter. Typically, a connective
tissue sheath may need to be incised w ith cautery to
isolate the tubing. (b) The distal part of the tubing is
then externalized through the clavicular incision.

One m ay use ultrasound to assist with tube localization


if it is not easily palpable. In cases of pseudocyst the
distal tubing m ay be used to drain the cyst, and the
cyst uid should be sent for stat Gram stain and culture.
Propionibacterium is a com m on cause of pseudocyst but
may take 2 weeks for a positive culture to grow.

21

Ventricular Shunt Malfunction

Wound Closure (Fig. 21.18)

Figure

Procedural Steps

Pearls

Fig. 21.18

A nylon purse string suture is used at tubing exit site and the catheter
is connected to a sterile, external CSF collection bag (inset).

Make sure that purse string suture is not to


tight and allows CSF passage.

367

III Nontraum atic Em ergencies

Fig. 21.19 Postoperative CT scan of same patient depicted in Fig. 21.2 after shunt revision.

Postoperative Management
Pract ice pat tern s var y: w e rout in ely obt ain an im m ediate postoperat ive CT if th e ven t ricu lar cath eter is revised. Th e im m ediate postop CT ser ves as a baselin e for th e follow up (Fig. 21.19).
A sh u n t series con sist ing of p lain radiograph s is reason able
after m ost p rocedu res to en su re proper p lacem en t of sh un t an d
as a baselin e assessm en t for com p arison in follow -u p sh ou ld
problem s arise.
Th e usual length of st ay in th e h ospital is 2472 h ou rs
dep en ding on com p lexit y of th e case an d clin ical con dit ion of
th e pat ien t . Typical follow -up occu rs at 2 w eeks for a w oun d
ch eckup th en at 6 w eeks w ith repeat im aging, t ypically a rapid
sequ en ce MRI.

Special Considerations
In pediat ric pat ien t s w e t yp ically follow -u p at yearly in tervals w ith or w ith ou t im aging, dep en d ing on sym ptom s. If th e
pat ien t is w ell, n o im aging m ay be n eeded except at sur veillan ce scan in ter vals of 15 years. We obtain a sh u n t series to
en su re n o cath eter discon n ect ion s are seen an d to follow th e
length of th e distal cath eter after th e last sh u n t in sert ion . If th e
pat ien t goes th rough a rapid grow th period or if th ere is any

368

sw elling in th e sh u n t t rack, an oth er su r veillan ce sh u n t series


m ay be ap p rop riate.
Program m able sh u n ts n eed to be reprogram m ed an d th e
valve set t ing con rm ed follow ing exp osu re to th e h igh m agn et ic eld of an MRI.

References
1. Brow d SR, Ragel BT, Got tfried ON, et al. Failu re of cerebrosp in al
uid sh un t s: part I: Obst ruct ion an d m ech an ical failure. Pediat r
Neurol 2006:34;8392
2. Brow d SR, Got tfried ON, Ragel BT, et al. Failu re of cerebrosp in al
uid sh un t s: part II: overdrain age, loculat ion , an d abdom in al
com plicat ion s. Pediat r Neurol 2006:34;171176
3. Barn es NP, Jon es SJ, Hayw ard RD, et al. Ven t ricu lop eriton eal
sh un t block: w h at are th e best predict ive clin ical in dicators?
Arch Dis Ch ild 2002:87;198201
4. ONeill BR, Pru th i S, Bain s H, et al. Rap id sequ en ce m agn et ic reson an ce im aging in th e assessm en t of ch ildren w ith hydroceph alus. World Neurosurg 2013;80(6):e307312
5. Pitet t i R Em ergen cy dep ar t m en t evalu at ion of ven t ricu lar sh u n t
m alfun ct ion: is th e sh un t series really n ecessar y? Pediat r Em erg
Care 2007:23;137141
6. Kestle JR, Garton HJ, W hitehead W E, et al. Managem ent of shunt infections: a m ulticenter pilot study. J Neurosurg 2006:105;177181

21
7. Kestle JR, Riva- Cam brin J, Wellon s JC, 3rd , et al. A st an dard ized protocol to reduce cerebrospin al uid shu nt in fect ion : th e
Hydroceph alu s Clinical Research Net w ork Qu alit y Im provem en t
In it iat ive. J Neu rosu rg Pediat r 2011:8;2229
8. Stein bok P, Coch ran e DD Rem oval of ad h eren t ven t ricu lar cath eter. Ped iat r Neu rosu rg 1992:18;167168
9. Parke r SL, An d e rson W N, Lilie n feld S, et al. Ce reb rosp in al
sh u n t in fe ct ion in p at ie n t s re ce ivin g an t ibiot ic- im p regn at ed ve rsu s st an d ard sh u n t s. J Ne u rosu rg Pe d iat r 2011:8;
259265

Ventricular Shunt Malfunction

10. Hayh urst C, Beem s T, Jen kin son MD, et al. E ect of elect rom agn et ic-n avigated sh un t placem en t on failure rates: a prospect ive
m u lt icen ter st udy. J Neurosu rg 2010:113;12731278
11. Tubbs RS, Maher CO, Young RL, et al. Dist al revision of ven t riculoperiton eal sh un t s using a peel-aw ay sh eath . J Neurosurg Pediat r
2009:4;402405
12. Naftel RP, Argo JL, Sh ann on CN, et al. Laparoscopic versus open
in sert ion of th e periton eal cath eter in ven t riculoperiton eal
sh un t placem ent: review of 810 consecut ive cases. J Neurosurg
2011:115;151158

369

22

Pituitary Apoplexy
Kalm on D. Post and Soriaya Mot ivala

Introduction
Pit uit ar y apoplexy is a n eu rosurgical em ergency in w h ich
p rom pt in ter ven t ion m ay h alt an d even reverse associated n eu rologic de cit s an d possible m or talit y. Th e con dit ion results
from h em orrh age or n ecrosis of a pit u it ar y t u m or. It h as been
fou n d to occu r in 0.6 to 10.5% of all p it u itar y aden om as.1
In 1950, Brough am w as th e rst to describe th e clin ical an d
p ath ologic n dings of ve p at ien t s w h o presen ted w ith ch anges
in m en tal st at u s, h eadach es, m en ingism u s, an d ocu lar dist u rban ces.2 Sin ce th en , th ere h as been exten sive in terest in th e
en t it y as w ell as con siderable debate on w h at th e term pit uitary apoplexy en com p asses. In fact , th ere h ave been rep or t s
of silen t pit uit ar y apoplexy.3 Moh r est im ated th e in ciden ce
of asym ptom at ic h em orrh ages in pit u it ar y aden om as to be
9.9% as opposed to 0.6% th at presen ted w ith clin ical n dings.4
Furth erm ore, On est i described ve pat ien ts w ith subclin ical
p it u it ar y ap oplexy, th at is, a clin ically silen t yet exten sive
h em orrh age in to a pit u it ar y aden om a.5
With su ch a broad in terp retat ion in th e literat u re it is in creasingly h elpfu l to de n e th e diagn osis of pit uitar y apoplexy by
clin ical param eters th at in clude th e sudden on set of h eadache,
m en ingism u s, visu al im p airm en t , an d occu lom otor abn orm alit ies in var ying com bin at ion s along w ith radiologic eviden ce of
h em orrh age in or su dden exp an sion of a pit u it ar y aden om a.

Th e m ost im port an t en t it y th at m ust be con sidered an d

Preprocedure Considerations
Radiographic Imaging
CT w ith ou t con t rast is m ost valu able th e

Indications
Diagn osis of ap oplexy requ ires evid en ce of h em orrh age or

370

rap id exp an sion on eith er com p u ted tom ography (CT) or


m agn et ic reson an ce im aging (MRI) w ith in a preexist ing
aden om a as w ell as clin ical correlat ion .
Pat ien t s often p resen t w ith su dden on set of h eadach e, m en ingism u s, dist u rban ces of m en t al st at u s, an d ocu lar n dings
th at can range from ophth alm oplegia an d visual eld defect s
to m on ocu lar or bin ocular blin dn ess.
Bacterial an d viral m en ingit is, in t racerebral h em atom a, opt ic
n eu rit is, brain stem in farct ion , tem p oral arterit is, en cep h alit is, t ran sten torial h ern iat ion , cavern ou s sin us th rom bosis,
an d m igrain e m ay all in on e form or an oth er m im ic an acu te
p it u it ar y vascu lar acciden t .1,6

exclu ded is an an eu r ysm al su barach n oid h em orrh age.7,8


A rupt ured Rath kes cleft cyst , th ough rare, m ay also m im ic
p it u it ar y apoplexy.9,10
In it ial m edical st abilizat ion w ith in t raven ou s u id an d steroids is requ ired in all cases to correct th e profou n d hypoadren alism th at m ay result .
Tran ssph en oidal resect ion is con sidered for th ose w ith con t in ued n eurologic de cit after in it ial con ser vat ive therapy,
an d im m ed iately for th ose w ith loss of acu it y an d/or eld s.6
W h ile oph th alm oplegia h as been sh ow n to correct as frequ en tly w ith con ser vat ive m an agem en t as w ith surgical
in ter ven t ion ,1113 su rgical resect ion o ers th e m ost h ope
of im proving visual eld an d acuit y de cits. Many st udies
h ave suggested th at decom p ression w ith in 1 w eek m ay o er
th e best ch an ce of visual recover y.11,14 Oth ers h ave sh ow n
im provem en t w ith decom pression m on th s after in it ial
visu al loss.15

rst 2 days of

h em orrh age (Fig. 22.1).


After 48 h ours, MRI is m ore sen sit ive, as it can bet ter
delin eate older blood from t um or an d areas of n ecrosis from
cyst ic ch anges (Fig. 22.2). Th e MRI is also h elpful in est im ating th e age an d t im e course of th e h em orrh age. Hem orrh ages
less th an 7 days w ill appear hypo- to isoin ten se on T1- an d
T2-w eigh ted im ages. During th e secon d w eek a hyperin ten se
sign al can be fou n d bordering th e h em atom a. By th e secon d
w eek in creasing hyp erin ten sit y w ill be seen th rough ou t th e
h em atom a on both T1- an d T2-w eigh ted im ages.
If clin ically w arran ted, an angiogram or m agn et ic reson an ce
angiogram (MRA) sh ou ld be obtain ed if n eith er CT n or MRI is
able to ru le ou t a con com it an t an eu r ysm .
MRI w ill also best dem on st rate th e exten sion of th e t u m or
or h em orrh age in to th e suprasellar space as w ell as ch iasm al
com pression an d cavern ous sin us exten sion . Fur th erm ore,
th e in t racarot id dist an ce can be delin eated in order to avoid
injur y during surgical resect ion .

22

Pituit ary Apoplexy

Fig. 22.1ac (a) Axial and (b, c) coronal CT scans showing hemorrhagic
cavit y with uid- uid level and surrounding enhancing sellar lesion.

b
Fig. 22.2a, b (a) T1-weighted sagit tal and (b) coronal MRI demonstrating a sellar m ass of heterogeneous signal intensit y, with suprasellar extension
of increased signal intensit y consistent with acute hemorrhage.

371

III Nontraum atic Em ergencies

Medication

Operative Field Preparation

It is ou r p ract ice to give d exam eth ason e 16 m g/day p rior

After in t ubat ion th e pat ien ts eyelids are gen tly t aped sh ut

to su rger y an d to tap er to a sligh tly su p rap hysiologic level


postoperat ively.
Fu rtherm ore, it is ou r pract ice to sen d a full en docrin e pan el
at th is t im e as a baselin e.
Th irt y m in utes prior to in it ial in cision , 1.5 g of cefuroxim e is
given (if th e pat ien t h as n o rep or ted allergies to p en icillin ;
oth er w ise, van com ycin an d gen t am icin are p referred).
An t ibiot ics are con t in u ed postop erat ively w h ile th e n asal
packings are in place.

an d bet adin e is ap p lied over th e n ares, ch eeks, an d u p per lip .


Betadin e-dip ped sw abs are used to clean th e in side of both
n ost rils as w ell as u n d er th e u p p er lip (for possible su blabial
ap p roach sh ou ld it becom e requ ired).
Th e righ t abdom en is prepped sterilely w ith a separate t ray of
bet adin e for possible fat graft .
Flu oroscopy or im age-gu ided n avigat ion are em p loyed
th rough out th e case to determ in e appropriate t rajector y in
a m idlin e p lan e.

372

22

Pituit ary Apoplexy

Operative Procedure
Microscopic Pituitary Tumor Resection
Positioning and Fluoroscopy (Fig. 22.3a, b)
a

Figure

Procedural Steps

Pearls

Fig. 22.3

Patient is placed on far right edge of table in supine position. Right arm
is bent 90 degrees and secured across chest w ith padding and tape.

Patient is positioned to allow for ease

(a) Head is placed on a foam holder w ith right ear tilted 45 degrees
in relation to right shoulder. Head of bed is exed just slightly such that
the chest does not interfere w ith use of instruments.

of trajectory to the sella.


If used, im age guidance system s
should be set up to allow ease of
viewing while surgeon is in operative
position.

(b) Fluoroscopy is positioned at the head of the bed to obtain lateral


view of the sella.

373

III Nontraum atic Em ergencies

Fluoroscopy Imaging (Fig. 22.4)

374

Figure

Procedural Steps

Fig. 22.4

Initial lateral skull uoroscopic images are obtained to evaluate trajectory to the sella.

22

Pituit ary Apoplexy

Draping and Operating Microscope (Fig. 22.5a, b)

Figure

Procedural Steps

Pearls

Fig. 22.5

(a) Surgical elds of the nasal passages and the right low er abdominal
quadrant are prepped and draped in a sterile fashion. (b) The
operating microscope is sterilely draped and positioned for optimal
view through the right nasal passage.

Abdom inal fat graft m ay becom e required

if cerebrospinal uid is encountered


during resection (see Fig 22.12).
When operating through the right nostril,
the observer is positioned to the left.

375

III Nontraum atic Em ergencies

Mucosal Flap (Fig. 22.6a, b)

Figure

Procedural Steps

Pearls

Fig. 22.6

(a) Using a handheld speculum as w ell as uoroscopy/image guidance to direct the


dissection tow ard the sella, the nasal mucosa is identi ed in the midline and 12 mL
of lidocaine w ith epinephrine 1:100,000 are injected betw een the mucosa and bony
nasal septum. This causes the mucosa to blanche and separate from the septum.

Trajectory to the sella

(b) A no. 15 blade is then used to make a linear incision in the mucosa and the
mucosa is dissected o the septum using a Freer instrument.

376

usually follows the


m iddle turbinate.

22

Pituit ary Apoplexy

Identi cation of the Sphenoid Bone (Fig. 22.7a, b)

Figure

Procedural Steps

Fig. 22.7a, b

(a) The septum is the deviated to the patients left and the keel-shaped vomer of the sphenoid is exposed.
(b) A hands free speculum is then placed w ith one blade on either side of the vomer.

377

III Nontraum atic Em ergencies

Exposure of the Sella (Fig. 22.8ac)

378

22

Pituit ary Apoplexy

Figure

Procedural Steps

Pearls

Fig. 22.8

(a) A combination of rongeurs and pituitary instruments are used


to remove the vomer, enlarging the bilateral ostia into the sphenoid
sinus. The sphenoid sinus mucosa is moved aside.

The rem oved bone is saved for later use

(b) A small osteotome and mallet is used to fracture the sella oor,
and then Kerrison rongeurs are used to remove it.
(c) Lateral uoroscopy image depicting the trajectory of the
speculum w ith instruments marking the superior and inferior limits
of the sella turcica.

at closure.
It is im portant to note that sphenoid sinus
septations are not usually m idline; the
vom er marks the m idline.
Fluoroscopy or im age guidance allows the
surgeon to be certain of being m idline at
this juncture.

379

III Nontraum atic Em ergencies

Dural Incision and Pituitary Tumor Resection (Fig. 22.9)

380

Figure

Procedural Steps

Pearls

Fig. 22.9

The dura, now exposed, is then incised using a no. 15 blade in a


cruciate fashion. Ring curettes of various sizes are then used to remove
the infarcted hemorrhagic tumor in a stepw ise fashion inferiorly then
laterally to the limits of the cavernous sinus and nally superiorly.

Resection in the superior plane is left


until the end to avoid the descent of
arachnoid into the operative eld,
m aking further resection di cult.

22

Pituit ary Apoplexy

Reconstruction of the Sella Floor (Fig. 22.10)

Figure

Procedural Steps

Pearls

Fig. 22.10

After irrigation the previously removed


bone fragments are placed to reconstruct
the sellar oor.

If CSF is seen, a piece of subcutaneous fat harvested from the


abdom en is packed in the sella and sphenoid sinus (see Fig. 22.12
for graft harvesting).

381

III Nontraum atic Em ergencies

Hemostasis and Closure (Fig. 22.11)

382

Figure

Procedural Steps

Pearls

Fig. 22.11

Hemostasis is secured and the retractor is removed. Using a


handheld speculum, a nasal tampon is placed in the right nares
to ensure that the mucosal ap is ush w ith the nasal septum.

Right-sided nasal packing is alm ost always


placed; however, left nasal packing is placed only
if CSF was seen or if bleeding was appreciated.

22

Pituit ary Apoplexy

Abdominal Fat Graft (Fig. 22.12)

Figure

Procedural Steps

Pearls

Fig. 22.12

If necessary an abdominal fat graft is harvested by making a small linear


incision in the right low er quadrant and removing a quarter-sized piece of
subcutaneous fat. The incision is then closed w ith 3-0 inverted absorbable
braided sutures and subcuticular absorbable mono lament closure.

It is im portant not to
contam inate the abdom en with
any instruments that have been
placed in the nose.

383

III Nontraum atic Em ergencies

Postoperative Management
Dexam eth ason e or hydrocort ison e is con t in u ed in th e im m e

diate postoperat ive period.


If a left sid ed packing w as placed it is rem oved th at even ing.
Th e pat ien t is m on itored for any sign s of addison ian crisis
as w ell as diabetes in sipidu s. To th at en d st rict m easu rem en t s of in t ake an d ou t p u t are t aken as w ell as daily sodiu m
an d osm olalit y levels. Sh ou ld th e p at ien t h ave m ore th an
200 m L/h r of urin e out put over th e course of 3 con secut ive
h ou rs repeat sodium level is draw n an d if it is elevated, desm op ressin acetate th erapy is in it iated.
Postop erat ive day 2 th e righ t p acking is rem oved an d th e
pat ien t is disch arged if th ey con t in ue to be st able.
En docrin e labs are sen t as out pat ien t to assess th e level of
pit uit ar y fun ct ion .
Neu rosu rgical, en docrin e, an d op h th alm ology follow -u p is
provided.

Special Considerations
It is ou r preferen ce to u se th e operat ing m icroscop e for th e

t ran ssph en oidal approach ; h ow ever, t ran ssph en oidal en doscopy is also often u sed to provide w ider exposure. Surgeon
com for t level sh ould dict ate w h ich tech n ique is u sed.
Cran iotom y is reser ved for pat ien ts w ith a n on aerated sph en oid sin u s, a sm all sella w ith a large su prasellar m ass, a t igh t
diaph ragm a sellae w ith a dum bbell-sh aped m ass, or an associated in t racerebral h em atom a.5,16

References
1. Naw ar RN, AbelMan n an D, Selm an W R, Arafan BM. Pit u it ar y
t um or apoplexy: a review. J In ten sive Care Med 2008:23(2):
7590

384

2. Brough am M, Heu sn er AP, Adam s RD. Acu te degen erat ive


ch anges in aden om as of th e pit u it ar y bodyw ith special referen ce to pit uit ar y apoplexy. J Neurosurg 1950:7(5):421439
3. Fin dling JW, Tyrrell JB, Aron DC, Fit zgerald PA, Wilson CB,
Forsh am PH. Silen t p it u it ar y apop lexy: su bclin ical in farct ion
of an adren ocor t icot ropin -produ cing pit uit ar y aden om a. J Clin
En docrin ol Met ab 1981;52(1):9597
4. Moh r G, Hardy J. Hem orrh age, n ecrosis, an d apop lexy in p it u it ar y aden om as. Surg Neurol 1982;18(3):181189
5. On est i ST, Wisn iew ski T, Post KD. Clin ical versu s su bclin ical p it uit ar y apoplexy: presen t at ion , surgical m an agem ent , an d outcom e in 21 pat ien t s. Neurosurger y 1990;26(6):980986
6. Mu rad-Kejbou S, Eggen berger E. Pit u it ar y ap oplexy: evaluat ion , m an agem en t , an d p rogn osis. Cu rr Op in Op h th alm ol
2009;20(6):456461
7. Su zu ki H, Mu ram at su M, Mu rao K, Kaw agu ch i K, Sh im izu T.
Pit u it ar y ap op lexy cau sed by ru pt u red in tern al carot id ar ter y
an eu r ysm . St roke 2001;32(2):567569
8. Okaw ara M, Yam agu ch i H, Hayash i S, Mat su m oto Y, In ou e Y,
Okaw ara S. [A case of r u pt u red in tern al carot id ar ter y an eu r ysm
m im icking pit uit ar y apoplexy]. No Shin kei Geka 2007;35(12):
11691174
9. On est i ST, Wisn iew ski T, Post KD. Pit u it ar y h em orrh age in to a
Rath kes cleft cyst . Neurosurger y 1990;27(4):644646
10. Ch aiban JT, et al. Rath ke cleft cyst ap op lexy: a n ew ly ch aracterized dist in ct clin ical en t it y. J Neurosurg 2011;114(2):318324
11. Ran deva HS, Sch oebel J, Byrn e J, Esiri M, Adam s CB, Wass JA. Classical pit uit ar y apoplexy: clin ical feat u res, m an agem ent an d outcom e. Clin En docrinol (Oxf) 1999;51(2):181188
12. Maccagn an P, Macedo CL, Kayath MJ, Noqu eira RG, Abu ch am J.
Con ser vat ive m an agem en t of pit u it ar y ap oplexy: a p rosp ect ive
st u dy. J Clin En docrin ol Met ab 1995;80(7):21902197
13. Nishioka H, Haraoka J, Miki T. Spontaneous rem ission of functioning pituitar y adenom as w ithout hypopituitarism follow ing infarctive apoplexy: t wo case reports. Endocr J 2005;52(1):117123
14. Mu th u ku m ar N, Rosset te D, Sou daram M, Sen th ilbabu S,
Badrin arayan an T. Blindn ess follow ing pit u it ar y apoplexy: t im ing of surger y an d n euro-oph th alm ic outcom e. J Clin Neurosci
2008;15(8):873879
15. Paren t AD. Visu al recover y after blin d n ess from pit u it ar y
apoplexy. Can J Neurol Sci 1990;17(1):8891
16. Cardoso ER, Peterson EW. Pit u it ar y ap op lexy: a review. Neu rosurger y 1984;14(3):363373

IV

Emergency Operations in Combat

23

Combat Cranial Operations


Leon E. Moores

Introduction
This chapter covers the procedure for a large hem icraniectom y
follow ing severe penetrating com bat traum a w ith m assive soft
tissue involvem ent. Sim ilar operative principles apply for less
severe penetrating w ounds, as well as for hem icraniectom y for
blunt traum a. W here blunt traum a is concerned, the m ost signi cant divergence involves preoperative decision m aking. We have
tended throughout recent con ict to be quite aggressive w ith surgical intervention for both blunt and penetrating traum a. Longterm outcom e studies are pending, but initial experience justi es
continuing this aggressive approach in our patient population.1,2
Com parisons bet w een civilian and com bat cranial traum a m ay
be di cult because of the service m em bers very young average
age and high overall level of tness, the nearly im m ediate availabilit y of basic and advanced life support care, and extraordinarily
robust resources on the bat tle eld and w ithin close proxim it y of
w ounding. Additionally, com bat injuries are n otable for m assive
soft tissue/bone/brain injury, gross contam ination (often w ith
aggressive organism s), concurrent injuries to face/neck/extrem ities/trunk, and extended patient transfers. Evacuation to facilities in Germ any and, then, onward to national m ilitary m edical
centers in Beth esda, Marylan d, con sists of t w o ights of m ore
than 6 hours duration w ithout in- ight neurosurgical capabilit y.3
How ever, th e m ajor goals of su rger y in both sit u at ion s are
rem oval of con tam in an ts (in clud ing devit alized t issue), brain stem decom pression , h em ost asis, sku ll base recon st ru ct ion
(w ith obliterat ion of air- lled sin u ses), dural coverage, soft t issue coverage, an d stabilizat ion for t ran sp or t w ith app rop riate
m on itoring in p lace an d fu n ct ion ing.

Indications

In t h e com bat set t in g, low GCS score (, 5) is n ot n ecessarily a con t rain d icat ion to su rgical in ter ven t ion . Ad d it ion ally, p u p illar y asym m et r y or d ilat ion m ay be t h e resu lt of
t rau m at ic ir id op legia or ch em ical ir r it at ion . Th e overall
clin ical p ict u re an d w ou n d ing h istor y m u st be t aken in to
accou n t before m akin g a d ecision to categor ize a p at ien t
as exp ect an t . Becau se of t h e d i eren ces in p at ien t p op u lat ion as ou t lin ed , t h is in d icat ion m ay n ot fu lly t ran slate in to
civilian p ract ice.

Preprocedure Considerations
Consultation/Teamw ork
Su ccessfu l m an agem en t of p at ien t s severely w ou n d ed in com bat operat ion s is t ruly a m ult idisciplin ar y e ort . Mult iple surgical sp ecialist s are often involvedin addit ion to e or ts from
an esth esiology, n u rsing, an d laborator y/blood ban k. A single
p at ien t m ay presen t w ith an ext rem it y am p ut at ion , an abd om in al pen et rat ion , exposed brain , a p ar t ially en ucleated globe,
an d severe soft t issu e/bon e loss involving th e m axilla, requ iring
sim u ltan eou s evalu at ion an d su rgical m an agem en t by ve sp ecialists. Con st an t com m un icat ion an d coordin at ion is required
am ong all m em bers of th e team .

Radiographic Imaging
Com puted tom ography (CT) scan is rou t in ely available at th e

Severe p en et rat ing t rau m a.


Blu n t t rau m a w ith sign i can t m ass e ect from h em isp h eric

386

sw elling or h em atom a.
Absen ce of m ajor disrupt ion of m idline deep cerebral n uclei
in th e region of th e sella (zon a fat alis). Disrupt ion of th e zon a
fatalist yp ically associated w ith Glasgow Com a Scale (GCS)
3 is a relat ive con t rain dicat ion to operat ive in ter ven t ion .4

m edical facilit ies in th eater w h ere n eu rosu rgical capabilit y


is presen t .
Angiography is n ot rout in ely available an d requires th e presen ce of both specialized equ ipm en t an d a t rain ed n eu roin ter ven t ion alist . W h ere angiograph ic capabilit y is available in
th eater, it h as proven u seful in th e m an agem en t of pen et rating t raum a of th e n eck an d h ead. Upon arrival to th e Un ited
St ates, angiography is often perform edw h eth er blu n t or
p en et rat ing m ech an ism due to th e in creased in ciden ce of
vasosp asm associated w ith blast-related t rau m a, even in th e
absen ce of cran ial pen et rat ion .5
Preoperat ive im aging (Fig. 23.1a, b).

23

Com bat Cranial Operations

b
Fig. 23.1a, b CT (a) brain and (b) bone images of a frontotemporoparietal IED injury demonstrating t ypical massive
soft tissue swelling, air- lled sinus disruption, intracranial fragments, and epidural hematoma. These are actual
hardcopy images from in-theater CT scan operating under extreme weather and force protection conditions. Digital
records are not available for higher resolution.

Medication

Operative Field Preparation

Recen tly p u blish ed guidelin es for p en et rat ing brain injur y

Vigorous clean sing of con tam in ated adjacen t soft t issue

recom m en d an t ibiot ic prophyla xis w ith cefazolin . Prophyla xis t yp ically is con t in u ed u n t il 24 h ours follow ing rem oval
of extern al ven t ricular device (EVD) or in t racran ial pressu re
(ICP) m on itor, or a total of 48 h ours if n o such devices are
p resen t . Con siderat ion m ay be given to exten ded coverage
w ith gen t am icin an d pen icillin if gross con t am in at ion is
p resen t . Pat ien t s w h o are allergic to p en icillin m ay be t reated
w ith van com ycin an d cipro oxacin .6
Seizu re p rop hylaxis w ith dip h enylhydan toin is in it iated preoperat ively.

is com pleted w ith irrigat ion , soap an d w ater, alcoh ol, an d


p ovidon e iodin e or ch lorh exidin e. Exposed brain t issu e is
irrigated w ith salin e on ly. Con t rar y to stan dard p ract ice in
th e elect ive set t ing, th e h air is clipped w idely both to rem ove
gross con t am in at ion an d to allow bet ter visu alizat ion of
addit ion al areas of pen et rat ion .
Th e in cision s are m arked an d in lt rated w ith 1% lidocain e
w ith epin eph rin e 1:100,000.

387

IV Em ergency Operations in Com bat

Operative Procedure
Positioning and Preparation (Fig. 23.2)

Figure

Procedural Steps

Pearls

Fig. 23.2

Removal of debris is recommended prior to nal prep. If a fragment


is rmly embedded or adjacent to vascular structures the fragment
is prepped into the eld.

Alcohol, iodine, and other noxious prep

The head is turned in a manner that optimizes visualization of the


most severely injured area. Typically, the most devastated portion
of the w ound is placed at the highest point in the operative eld,
angled slightly tow ard the surgeon for best visualization and
operative control of any deep injuries along the w ound tract.
Copious normal saline irrigation is used on any exposed brain
tissue.
If there is su cient uninjured space on the lateral thigh, it is
prepped for a potential fascia lata graft.

388

agents are not applied to exposed brain.

23

Com bat Cranial Operations

Urgent Hemostasis (Fig. 23.3)

Figure

Procedural Steps

Pearls

Fig. 23.3

Hemostasis w ithin the brain parenchyma must be achieved


rapidly in the case of severe penetrating trauma. Signi cant
intracranial sources of bleeding often preclude w orking slow ly
from super cial to deep. Continuous arterial bleeding from
intracranial sources is commonly encountered upon removal of
eld dressings and use of saline irrigation. Hemostasis must be
achieved before attending to non-lifesaving interventions such
as soft tissue debridement.

Often, excellent hem ostasis of low-volum e


bleeding zones within a m assive area of injury can
be achieved by allowing the topical hem ostatic
agents to rem ain in placeif one can resist the
temptation to rem ove them .

All methods of hemostasis must be considered. The best


method is often time. When encountering multiple areas
of signi cant active hemorrhage, the surgeon must pack o
the least w orrisome w ith gelatin sponge, strips of hemostatic
oxidized cellulose polymer, cotton patties, etc. and gain control
of the most vigorous bleeding points.

389

IV Em ergency Operations in Com bat

Soft Tissue Debridement (Fig. 23.4)

390

Figure

Procedural Steps

Pearls

Fig. 23.4

Soft tissue debridement is accomplished w ith a combination of


sharp and blunt dissection. Devitalized and grossly contaminated
soft tissue is removed. It is important to keep in mind the
requirement for soft tissue coverage of the nal construct and to
minimize the excision of soft tissue w hich is not clearly devitalized.
A signi cant portion of the muscle and skin may be severely
contused, yet quite viable, and should be salvaged.

Even with wounds such as in Fig. 23.2, the


elasticit y of the scalp is such that prim ary
closure is the norm . Aggressive undermining
of the scalp (which aids in pericranial graft
harvest) also helps to achieve prim ary
coverage if a signi cant portion of the scalp
has been devitalized.

23

Com bat Cranial Operations

Bony Debridement (Fig. 23.5)

Figure

Procedural Steps

Pearls

Fig. 23.5

Aggressive debridement of super cial bone


fragments is indicated. The availability of
excellent modern modeling techniques for
calvarial reconstruction precludes the need
to preserve complex, three -dimensional
bony structures w here comminution is
present. 7

Particularly in the case of contaminated wounds, the absence of


blood supply to bone fragm ents m ay increase infection risk.

391

IV Em ergency Operations in Com bat

Scalp Incision (Fig. 23.6a, b)

Figure

Procedural Steps

Pearls

Fig. 23.6

(a) An extended reverse question mark incision allow s for a generous


hemicraniectomy and provides excellent access to harvest a large,
vascularized pericranial graftessential to the reconstruction of often
massive skull base and aerated sinus defects.

(b) Extension of the lateral incision

(c) In some cases, the very large scalp ap described above may be
vulnerable to posterior scalp breakdow n. The surgeon may consider
a midline incision and ipsilateral extension of Kempe, as revisited by
Martin, 1 taking advantage of the angiosomes of the occipital artery to
improve results w ith cosmetic reconstruction. 8

392

anterior to the tragus and the m idline


incision behind the contralateral hairline,
if necessary, can provide excellent
exposure of the frontal fossa and
zygom a.
While this incision forfeits the advantage
of a vascularized pericranial pedicle,
free grafts m ay be harvested from the
posterior scalp.

23

Com bat Cranial Operations

Hemicraniectomy (Fig. 23.7)

Figure

Procedural Steps

Pearls

Fig. 23.7

The ideal bony incision is just lateral to the superior sagittal


sinus, just above the transverse sinus, and along the
temporal and frontal fossa oors.

Over the course of the recent con ict, we have


becom e advocates of very large, nearly hem ispheric
bone apsin part, due to an inabilit y to provide
emergency neurosurgical intervention during a
lengthy transport. On occasion, if m inim al dam age
to the brain is accompanied by signi cant loss of
brain tissue and very lit tle postoperative swelling is
anticipated, prim ary reconstruction of the bony injury
can be accomplished acutely. Primary reconstruction
should be considered for relatively super cial
wounds, even with severe fragm entation of bone
and disruption of soft tissue. Frontal injuries, where
the potential for brainstem compression is less of a
concern, are often good candidates. The abilit y to
m onitor ICP becom es m ore important in this set ting.

393

IV Em ergency Operations in Com bat

Brain Debridement (Fig. 23.8)

394

Figure

Procedural Steps

Fig. 23.8

Brain debridement is performed using normal saline bulb irrigation to w ash aw ay large fragments of obviously
devitalized brain tissue. Hemostasis is attained, further irrigation is applied, and gross areas of contamination
are removed. Gentle exploration of w ound tracts is appropriate in order to remove obvious and easily accessible
contaminants, but deeply embedded fragments are not removed unless indicated by later angiography or a
subsequent infection.

23

Com bat Cranial Operations

Skull Base Reconstruction, Pericranial Graft (Fig. 23.9)

Figure

Procedural Steps

Fig. 23.9

Dural coverage is obtained using primary dural tissue w hen available. Fascia lata is harvested if su cient dura is not
available. Dural substitutes are available in theater if neither can be used.
Reconstruction of the skull base is done w ith local bone, if available ; otherw ise, harvested bone is employed for
this purpose. In the rare circumstance that neither is available, arti cial materials such as titanium can be used over
small areas as long as pericranial coverage is used.
It is important to ensure obliteration of any involved air- lled sinuses. This is done by w idely opening the sinus,
removing mucosa, and packing the sinus fully w ith muscle and/or fat.
Extensive pericranial graft tissue, w ith a vascularized pedicle, can be harvested due to the expansive scalp exposure
(see Fig. 23.6). The graft can be maneuvered into place to cover an exenterated air- lled sinus (or skull base
reconstruction) and sew n over the packed sinus cavity to the adjacent dura.
When possible, anchor the temporalis muscle to scalp or bone in order to preserve its normal anatomic position and
allow for later optimal cosmetic reconstruction.

395

IV Em ergency Operations in Com bat

Closing

Sedat ion , p ain con t rol m easu res, an d ven t ricu lar drain age to
con t rol ICP are closely m on itored an d m an aged by on board
in ten sivists an d crit ical care n ursing st a .

Cranial Incision
Th e in t racran ial space an d w oun d cavit y are irrigated w ith

copious am oun ts of salin e. Th e surgical site is reassessed for


h em ostasis.
An ICP m onitoring device is placed prior to closure. Ventriculostom y is preferred, since it is both diagnostic and therapeutic.
Care m ust be taken to properly allow for pressure relief w hen
the patient is taken high altitudes for intercontinental transport.
Th e tem poralis an d su bcut an eous t issue are reapproxim ated
w ith absorbable 0 or 2-0 sut ure. Th e scalp t ypically is closed
w ith staples.

Medication
An t iepilept ic prophylaxis is con t in u ed for 7 days.
Prophylact ic an t ibiot ics are con t in ued for 4872 h ours.

Radiographic Imaging
Repeat CT im aging is t ypically obt ain ed postoperat ively, th e

Low er Extremity Incision


After cop iou s an t ibiot ic irrigat ion , th e fascia lat a h ar vest ing

site is closed w ith a deep layer of 2-0 absorbable su t u re, follow ed by skin staples.

Postoperative Management
Monitoring

n ext m orn ing, an d on an as-n eed ed basis th ereafter for n eu rologic ch anges. Im aging requirem en t s are balan ced again st
h em odyn am ic st abilit y an d oth er risks of t ran sport to im aging suite.
We h ave becom e m uch m ore aggressive w ith angiography
due to in creased in ciden ce of vasospasm , pseudoan eur ysm ,
an d delayed h em orrh age in pat ien t s exp osed to blast en ergy.
In addit ion to in ciden ces of obviou s vascu lar inju r y, w e rou t in ely perform angiogram s in th e follow ing pat ien t s to look
for occu lt inju r y: p en et rat ing inju r y n ear th e circle of Willis, Sylvian ssure, or posterior fossa; kn ow n vasospasm ; an d
blast-associated blun t t raum a.
Postop erat ive im aging (Fig. 23.10a, b).

If placed in th eater, invasive ICP m on itoring devices are


retain ed th rough out t ran spor t to Germ any an d th e con t in en tal Un ited St ates.
Fig. 23.10a, b CT (a) brain and (b) bone
windows obtained in the postoperative period.

396

23

Special Considerations
We h ave n oted postoperat ive ch allenges w ith vasospasm ,

p seu doan eu r ysm form at ion , ver y low pressu re hydroceph alu s, an d m ult idrug resist an t organ ism ven t ricu lit is.
Additionally, reconstructive procedures for the m ore m assive
injuries require a m ultidisciplinary e ort involving neurosurgery,
plastic surgery, oral and m axillofacial surgery, otolaryngology
head and neck surgery, ophthalm ology, prosthodontics, and
im aging/three-dim ensional fabrication experts.

References
1. Bell RS, Mossop CM, Dirks MS, et al. Early decom pressive cran iectom y for severe pen et rat ing an d closed h ead injur y du ring
w ar t im e. Neu rosu rg Focu s 2010;28(5):E1
2. Ragel BT, Klim o P Jr, Mar t in JE, Te RJ, Bakken HE, Arm on da RA.
War t im e d ecom p ressive cran iectom y: tech n iqu e an d lesson s
learn ed. Neurosu rg Focu s 2010;28(5):E2

Com bat Cranial Operations

3. Fang R, Dorlac GR, Allan PF, Dorlac WC. In tercon t in en t al aerom edical evacuat ion of pat ien t s w ith t raum at ic brain inju ries during Operat ion s Iraqi Freedom an d En during Freedom .
Neurosurg Focus 2010;28(5):E11
4. Kim KA, Wang MY, McNat t SA, Pin sky G, Liu CY, Gian n ot t a SL,
Apu zzo ML. Vector an alysis correlat ing bu llet t rajector y to
ou tcom e after civilian th rough -an d-th rough gun sh ot w oun d to
th e h ead: u sing im aging cu es to p redict fat al ou tcom e. Neu rosu rger y 2005;57(4):737747; d iscu ssion 737747
5. Arm on da RA, Bell RS, Vo AH, et al. War t im e t rau m at ic cerebral
vasospasm : recen t review of com bat casualt ies. Neurosurger y
2006;59(6):12151225; discussion 1225
6. Wor t m an n GW, Valadka AB, Moores LE. Preven t ion an d m an agem en t of in fect ion s associated w ith com bat-related cen t ral nervous system injuries. J Traum a 2008;64(3 Suppl):S252256
7. Steph en s FL, Mossop CM, Bell RS, et al. Cran iop last y com plicat ion s follow ing w ar t im e decom pressive cran iectom y. Neurosu rg
Focus 2010;28(5):E3
8. Hou sem an ND, Taylor GI, Pan W R. Th e angiosom es of th e
h ead an d n eck: an atom ic st udy an d clin ical applicat ion s. Plast
Reconst r Surg 2000;105(7):22872313

397

24

Combat-Associated Penetrating
Spine Injury
Corey M. Mossop, Christopher J. Neal, Michael K. Rosner, and Paul Klim o Jr.

Introduction
Com bat-related pen et rat ing spin e inju ries (PSIs) are due to

rearm s an d exp losive devices, m ost n ot ably im p rovised exp losive d evices (IEDs).
PSIs accoun t for up to 25% of all spin al cord injuries, of w h ich
app roxim ately h alf presen t w ith com p lete parap legia an d
m ore th an on e-qu arter are associated w ith oth er inju ries.1
An ar t icle com paring pen et rat ing an d blun t m ilitar y spin e
injuries in th e recen t U.S. m ilit ar y con ict s (Operat ion Iraqi
Freedom an d Operat ion En during Freedom ) repor ted th at
of 598 injured ser vice m em bers, 104 (17%) sust ain ed spinal
cord injuries, com prising 10% of blun t injuries an d 38% of
p en et rat ing inju ries (p , 0.0001).2
Th e th oracic spin e accoun t s for th e m ajorit y of injuries, w ith
th e lu m bosacral an d cer vical spin e follow ing in secon d an d
th ird, respect ively.1,3
Given th e relat ion sh ip of kin et ic en ergy (KE), m ass (m ), an d
velocit y (v) (KE 5 1/2m v 2 ), th e m ost crit ical factor a ect ing
th e dest ruct iven ess of a project ile is its velocit y,4 m aking th e
h igh -velocit y PSIs seen in com bat set t ings part icu larly d evastat ing.3,5 Th erefore, it is n ot surprising th at pat ien t s w ith
m ilit ar y PSI in gen eral h ave a w orse n eu rologic inju r y on p resen t at ion an d h ave less poten t ial for n eu rologic recover y th an
th ose w ith closed spin al cord t raum a.3

Indications
Fig. 24.1 depicts a t reat m ent algorithm for com bat-related PSI.
In com p lete sp in al cord inju r y w ith m ass lesion in th e sp in al
can al, w ith or w ith out progressive n eurologic de cit
W h ile th e literat u re is m ixed regarding th e exact ben e t of
decom pressive su rger y (usu ally in th e form of m ult ilevel
lam in ectom ies), m ost st ill favor op erat ive in ter ven t ion in
a m edically st able p at ien t w ith an in com plete sp in al cord
inju r y an d eviden ce of persisten t cord com pression such as

Discla im e r : Th e vie w s e xp r e sse d in t h e follow in g t e xt (o r p r e se n t a t ion , m a n u scr ip t , e t c.) a r e t h o se of t h e a u t h o r s a n d d o n ot n e ce ssa r ily r efle ct t h e officia l p o licy or p o sit ion of t h e De p a r t m e n t o f
t h e Ar m y, De p a r t m e n t of t h e Nav y, De p a r t m e n t of Defe n se , n o r t h e
U.S. Gove r n m e n t .

398

bon e or m etallic fragm en t s w ith in 2448 h ours of th e in it ial injur y .1,310 An in com p lete spin al cord inju r y m ay exist
w ithout im pingem en t on th e sp in al can al du e to th e en ergy
released to th e surrou n ding st ru ct u res by th e p assage of
th e project ile (i.e., sh ock w ave). In th is scen ario, surger y
is n ot recom m en ded.
CSFcu t an eou s/p leu ral st u la
Prolonged CSF leakage an d it s con com itan t in fect ious risks
con st it u te a de n it ive surgical in dicat ion in PSI1,3 (Fig. 24.2).
Fragm en t-in duced n er ve root com pression
Pat ien t s w ith both clin ical an d radiograp h ic eviden ce of eith er bony or foreign bodyin duced n er ve root com pression
sh ou ld h ave th e involved root s decom pressed, ideally in
th e rst 2448 h ours after inju r y.1
Sp in al in stabilit y
Sin ce th e m ajorit y of civilian PSIs are from low -m u zzle
velocit y h an dgu n s an d kn ife w ou n ds, biom ech an ical in st abilit y is n ot , in gen eral, an issu e. As su ch , th ese pat ien t s require n o in st rum en t at ion an d/or fusion during
operat ive in ter ven t ion .1,3,9,10 In com bat PSI, h ow ever, th e
project iles involved (bullet s or fragm en t s from an explosive device) h ave a greater en ergy th at can be dissipated
to th e surrou n ding an atom ic st ruct ures, th us in creasing
th e likelih ood of spin al in st abilit y. With h igh -velocit y ballist ic t raum a, th e rate of in stabilit y can approach 20% an d
is m ost com m on in injuries w ith a side-to-side t rajector y
involving th e facet join t s bilaterally 7 ; h ow ever, th e con cept
of spin al stabilit y rem ain s n ebulous an d ult im ately rests on
a case-by-case con siderat ion of m u ltiple clin ical an d rad iograp h ic n dings w ith clin ical in t u it ion p laying an equ ally
st rong role (Fig. 24.3).
If t h e p at ien t h as a t ran sgast roin test in al an d u n st able
sp in al inju r y, w e recom m en d t h at in st r u m en t at ion be
p ost p on ed u n t il t h e p at ien t h as com p leted a fu ll cou rse of
in t raven ou s an t ibiot ic t h erapy an d , if n ecessar y, t h e abd om en h as been t h orough ly d ebr id ed an d w ash ed ou t by a
gen eral su rgeon .
Recen t literat ure h as est ablish ed th at th e follow ing clin ical
scen arios are not in dicat ion s (in an d of th em selves) for operat ive in ter ven t ion :
Com plete spin al cord injur y (in th e absen ce of spin al in st abilit y or CSF leakage) (Fig. 24.4) 1,310
Woun d debridem en t/closure (in th e absen ce of gross
w ou n d con t am in at ion ) 11
Copper- an d/or lead-based fragm en ts
Given h ow rare h eavy m et al toxicit y is w ith PSI, th e com p osit ion of a fragm en t sh ould n ot dictate operat ive in terven t ion based on cu rren t evid en ce.3

24
Com bat-Associated Penetrating Spine Injury

399

IV Em ergency Operations in Com bat

Fig. 24.2 This is an example of a complex exit wound from a penetrating


spine injury. Management of dural violation and cerebrospinal uid
stulas is paramount for wound healing in these patients. Vascularized
tissue coverage is critical and may require the assistance of a plastic
surgeon.

400

Fig. 24.3ae This 27-year-old man sustained a highvelocit y gunshot wound that entered through the left
neck (with associated tracheal/esophageal injuries and
severe bilateral pulmonary contusions) and resulted
in complex (a, b) multicolumn fractures of T2-4 with
bilateral facet joint involvement, (c, d) complete cord
transection, and a resultant complete (ASIA A) spinal
cord injury. His tracheal and esophageal injuries were
repaired and the entry/exit sites were debrided and
closed while in theater. Because of the patients poor
pulmonary and infectious status, his spinal injuries
could not be addressed until post-injury day 15.
(continued)

24

Com bat-Associated Penetrating Spine Injury

e
Fig. 24.3 (continued) (e) At that time, he underwent a C7-T5 posterior spinal fusion with ligation of the thecal sac above
the level of injury.

Fig. 24.4ac This 39-year-old man sustained a gunshot


wound that entered medial to the left scapula and traversed
the left T2-3 pedicle, (a, b) exiting into the thoracic cage via
the right T2-3 neuroforamen. He presented with a complete
(ASIA A) spinal cord injury with no sacral sparing and MRI
evidence of severe spinal cord injury (c). Given that the injury
was thought to be stable and that there was no evidence of
CSF leakage, it was managed nonoperatively with bracing.

401

IV Em ergency Operations in Com bat

Preprocedure Considerations

Place in -dw elling (Foley) u rin ar y cath eter an d n asogast ric

Initial Evaluation

Fu ll evalu at ion /resu scitat ion protocol in accordan ce w ith th e

Advan ced Trau m a Life Su p port (ATLS) gu idelin es.


Det ailed n eu rologic assessm en t to in clu d e m otor fu n ct ion in
all key m u scle grou ps, sen sor y st at u s, re exes, an d sp h in cter
ton e as det ailed by th e Am erican Spin al Inju r y Associat ion
(ASIA) exam in at ion protocol.11
Exam in at ion of en t ran ce/exit w ou n ds for eviden ce of cerebrospin al uid (CSF) leakage.
Th orough evaluat ion an d assessm en t of any associated soft
t issue or visceral inju ries.

Radiographic Imaging
Plain X-ray
Dem on st rates an atom ic align m en t , th e p resen ce or absen ce
of overt bony injur y, an d th e locat ion of m ost retain ed foreign bodies.

Computed Tomography (CT)


Provides superior im aging of th e bony an atom y an d inju r y

pat tern (s). In addit ion , it also provides in form at ion regarding
th e locat ion of retain ed foreign bodies. Met allic st reak ar t ifact from ret ain ed foreign bodies m ay degrade th e im aging.
For cer vical spin e injur y, CT angiography (CTA) sh ou ld be
perform ed on all pat ien t s to evaluate for carot id or vertebral
arter y inju r y: disru pt ion , dissect ion , th rom bosis, or pseu doan eu r ysm form at ion . For th oracic or lum bar involvem en t , CTA
an d CT ven ograp hy sh ou ld be don e to evalu ate for large vessel inju r y (e.g., th oracic an d abdom in al aort a, com m on iliac
arteries, in ferior ven a cava).
CT m yelograp hy is rarely in dicated in th e acu te set t ing;
it m ay be valu able in a p at ien t in w h om m agn et ic reson an ce
im aging (MRI) is con t rain dicated bu t in w h om con cern exist s
for a com p ressive dural lesion n ot app aren t on bon e w in dow s
su ch as an epidu ral or su bdu ral h em atom a.

t ube (con n ected to su ct ion ) to preven t u rin ar y reten t ion an d


vom it ing/asp irat ion , resp ect ively.
High -dose m ethylp redn isolon e is n ot in d icated in th e m an agem en t of PSI.14
St ress ulcer an d ph arm acologic deep vein th rom bosis prophylaxis is en couraged.
High -dose broad-spect ru m in t raven ou s an t ibiot ics given for
710 days are indicated, especially in th e case of a t ran sab dom in al t rajector y w ith an associated bow el injur y.15,16

Operative Considerations/
Techniques
Th e pat ien t w ith a PSI is at h igh risk for a w ide range of
perioperat ive com plicat ion s th at th e surgeon m u st an t icipate an d t r y to preven t . In a recen t art icle by Possley et al,17
com plicat ion sd e n ed as unplan n ed m edical even t s (su rgical or n on surgical) th at require furth er in ter ven t ion occurred
in 35% of ser vice m em bers w ith PSI w h o u n der w en t su rgical
in ter ven t ion .

Tactical Scenario
Does th e cu rren t t act ical set t ing allow for operat ive in ter ven t ion in a safe, sterile environ m en t?

Associated Injuries
For t ran sth oracic injuries: Is th e pat ien t able to tolerate being

pron e from a respirator y an d h em odyn am ic st an dpoin t?


For t ran speriton eal injuries: Does th e pat ien t requ ire in terven t ion for a possible in test in al/vascu lar inju r y? Can th e pat ien t tolerate being pron e for th e durat ion of th e operat ion ?

Operative Field Preparation


Radiographic Imaging
See Im aging sect ion for det ails
Plain X-rays: For p osterior th oracic ap p roach es to determ in e

MRI (When Available)

th e n um ber of ribs for localizat ion

Excellen t for sh ow ing soft t issue an atom y: th e in tegrit y of th e


spin al cord, n er ve root s, ligam en ts, m u scles, join t cap su les,
an d in ter ver tebral disks. MRI is u su ally con t rain d icated in PSI
if th ere are ret ain ed m et allic fragm en ts.

Initial Medical Management 12


Adm ission to m on itored set t ing.
Im m obilizat ion u n t il spin al st abilit y est ablish ed .
Avoid hypoten sion (systolic blood p ressu re , 90 m m Hg) an d
m ain t ain m ean ar terial pressu res at 8590 m m Hg for th e
rst 7 days if th e p at ien t h as su ered a sp in al cord inju r y.13
Use carefu l in t raven ou s hydrat ion w ith p ressors ( dop am in e)
if n eeded to m ain t ain m ean ar terial pressu re (MAP) goals.

402

Equipment/Set-Up

Head ligh t , lou pes, bip olar/Bovie cau ter y


In t raop erat ive u oroscopy
May eld h ead h older: For posterior cer vical ap p roach es
Pron e t able: Open /closed Jackson table w ith Wilson fram e
or bolsters depen ding on surgeon preferen ce for posterior
th oracolum bar approach es
Basic sp in e t ray w ith Kerrison rongeurs
High -sp eed drill
Basic spin al in st rum en t at ion t ray: Sh ou ld h ave on st an d-by
for all cases
Du ral rep air m aterials: Sh ou ld h ave ap p ropriate su t u res
(4-0 braided nylon , etc.) available for prim ar y dural repair,

24

syn th et ic du ral su bst it u tes, an d du ral sealan t s for all cases.


Also, m aterials for th ecal sac ligat ion if in dicated (see Fig. 24.1
an d Op erat ive Tech n iqu e sect ion ) sh ou ld be available.
Lu m bar drain : Sh ould h ave available if n eeded for CSF diversion in lu m bosacral decom p ression s

Anesthesia Issues
Con sider aw ake

Com bat-Associated Penetrating Spine Injury

Ar terial lin e to m ain t ain m ean ar terial pressure . 85 m m Hg


for th e en t iret y of th e case

Neuromonitoring
Recom m en ded if available for m on itoring of som atosen sor y
evoked p oten t ials (SSEPs) an d elect rom yograp hy (EMG)

beropt ic in t ubat ion if spin al in stabilit y

su spected
Prophylact ic in t raven ous an t ibiot ics 30 m in utes prior to
in cision if n ot already on broad-sp ect rum an t ibiot ics
Foley cath eter

Prepping/ Incision
Sh ave w ith elect ric h air clip p ers
Su rgical prep arat ion in th e st an dard sterile fash ion

403

IV Em ergency Operations in Com bat

Operative Procedure
Positioning (Fig. 24.5a, b)

404

24

Com bat-Associated Penetrating Spine Injury

Figure

Procedural Steps

Pearls

Fig. 24.5

(a) Posterior cervical approach: Prone in May eld head holder


on standard operating room table w ith appropriate padding and
arms tucked on the patients sides in reverse Trendelenburg to
promote venous drainage. Use uoroscopy to con rm normal
physiologic cervical alignment.

Use uoroscopy to plan the incision to span at

(b) Posterior thoracolumbar approaches: Prone on open/


closed spinal table w ith Wilson frame or bolsters depending on
surgeon preference. For pathology above T6-7, the arms should
be tucked at the patients side. Below this level, the arms may be
abducted and placed on a padded surface.

least t wo levels above and below the levels of


planned decompression and/or fusion.
Consider both anteroposterior and lateral
uoroscopy to aid in localization for posterior
thoracic approaches (requires preoperative
knowledge of rib num ber). Bony injury or
retained m etallic fragm ents will allow rapid
localization of the injured level(s).

405

IV Em ergency Operations in Com bat

Dissection (Fig. 24.6)

Figure

Procedural Steps

Fig. 24.6

A midline incision is made w ith no. 10 scalpel blade (length as dictated by


uoroscopic localization).
Using monopolar cautery, continue a midline dissection w ith the assistance of
self-retaining retractors to the level of the spinous processes.
Verify operative level uoroscopically.
Complete a bilateral subperiosteal dissection on the planned levels of
decompression to the medial edges of the facet joints. If an instrumented fusion
is not planned, take special care to leave the facet joint capsules intact.

406

24

Com bat-Associated Penetrating Spine Injury

Laminectomy (Fig. 24.7)

Figure

Procedural Steps

Fig. 24.7

Using the high-speed drill and Leksell/ Kerrison rongeurs, remove the
spinous processes and perform laminectomies at least one level above
and below the pathologic level.
Remove the underlying ligamentum avum w ith Kerrison rongeurs.

407

IV Em ergency Operations in Com bat

Decompression (Fig. 24.8)

408

Figure

Procedural Steps

Fig. 24.8

Carefully remove any foreign bodies or bony fragments causing any compression
on the underlying nerve roots, thecal sac, or spinal cord.

24

Com bat-Associated Penetrating Spine Injury

Dural Exploration/ Repair (Fig. 24.9)

Figure

Procedural Steps

Pearls

Fig. 24.9

Carefully explore the thecal sac and exiting nerve roots


for the presence of any dural tears.

Further augm entation with synthetic dural substitutes

If present, attempt primary repair w ith 4-0 braided nylon


suture that can be augmented by the use of either dorsal
autologous fascia/muscle or a suturable synthetic dural
substitute for larger defects.

and sealants m ay then be at tempted.


In the instance of CSF leakage in the set ting of a
complete spinal cord injury, consideration m ay then be
given to ligation of the thecal sac as a prim ary m eans of
halting CSF egress.
Consider intraoperative placement of a lum bar drain for
protection of lum bosacral dural repairs.

Perform Valsalva maneuver to judge the integrity of the


dural repair.

409

IV Em ergency Operations in Com bat

Instrumentation/ Fusion
(See Chapters 14 and 15)

in th ose pat ien t s w ith com plete spin al cord injur y an d th ose
w ith in com plete inju r y but w h o are n on am bulator y.

If in dicated, p erform in st ru m en t at ion an d fu sion after th e


prim ar y operat ive goals of decom pression an d dural repair
h ave been accom plish ed.

Closing
Su ct ion can ister/Jackson -Prat t drain (s) if n eeded (avoid w h en

dural repair perform ed).


Close dorsal fascia in a w atert igh t m an n er w ith in terrupted
0-0 braided absorbable sut ures.
Close subcu tan eou s t issu e w ith inverted, in terrupted
2-0 braided absorbable sut ures.
Close skin w ith either staples or running 2-0/3-0 nylon sut ure.

Postoperative Management
Adm ission to a m on itored set t ing w ith con t in u ed blood p res

410

su re goals as sp eci ed for u p to 7 days after th e in it ial inju r y.


Mon itor drain ou t p u t w ith rem oval w h en ou t p u t is m in im al
or if any con cern exists for CSF leakage.
Obt ain early p ostop erat ive im aging if in st ru m en t at ion p erform ed.
Main tain ap prop riate an t im icrobial coverage w ith in t raven ou s an t ibiot ics for 7 days if visceral injur y is con rm ed.
In th e case of a low th oracic or lu m bar du ral rep air, m ain t ain
th e pat ien t at for 4872 h ours postoperat ively. For cer vical
or proxim al th oracic dural repairs, m ain tain th e pat ien t w ith
th e h ead of bed at 90 degrees for 4872 h ours in th e postop erat ive set t ing. In th e case of m id-th oracic du ral rep airs, th e
posit ion ing of th e pat ien t postoperat ively is at th e discret ion
of th e operat ing surgeon .
Mech an ical deep vein th rom bosis (DVT) p rop hylaxis sh ou ld
be in it iated u pon adm ission an d con t in ued th rough out surger y an d p ostop erat ively. W h en it is determ in ed to be ap p ropriate, in st it ute ph arm acologic DVT prophylaxis.
Recom m en d postoperat ive scoliosis sur vey in th e sit t ing or
stan ding posit ion (depen ding on th e pat ien ts clin ical st at u s)
to p rovide baselin e kn ow ledge regarding region al an d global
spin al balan ce. Th is sh ou ld be repeated at regu lar in ter vals (as
determ in ed by th e operat ing surgeon ) to m on itor for any deform it y p rogression in th e p ost-su rgical set t ing, part icularly

References
1. Bu xton N. Spin al injur y. In: Brooks A, et al, eds. Ryans Ballist ic
Trau m a: A Pract ical Gu ide. Lon don : Sp ringer; 2011: 341347
2. Blair JA, Possley DR, Pet eld JL, et al. Milit ar y p en et rat ing sp in e
injur y com pared w ith blu n t . Spin e J 2012;12:762768
3. Klim o P, Ragel BT, Rosn er M, et al. Can su rger y im prove n eu rological fun ct ion in penet rat ing spin al injur y? A review of th e
m ilitar y an d civilian literat ure an d t reat m en t recom m en dat ion s
for m ilit ar y neu rosurgeon s. Neurosurg Focus 2010;28(5):E4
4. DeMu th W E Jr. Bu llet velocit y as ap p lied to m ilit ar y ri e w ou n ding capacit y. J Traum a 1969;9:2738
5. Blair JA, Pat zkow ski JC, Sch oen feld AJ, et al. Are spin e inju ries
sust ain ed in bat tle t ru ly di eren t? Spin e J 2012;12:824829
6. Clin ical assessm en t after acute cer vical spin al cord inju r y.
Neurosu rger y 2002;50(3 Suppl):S2129
7. Man agem en t of acu te spin al cord inju ries in an in ten sive care
un it or oth er m on itored set t ing. Neurosurger y 2002;50(3 Suppl):
S5157
8. Blood pressu re m an agem en t after acute spin al cord injur y.
Neurosu rger y 2002;50(3 Suppl):S5862
9. St illerm an CB. Use of m ethylpred n isolon e as an adju n ct in th e
m an agem en t of pat ien t s w ith pen et rat ing spin al cord inju r y:
outcom e an alysis. Neurosurger y 1996;39:11411149
10. Lin SS, Vaccaro AR, Reisch S, et al. Low -velocit y gu n sh ot w ou n ds
to th e spin e w ith an associated t ran speriton eal injur y. J Spin al
Disord 1995;8:136144
11. Qu igley KJ, Place HM. Th e role of debridem en t an d an t ibiot ics in
gun sh ot w oun ds to th e spin e. J Trau m a 2006;60:814820
12. Aarabi B, Alibaii E, Taghipur M, et al. Com parative study of functional recovery for surgically explored and conservatively m anaged
spinal cord m issile injuries. Neurosurgery 1996;39:11331140
13. Du z B, Can sever T, Secer HI, et al. Evalu at ion of sp in al m issile
injuries w ith respect to bullet t rajector y, su rgical in dicat ion s
an d t im ing of su rgical in ter ven t ion : a n ew gu idelin e. Spin e
2008;33:E746E753
14. Ham m ou d MA, Haddad FS, Mou farrij NA. Sp in al cord m issile
injuries during the Leban ese civil w ar. Surg Neu rol 1995;43:
432442
15. Velm ah os GC, Degian n is E, Har t K, et al. Ch anging p ro les in sp in al cord injuries an d risk factors in uen cing recover y after pen et rat ing injuries. J Traum a 1995;38:334337
16. Waters RL, Sie IH. Sp in al cord inju ries from gu n sh ot w ou n ds to
th e sp in e. Clin Or th op Relat Res 2003;408:120125
17. Possley DR, Blair JA, Sch oen feld AJ, et al. Com plicat ion s associated w ith m ilit ar y sp in e inju ries. Spin e J 2012;12:756761

Reconstructive Surgery

25

Replacement of Cranial Bone Flap


Jam ie S. Ullm an

Introduction
Cran iotom y bon e aps are often frozen or stored in th e su bcu t an eous layer of th e abdom in al w all after decom pressive cran iectom y for in t racran ial hyp erten sion from t rau m at ic brain
inju r y, cerebrovascular disease, or oth er causes. Bon e ap restorat ion w ill be n eeded on ce th e acute issues h ave resolved.
Th ere is n o con sen sus regarding th e opt im al t im ing of bon e ap
rep lacem en t .14 Replacem en ts can be p erform ed from as lit tle
as 2 w eeks to m ore th an 1 year after inju r y.5,6

Indications
Su cien t abatem en t of sw elling h as occu rred w ith th e brain

n oted on clin ical or radiological exam in at ion to be su n ken


or n ot sign i can tly prot ruding beyon d th e defect .
Th ere is n o in dicat ion of system ic or local in fect ion , or eviden ce of sign i can t decubit us ulcers in proxim it y to th e cran ial defect or in cision .
In creasing leth argy or n ew focal de cit is p resen t on exam in at ion an d n ot oth er w ise at t ribu ted to m et abolic or st ru ct ural abn orm alit ies. Such de cit s are poten t ially due to th e
e ects of altered cerebrosp in al u id (CSF) dyn am ics or at m osp h eric pressu re on th e brain .
Th ere m ay be sign i can t brain depression at th e defect an d
com puted tom ography (CT) m ay reveal brain sh ift ing to th e
con t ralateral side. Eviden ce suggest s th at earlier restorat ion
of cran ial in tegrit y can im prove n eurologic de cits in addit ion to h elping th ose pat ien t s w ho exh ibit early sign s of com m u n icat ing hydrocep h alu s.5,7,8

Fig. 25.1 Preoperative computed tomography study indicating a large


left cranial defect. The brain is largely ush with the bone edges.

Medication
Th e auth or prefers van com ycin an d gen t am icin for an t ibi-

ot ic prophylaxis, provided th e pat ien t does n ot h ave ren al


failu re or oth er con t rain dicat ion s. Often pat ien t s h ave been
h ospit alized for sign i can t p eriods of t im e an d th ere is a possibilit y for th e skin to be colon ized w ith m eth icillin -resist an t
Staphylococcus aureus.
Diphenylhydantoin is adm inistered at 15 m g/kg in nonallergic
patients w ho are not on standing antiepileptic m edication. Levetiracetam can be used alternatively at a 1000-m g loading dose.

Preprocedure Considerations
Radiographic Imaging

Operative Field Preparation


Alcoh ol prep is perform ed before povidon e iodine or chlorh ex-

CT is essen t ial to evalu ate th e con dit ion of th e brain an d it s


relat ion sh ip w ith th e defect prior to perform ing recon st ruct ion (Fig. 25.1).

412

idin e application .
Th e in cision s are m arked an d in lt rated w ith 1% lidocain e
w ith epin eph rin e 1:100,000.

25

Replacem ent of Cranial Bone Flap

Operative Procedure
Positioning and Preparation (Fig. 25.2a, b)

Figure

Procedural Steps

Pearls

Fig. 25.2

(a) Patient positioning. The head is


turned approximately 60 degrees in the
contralateral direction and the prior
frontotemporoparietal scalp incision is
exposed and prepared.

While this chapter discusses subcut aneously placed autogenous

(b) The abdominal incision housing


the subcutaneously placed bone ap is
exposed and prepared.

bone graft s as opposed to those stored in a freezer, the techniques


of reopening the craniotom y incision and bone ap replacem ent
rem ain the sam e. For the com m only perform ed hem icraniectom y or
frontotem poropariet al (occipit al) defect, the patient is positioned in
the supine position with the head t urned approxim ately 60 degrees
in the contralateral direction. The head is placed on a donut
and a roll is placed under the ipsilateral shoulder. For bifront al
craniectom ies, the patient is placed supine, head straight position;
the subcut aneous dissect ion described forthwith is essentially the
sam e (see Chapter 26).

413

V Reconstructive Surgery

Skin Incision (Fig. 25.3a, b)

Figure

Procedural Steps

Pearls

Fig. 25.3

(a) The incision is made w ith a no. 10 blade from the


superoanterior frontal region rst and opened in progressive
fashion. The bone edge is palpated under the incision. If there
is no bone edge, a straight clamp is used to separate the
pericranium from the galea to provide protection from the knife
blade w hen bone cannot be palpated underneath the incision.

In cases where the pericranium was elevated

(b) The incision is opened in stages starting w ith the frontal,


superior portion, placing galeal clamps w hen this layer has been
properly separated. The plane betw een the pericranium and
galea is developed w ith sharp dissection. The scalp layer can be
properly re ected forw ard by developing the plane betw een the
vascularized pericranium and the galea.

414

with the scalp during the initial procedure,


this layer is virtually unscarred. The galea
pericranial plane is developed with a
Met zenbaum scissors. Unscarred planes can
also be developed with blunt dissection using
a gauze sponge. The pericranium will cover
the defect as the new pseudodural plane.
If the pericranium is intact, the defect area
will be well-vascularized and the underlying
duraplast y or brain tissue will not be seen.

25

Replacem ent of Cranial Bone Flap

Subcutaneous Dissection (Fig 25.4)

Figure

Procedural Steps

Pearls

Fig. 25.4

After dissection becomes limited, the skin is opened further.


Progressive alternation of skin opening and galealpericranial
plane dissection is completed until the w ound is completely
reopened and the entire scalp ap has been re ected. Galeal
clamps are placed for hemostasis. The scalp ap is then retracted
anteriorly w ith scalp hooks or 2-0 braided nylon sutures attached
to rubber bands and clamps. Hemostasis is achieved w ith mono and bipolar cautery.

Maintaining vascularized tissue in the epidural


plane can help com bat potential infections
and prom ote osteoinduction.9 Surgeons who
have previously perform ed a duraplast y with
collagen or allo/xenographic dural substitutes
m ay choose to dissect the pericranial
dural plane. However, if the cranioplast y is
perform ed prior to su cient incorporation of
the dural graft m aterial, the resulting dural
layer m ay not yet have su cient vascularit y.

415

V Reconstructive Surgery

Identifying the Temporalis Muscle and Separation (Fig. 25.5ac)

416

25

Replacem ent of Cranial Bone Flap

Figure

Procedural Steps

Pearls

Fig. 25.5

(a) Monopolar cautery or a scalpel is used along the posterior


bone edge to expose and incise the temporalis muscle for
dissection and transposition.

There is scant discussion in the literature

(b) The plane betw een the muscle layer and the underlying
duraplasty is developed w ith dissecting scissors. If a dural plane
is not w ell established underneath the muscle during the initial
procedure, disruption of the cerebral cortex may occur. Wellpreserved muscles can be separated from the underlying tissues
safely using sharp dissection and leaving behind a thin layer of
muscle bers.
(c) The fascia is incised w ith the temporalis muscle and re ected
inferiorly w ith a 2-0 suture although it is not alw ays easy to
distinguish the temporalis fascia from the surrounding tissues.

about the temporalis m uscle disposition


during cranioplast y.10
The author at tempts to transpose the
temporalis if there is su cient m uscle volum e
to warrant such at tempts.
If the bone ap is replaced over functional
m uscle tissue, the patient m ay experience
m ovement restriction and discomfort during
m astication. If signi cant m uscle atrophy
is present along with the risk of disrupting
cerebral cortex, it is advisable to abandon
m uscle transposition. Methods to preserve
the temporalis during the initial craniectomy
procedure have been reported.11

417

V Reconstructive Surgery

Subcutaneous Abdominal Bone Flap Retrieval (Fig. 25.6a, b)

Figure

Procedural Steps

Fig. 25.6

(a) The prior abdominal w all incision is opened w ith a no. 10 blade dow n to the
bone. The bone is dissected from its pseudocapsule and surrounding tissues w ith
a periosteal elevator along the super cial surface, then the lateral edges, then the
undersurface, then, lastly, the superior, inferior, and medial edges. A laparotomy
pad is placed in the abdominal w all pocket to assist w ith hemostasis. The bone is
brie y soaked in a half peroxide/saline solution then irrigated clean w ith saline.
Debris is scraped from the bone surface w ith a periosteal elevator.
(b) Before bone ap replacement, tangential holes are created w ith the drill along
the superior temporal line for temporalis xation to re -create the temporalis
insertion, if the temporalis is to be transposed.

418

Pearls

25

Replacem ent of Cranial Bone Flap

Bone Flap Replacement (Fig. 25.7a, b)

Figure

Procedural Steps

Pearls

Fig. 25.7

The craniectomy defect is prepared to receive


the graft. Hemostasis, especially epidural, is
obtained w ith bipolar coagulation and irrigation.
The bone edges are palpated. The posterior and
anteroinferior portion of the pericranial graft is
left attached to its vascular pedicle.

If extant, protrusion of the brain through the defect during

(a) The bone ap is then placed into the defect


for alignment and to mark the areas for titanium
plate placement. Titanium plates are screw ed
onto the graft bone edge. The graft is then
replaced onto the defect and the plates are
secured to the bone edge. Where pericranium
has been left on the bone surface to maintain
its vascularity, the screw is placed through the
pericranium.

surgery can be controlled with head of bed elevation,


m annitol, and/or mild hyperventilation. If an intradural cyst is
causing protrusion, it can be drained with ultrasonic guidance
prior to replacing the bone ap. On occasion the author
has elected to hinge the bone ap at the superior edge to
allow brain swelling to decrease slowly over tim e. If hinged,
placem ent of plates around the circum ference of the ap can
help to prevent sinking of the ap once the swelling resolves.
It is often not necessary to secure these other plates in the
future, but the option rem ains open.
In cases where the bone has rem odeled and the graft t is
not precise, a bur m ay be used to m ake the bone edges more
even. (b) In such cases where there m ay be signi cant gaps
or a good deal of temporal and sphenoid bone resection was
perform ed at the initial procedure, titanium mesh m ay be
placed atop the graft and the inferior bone edges and secured
with titanium screws.

419

V Reconstructive Surgery

Temporalis Transposition (Fig. 25.8a, b)

Figure

Procedural Steps

Pearls

Fig. 25.8

(a) If preserved, the temporalis muscle is secured


to the holes created as its insertion at the
superior temporal line w ith 2-0 braided nylon
sutures to complete its transposition.

It is optional to place polym ethylm ethacrylate or

(b) The posterior portion of the temporalis is


reapproximated w ith 2-0 braided nylon suture or
absorbable suture.

420

hydroxyapatite atop the m esh or any other existing defect


after the bone ap has been replaced. Precontoured m aterials
for these defects are available (see Chapter 26).

25

Replacem ent of Cranial Bone Flap

Completed Construct (Fig. 25.9)

Figure

Procedural Steps

Fig. 25.9

Photograph of completed construct prior to closing.

421

V Reconstructive Surgery

Closing
Cranial Incision
Th e w oun d is h eavily irrigated.
A m ediu m su ct ion d rain age device is p laced in th e su bgaleal

plan e.
Th e scalp is approxim ated w ith 3-0 braided absorbable su t ure in an inverted, in terrupted fash ion .
Th e skin is closed w ith 3-0 nylon or w ith staples.

Abdominal Incision
After h em ost asis is obt ain ed at th e abdom in al site w ith m o

n op olar cauter y, an opt ion al su ct ion drain age device is placed


in th e abdom in al w all cavit y.
Th e pseudocapsu le an d fat layers are closed w ith 3-0 absorb able su t u re.
Th e skin is closed w ith st aples or 3-0 nylon sut ures.

Postoperative Management

Fig. 25.10 Computed tomography head scan after bone ap replacement.

Monitoring
It is th e au th ors pract ice to p lace th e p at ien t in a m on itored
set t ing overn igh t in th e p ostoperat ive period to obser ve for
seizu re act ivit y or eviden ce of in t racran ial bleeding.

Medication
Th e prophylact ic an t iepilept ic agen t is cont in u ed for a total of

7 days provided th ere are n o in terim seizures.


It is opt ion al to give t w o to th ree doses of prop hylact ic an t ibiot ics in th e im m ediate postop erat ive p eriod .

Radiographic Imaging
A p ostoperat ive CT scan m ay be obtain ed to evalu ate for
ext ra-axial collect ion s or oth er h em orrh age (Fig. 25.10).

Further Management
Drain s are rem oved in 1 or 2 days.
Skin su t u res or stap les are rem oved after 2 w eeks.

Special Considerations
Explan ted craniotom y aps can also be stored in sub-zero freezers u n der aseptic con dit ion s.12,13 Th e available literat u re suggests th at th e rate of in fection or com plicat ion s do n ot di er
bet w een grafts stored by either m ethod.9,12,13 The disadvan tage
of subcutan eously stored bone grafts is that bone rem odeling

422

occurs over tim e. Though this tim e period is not certain, it is


likely to occur som etim e after 3 m onths of storage.14 Su bcu tan eously stored bone grafts have been noted to h ave histological evidence of both bone destruct ion and osteogenesis.14,15 Th erefore,
earlier placem en t of th is t ype of stored graft m ay be preferable.
Frozen grafts m ay have a high er incidence of bone resorption
on ce im planted, especially in children.9,12,16,17 This resorpt ion
m ay also be m it igated by earlier bon e ap replacem en t.6
W h ile th e focus of th is ch apter does n ot in clude in dicat ion s
for sh u n t ing, qu est ion s arise as w h eth er to p erform a sh u n t or
h ow to m an age an exist ing sh u n t p rior to bon e ap rep lacem en t .1,8,1820 It is th e au th ors p ract ice th at , w h en p at ien t s develop post t rau m at ic n orm al p ressu re hydroceph alu s w ith n o
prot rusion of brain th rough th e defect an d pat ien ts are ready
for bon e ap restorat ion , th e lat ter is perform ed rst w ith carefu l postoperat ive m on itoring of th e n eu rologic exam in at ion an d
radiograph s. Th e sh u n t is th en p laced in a delayed fash ion (1 to
2 w eeks postoperat ively) to allow for ext ra-axial air or uid to
resolve prior to sh un t placem en t so as to avoid p oten t iat ing a
collect ion in th is space. In pat ien t s w h o h ave sh un t s prior to
cran ioplast y, th e clin ical con dit ion m ay allow for tem porar y
sh u n t occlu sion in th e pre- an d p erioperat ive p eriod w ith close
m on itoring to e ect brain exp an sion an d th ereby m in im izing
su bdu ral collect ion d evelop m en t . How ever, th is decision is
based u pon taking in to con siderat ion th e pat ien ts clin ical con dit ion , h istor y of sh un t depen den ce, an d radiograph ic st udies.
Program m able sh un t valves m ay perm it th e pract it ion er to adju st drain age p ressure to a h igh er set t ing prior to cran ioplast y.
After w ard, progressive reduct ion s in th e pressure set t ings can
h elp p reven t su bdu ral collect ion s.1 Th ese p rogram m able valves
m ay also be u sefu l in sh orten ing th e t im e fram e bet w een cran ioplast y an d delayed de n ovo sh u n t ing.

25

References
1. Ch eng YK, Weng HH, Yang JT, et al. Factors a ect ing graft in fect ion after cran ioplast y. J Clin Neurosci 2008;15:11151119
2. Liang W, Xiaofeng Y, Weigu o L, et al. Cran iop last y of large cran ial defect at an early st age after decom pressive cran iectom y
perform ed for severe h ead injur y. J Cran iofac Surg 2007;18:
526532
3. Iw am a T, Yam ada J, Im ai S, et al. Th e u se of frozen au togen ou s
bon e aps in delayed cran ioplast y revisited. Neurosurger y
2003;52:591596
4. Hu ang YH, Lee TC, Yang KY, et al. Is t im ing of cran ioplast y follow ing post t raum at ic cran iectom y related to n eurological ou tcom e?
In t J Su rg 2013;11:886890
5. Beau ch am p KM, Kash u k J, Moore EE, et al. Cran iop last y after
post injur y decom pressive cran iectom y: is t im ing of th e essen ce?
J Trau m a 2010;69:270274
6. Piedra MP, Th om pson EM, Selden NR, et al. Opt im al t im ing of
autologous cran ioplast y after decom pressive cran iectom y in
children . J Neurosurg Pediat r 2012;10:268272
7. Gran t GA, Jolley M, Ellen bogen RG, et al. Failu re of au tologou s
bon e-assisted cran ioplast y follow ing decom pressive cran iectom y in ch ildren an d adolescen t s. J Neurosurg 2004;100:163168
8. Han PY, Kim JH, Kang HI, et al. Syn drom e of th e sin king skin - ap
secon dar y to th e ven t riculoperiton eal sh un t after cran iectom y.
J Korean Neu rosu rg Soc 2008;43:5153
9. Flan n er y T, McCon n ell RS. Cran iop last y: w hy th row th e bon e ap
out? Br J Neurosurg 2001;15:518520
10. Zingale A, Albanese V. Cryopreservation of autogenous bone ap in
cranial surgical practice: w hat is the future? A grade B and evidence
level 4 m eta-analytic study. J Neurosurg Sci 2003;47:137139

Replacem ent of Cranial Bone Flap

11. Di Rien zo A, Iacoangeli M, Alvaro L, et al. Autologou s vascularized


dural w rapping for tem poralis m uscle preser vat ion an d recon st ruct ion after decom pressive cran iectom y: report of t w en t yve cases. Neurol Med Ch ir (Tokyo) 2013;53:590595
12. Missori P, Polli FM, Pesch illo S, et al. Double dural patch in decom pressive cran iectom y to preser ve th e tem poral m uscle: tech n ical n ote. Surg Neurol 2008;70:437439
13. Oh CH, Par CO, Hyu n DK, et al. Com parat ive st udy of outcom es
bet w een sh un t ing after cran ioplast y an d in cran ioplast y after
sh un t ing in large con cave accid cran ial defect w ith hydroceph alus. J Korean Neu rosurg Soc 2008;44:211216
14. St iver SI, Winterm ark M, Man ley GT. Reversible m on oparesis
follow ing d ecom p ressive h em icran iectom y for t rau m at ic brain
inju r y. J Neu rosurg 2008;109:245254
15. Car vi Y Nievas MN, Hollerh age HG. Early com bin ed cran ioplast y
an d program m able sh un t in pat ient s w ith skull bon e defect s an d
CSF circu lat ion disorders. Neu rol Res 2006;28:139144
16. Waziri A, Fusco D, Mayer SA, et al. Postoperat ive hydrocephalus
in pat ient s undergoing decom pressive h em icraniectom y for isch em ic or h em orrh agic st roke. Neurosurger y 2007;61:489493
17. Dun isch P, Walter J, Sakr Y, et al. Risk factors of asept ic bon e resorpt ion : a st udy after autologous bon e ap rein ser t ion due to
decom pressive cran iectom y. J Neurosurg 2013;118:11411147
18. Movassagh i K, Ver Halen J, Gan ch i P, et al. Cran ioplast y w ith sub cu t an eou sly p reser ved au tologou s bon e graft s. Plast Recon st r
Surg 2006;117:202206
19. Acikgoz B, Ozcan OE, Erbengi A, et al. Histopath ologic an d m icroden sitom et ric an alysis of cran iotom y bon e aps preser ved bet w een abdom in al fat and m u scle. Surg Neurol 1986;26:557561
20. Heo J, Park SQ, Ch o SJ, et al. Evaluat ion of sim ult an eous cran ioplast y an d ven t riculoperiton eal sh un t procedures. J Neurosurg
2014;121(2):313318

423

26

Techniques of Alloplastic Cranioplasty


Erin N. Kiehna and John A. Jane Jr.

Bon e w as con tam in ated at th e t im e of inju r y (foreign body

Introduction
W hen an autologous cranioplast y is not an optionw hether from
contam ination, infection, fragm entation, bony reabsorption, or
grow th in the cranial vault (in children)neurosurgeons often
have to turn to im plantable synthetic cranioplasties. The goals
of a cranioplast y rem ain the sam e: lasting repair of the cranial
defect w ith good anatom ic contour. This can be perform ed at any
tim e point follow ing a reduction in brain swelling.1 Since the
1600s, neurosurgeons have experim ented w ith several di erent
constructs in the quest for the perfect cranioplast y.2 Recent developm ents in com puter-aided design and m anufacturing, tissue
engineering, and osteoinductive capabilities allow for the fabrication of an alloplastic im plant w ith excellent aesthetics that w ithstands biom echanical stresses and allow s for tissue integration.3

Indications

con tam in at ion or open fract ures)


Bon e ap in fect ion /osteom yelit is
Sign i can t dispropor t ion bet w een th e skull an d th e bon e
ap resu lt ing in aesth et ically u npleasing ou tcom e
Bony reabsorpt ion follow ing in it ial autologou s cran iop last y (Fig. 26.1).
Bony rem odeling
Sign i can t grow th of th e cran ial vault (in ch ildren )
Grow ing skull fract ures an d t rau m at ic defect s in th e sku ll
(Fig. 26.2)

Preprocedure Considerations
Radiographic Imaging
Neu roim aging is requ ired p rior to any cran iop last y to evalu -

Su cien t abatem en t of sw elling h as occu rred w h en n eu roim aging dem on st rates th at brain is n ot prot ruding beyon d th e
defect an d lacks any eviden ce of system ic or local in fect ion .
Un suitabilit y of au tologous cran ioplast y
Bon e w as fragm en ted (prim ar y inju r y w as a dep ressed
sku ll fract u re)

ate th e con dit ion of th e brain , it s relat ion sh ip w ith th e cran ial
defect , any degree of hydroceph alus, extern al hydroceph alu s,
an d/or leptom en ingeal cyst s.
Magn et ic reson an ce im aging (MRI), w h ile n ot n ecessar y,
allow s for m ore det ail of th e brain ; it also m ay be m ore
su itable for ch ildren w h en th ere is a goal to lim it radiat ion
exposu re.

Fig. 26.1 Three-dimensional CT scan of


bony reabsorption following cranioplast y in
an infant.

424

26

Techniques of Alloplastic Cranioplast y

Com puted tom ography (CT) allow s for visualization of the

thickness of the bone to determ ine the splitabilit y in children.


A th ree-dim en sion al an atom ic CT is n ecessar y for con st ruct ion of custom , im plan t able cran ioplast ies.

Medication
Antibiotic prophylaxis includes the standard preoperative dose

3060 m inutes prior to skin incision. Som e neurosurgeons also


provide 24 hour antibiotic prophylaxis postoperatively.
An t iepilept ic prophylaxis m ay be con sidered in pat ien t s w h o
are n ot on stan ding an t iep ilept ic m edicat ion . Ou r in st it u t ion
u t ilizes ph enytoin or levet iracet am .

Operative Site Preparation


Th e skin in cision used for th e decom pressive cran iectom y or

Fig. 26.2 Growing skull fracture in an infant.

cran iotom y site is t ypically su cient .


In cision s sh ou ld be m ad e as cosm et ic as possible, st aying beh in d th e h airlin e an d p reser ving blood ow to th e scalp ap .
Approxim ately 12 cm of h air clipping m ay be perform ed.
Th e skin is prepped as per physician preferen ce, w ith th e recom m en dat ion th at alcoh ol is u sed during a stage of th e skin
clean sing process.
Th e in cision s are m arked an d in lt rated w ith 0.2% ropivacain e w ith epin eph rin e 1:100,000.
Algorith m for cran ioplast y select ion (Fig. 26.3).

425

V Reconstructive Surgery

Bony defect

s/p calvarial t um or
resect ion

s/p in fect ion


delayed
reconst ruct ion

s/p t rau m a

Im m ed iate
cran iop last y w ith
pre-ordered im p lan t

Im m ed iate
cran iop last y w ith
p orou s polyethylen e
or HA or PMMA
con tou red on th e
field

If sw elling th en
delayed
recon st ru ct ion

Bon e flap in tact an d


n ot con tam in ated ?
Au tologou s bon e

At tem pt p at ien t ow n
bon e if available (an d
n ot con tam in ated)

Bon e flap
fragm en ted or
con tam in ated

Use p re-ordered
im p lant for large
con st ru ct s

Sm all defect: Titan iu m m esh ,


porou s polyethylen e, HA or
PMMA con tou red on th e field
Large defect: Order cu stom
im p lan t if au tologou s bon e flap is
n ot suitable for reim plan tat ion

If n o sw elling th en
im m ediate
reconst ru ct ion

Bon e flap in tact an d


n ot con tam in ated?
Autologou s bon e
Bon e flap
fragm en ted or
con tam in ated

Sm all defect: Titan iu m m esh ,


p orou s p olyethylen e, HA or PMMA
con tou red on th e field
Large defect: Ord er custom im p lan t
if au tologou s bon e flap is n ot
su itable for reim p lan tat ion
Fig. 26.3 Algorithm for cranioplast y selection. HA, hydroxyapatite; PMMA, polymethylm ethacrylate.

426

26

Techniques of Alloplastic Cranioplast y

Operative Procedure
Positioning Unilateral Craniectomy (Fig. 26.4)

Figure

Procedural Steps

Pearls

Fig. 26.4

For most cranioplasties, it is su cient to place the head on a donut


or horseshoe w ith a roll placed under the ipsilateral shoulder for
relief of strain. The head is turned approximately 60 degrees in the
contralateral direction and the prior frontotemporoparietal scalp
incision is exposed and prepared.

For cranioplasties that extend to the occipital


region, it m ay be necessary to pin the
patient to optim ize the surgical eld.

427

V Reconstructive Surgery

Positioning for Bifrontal Craniectomy (Fig. 26.5)

428

Figure

Procedural Steps

Pearls

Fig. 26.5

For bifrontal cranioplasties, the patient is


positioned supine w ith the head in a neutral
position on either a gel donut or three -point
xation.

For bilateral hem icraniectom ies it m ay be necessary to do one


side at a tim e, reprepping and redraping in bet ween.

26

Techniques of Alloplastic Cranioplast y

Skin Incision Unilateral (Fig. 26.6)

Figure

Procedural Steps

Pearls

Fig. 26.6

The incision is made w ith a no. 10 blade from the superoanterior


frontal region rst and opened in progressive fashion until the
temporalis muscle is reached. The bone edge is palpated under
the incision. If there is no bone edge, a straight clamp is used to
separate the pericranium from the galea to provide protection
from the knife blade w hen bone cannot be palpated underneath
the incision. Care should be taken to open the scalp ap separately
from temporalis muscle.

Alternatively, one can open with a m onopolar


electrocautery with a needle tip cautery.

The incision is made w ith a no. 10 blade from the sagittal suture
dow n to the zygoma bilaterally.

429

V Reconstructive Surgery

Subcutaneous Dissection (1) (Fig. 26.7)

430

Figure

Procedural Steps

Pearls

Fig. 26.7

The incision is opened in stages starting w ith the frontal,


superior portion, and w rapping around to the temporalis,
placing galeal clamps w hen this layer has been properly
separated. The plane betw een the pericranium and galea
is developed w ith sharp dissection (Metzenbaum scissors
or no. 15 blade scalpel). The scalp layer can be properly
re ected forw ard by developing the plane betw een the
vascularized pericranium and the galea.

The galeapericranial plane m ay also be developed

with a no. 10 or no. 15 blade scalpel, or with


m onopolar electrocautery.
In cases where the pericranium was elevated with
the scalp during the initial procedure, this layer is
virtually unscarred and m ay be dissected bluntly,
leaving the pericranium against the dura.

26

Techniques of Alloplastic Cranioplast y

Subcutaneous Dissection (2) (Fig 26.8a, b)

Figure

Procedural Steps

Fig. 26.8

Once the entire scalp ap has been re ected it is retracted anteriorly


w ith scalp hooks, 2-0 braided sutures, or skin clamps attached to rubber
bands and clamps. This is demonstrated for (a) unilateral and (b) bifrontal
openings. Hemostasis is meticulously achieved w ith mono - and bipolar
cautery.

431

V Reconstructive Surgery

432

26

Techniques of Alloplastic Cranioplast y

Dissecting the Temporalis Muscle (Fig. 26.9ad)

433

V Reconstructive Surgery

434

Figure

Procedural Steps

Pearls

Fig. 26.9

(a) The temporalis should be dissected from posterior bone


edge w ith monopolar cautery and then re ected from the
dural surface w ith the use of sharp dissection (b, c). (d) The
temporalis is then retracted anteriorly w ith scalp hooks, 2-0
braided nylon sutures, or skin clamps attached to rubber
bands and clamps depicted here w ith the bifrontal approach.

If the bone ap is replaced over functional muscle

tissue, the patient m ay experience m ovement


restriction and discomfort during m astication.
If signi cant m uscle atrophy is present along
with the risk of disrupting cerebral cortex, it is
advisable to abandon m uscle transposition.

26

Techniques of Alloplastic Cranioplast y

Preparation of the Craniectomy Site (Fig. 26.10)

Figure

Procedural Steps

Pearls

Fig. 26.10

A combination of monopolar cautery and curettes may


be used to re ect all of the soft tissue o of the bony
edges to allow for a tight t.

If there is protrusion of the brain through the defect during

Any lacerations of the dura should be closed


primarily. If there is a large dural defect, one may use
pericranium or a dural substitute to close it (depicted
in the unilateral approach).

surgery it can be controlled with head of bed elevation,


m annitol, and/or m ild hyperventilation.
If it persists, one m ay pass a brain needle into the
ventricles using anatom ic landmarks or ultrasound
guidance to allow for enough decompression to perform
the cranioplast y.

435

V Reconstructive Surgery

Implant Types (Fig. 26.11af)

436

26

Techniques of Alloplastic Cranioplast y

437

V Reconstructive Surgery

438

26

Techniques of Alloplastic Cranioplast y

Implant Type

Pros

Cons

Fig. 26.11a

Porous polyethylene

High strength and stabilit y


Radiolucent
Excellent cosm esis
Easily contoured
May be molded in the eld
Easily xated
Custom and anatomic options
Minimal surgical tim e for implantation

Price
Custom implants require advance
planning, usually 3D CT im aging
(but noncustom anatom ic implants
available)

Fig. 26.11b

PEEK (polyetheretherketone)

High strength and stabilit y


Radiolucent
Excellent cosmesis
Easily contoured
Easily xated
Minim al surgical time for implantation

Price
Custom im plants require advance
planning, usually 3D im aging
Can be contoured with a drill but not
m olded in the eld

Fig. 26.11c

Titanium plate

High strength and stabilit y


Excellent cosm esis
Minim al surgical tim e for implantation

Price
Custom implants require advance
planning
Radiopaque with artifact on im aging
Cannot be contoured or m olded in
the eld
May require special xation set

Fig. 26.11d

Titanium m esh

High strength and stabilit y


Easily contoured
Easily xated

Radiopaque with artifact on imaging


More time spent contouring and
plating in the surgical eld.

Fig. 26.11e

Hydroxyapatite cem ent


compound

Osteoinductive
Radiolucent
Excellent cosm esis
Easily contoured
Easily xated
Less surgical tim e for implantation than
PMMA
No advance planning needed

Price
May require m esh for strength,
stabilit y, and contouring in larger
areas

Fig. 26.11f

PMMA
(polym ethylm ethacrylate)

Radiolucent
May be contoured in the eld
No advance planning needed

Long surgical tim e for set up and


contouring, hypertherm ic reaction
while solidifying requiring irrigation
May require mesh for strength,
stabilit y, and contouring in larger
areas

439

V Reconstructive Surgery

Repairing the Temporal Defect (Fig. 26.12)

440

Figure

Procedural Steps

Fig. 26.12

Anatomic constructs may be placed atop a temporosphenoid defect to


improve contour and minimize furrow ing of the temporal region.

26

Techniques of Alloplastic Cranioplast y

Temporalis Transposition (Fig. 26.13)

Figure

Procedural Steps

Fig. 26.13

If preserved, the temporalis muscle is secured to the holes placed to


re -create its insertion at the superior temporal line w ith 2-0 braided
nylon sutures to complete its transposition.

441

V Reconstructive Surgery

Closing

Special Considerations

Hydrogen p eroxid e m ay be u sed at th e su rgeons discret ion

Th e pat ien ts ow n bon e ap is th e ideal m aterial for a cran ioplast y; h ow ever, if th e bon e ap is lost to osteolysis or in fect ion ,
au tologou s bon e (sp lit th ickn ess or h ar vest from oth er p ar ts of
th e body) is less ideal because of don or site m orbidit y an d sh ap ing problem s. As such , in th ese sit uat ion s, an alloplast ic cran ioplast y is an app rop riate solu t ion . Th e t yp e of cran ioplast y
m ost often dep en ds on th e su rgeons preferen ce an d exp erien ce as w ell as costs an d availabilit y. Th e m ost frequ en tly u sed
cran ioplast y m aterials are polym ethylm eth acr ylate (PMMA),
hydroxyapat ite, t it an iu m , polyethylen eth erketon e (PEEK), an d
porous polyethylen e.
PMMA is th e m ost frequ en tly u sed allop last ic m aterial becau se of it s good biocom pat ibilit y an d low cost an d proven efcacy in th e long term .4 Alth ough it can be u sed at th e t im e
of cran iotom y for im m ediate single st age cran ioplast y, th e
in t raoperat ive t im e an d en ergy spen t con tou ring th e m aterial exceeds th at of oth er im p lan t s. In add it ion , it is d i cu lt to
obt ain a cosm et ic resu lt th at ap proxim ates th at of th e cu stom
im plan t s. Ut ilizing a cu stom design ed m esh w ith t h e PMMA
im plan t w ith larger cran ial defect s m ay allow for th e opt im al cosm et ic im p lan t at a lesser exp en se th an oth er cu stom
im plan t s.5
Hydroxyap at ite (HA) is probably th e m ost frequ en tly u sed
ceram ic in cran ioplast y secon dar y to its h igh biocom pat ibilit y
arising from osteoin tegrat ion .6 It set s u p faster, is easier to con tour, an d is isoth erm icall bene t s over PMMA.7 How ever, in am m ator y react ion s h ave been described in th e postoperat ive
period. Furth erm ore, th e cost s of HA, especially if com bin ed
w ith a custom m esh for larger im plan t s, m ay be exceed th at of
custom im plan ts an d thu s be cost proh ibit ive.
PEEK8 an d porous polyethylen e 9 are both biocom pat ible m aterials th at provide h igh st rength an d radiolu cen cy for postoperat ive im aging. Th e u se of custom design ed im plan t s for
cran ioplast y is in creasing in calvarial recon st ruct ion , due to
th e ease of use, st rength , an d excellen t cosm et ic results. Th ey
can both be con toured in th e surgical eld an d easily xated.
Furth erm ore, sh ou ld a postoperat ive in fect ion occur, th ey m ay
be rem oved an d re-sterilized for later reim plan t at ion . Porous
polyethylen e h as th e addit ion al advan tage of being able to be

for w ou n d clean sing an d h em ost asis.


Th e w oun d is h eavily irrigated w ith salin e w ith or w ith out
an t ibiot ics.
A suction drainage device m ay be placed in th e subgaleal plane.
Th e posterior port ion of th e tem poralis m u scle is reapproxim ated w ith 2-0 braid ed su t u res.
Th e scalp is approxim ated w ith 3-0 braided absorbable
su t u re in an inver ted, in terru pted fash ion .
Th e skin is closed w ith 3-0 nylon in a vert ical m at t ress fash ion
or w ith st aples.

Postoperative Management
Monitoring
It is th e au th ors p ract ice to place th e p at ien t in a m on itored
set t ing overn igh t in th e p ostoperat ive period to obser ve for
seizu re act ivit y or eviden ce of in t racran ial bleeding.

Medication
Ph enytoin or levet iracetam is m ain tain ed at previou sly m en

t ion ed levels for a total of 7 days.


It is opt ion al to give t w o to th ree doses of prop hylact ic an t ibiot ics in th e im m ediate postop erat ive p eriod .

Radiographic Imaging
A postop erat ive CT scan m ay be obtain ed to evalu ate for su b dural collect ion s or oth er h em orrh age.

Further Management
Drain s are rem oved th e n ext p ostop erat ive day or soon er if

th ey appear to be drain ing cerebrospin al u id.


Skin su t u res or stap les are rem oved after 2 w eeks.

Fig. 26.14 Three-dimensional CT rendering of preoperative


soft tissue defect and axial CT image of porous polyethylene
pterional implant (arrow).

442

26
resh aped w ith h ot salin e at th e t im e of su rger y,10 an d prem ade
an atom ic con tou rs, sh eet s, an d blocks are available at a d ecreased cost com pared to custom im plan t s.11
Cu stom t itan iu m im plan t s o er a good ch oice for cran ioplast y
based on th eir st rength , biocom pat ibilit y, h an dling ch aracteristics, an d su it abilit y for postoperat ive im aging tech n iques.12
How ever, th ey are m ore di cu lt to sh ap e in th e eld an d m ay
requ ire sp ecial xat ion system s. In addit ion , th e t it an ium art ifact m ay be su bopt im al for th e follow -u p of m en ingiom a an d
oth er t u m ors.
An other con siderat ion after recon st ru ct ing th e calvarial defect is soft t issu e recon st ru ct ion over th e calvariu m /allop last ic
cran ioplast y. Often w h en a decom pressive cran iectom y h as
been perform ed, an d th e tem poralis m u scle u n dergoes w asting an d is n ever restored to it s previou s bulk, cau sing tem poral h allow ing. Both porou s p olyethylen e pterion al im p lan ts
(Fig. 26.14) an d/or hydroxyap at ite cem en t m ay be u sed to augm en t th e tem poralis an d restore aesth et ics.7

References
1. Goodrich, JT. Cranioplast y. In: Albright AL, ed. Principles and Practice of Pediatric Neurosurgery. New York: Thiem e; 2008:864877
2. San an A, Hain es SJ. Repairing h oles in th e h ead: a h istor y of
cran ioplast y. Neu rosurger y 1997;40(3):588603

Techniques of Alloplastic Cranioplast y

3. Ch im H, Sch an t z JT. New fron t iers in calvarial recon st r u ct ion :


in tegrat ing com puter-assisted design an d t issue engin eering in
cran ioplast y. Plast Recon st r Surg 2005;116(6):17261741
4. Moreira- Gon zalez A, Jackson IT, Miyaw aki T, et al. Clin ical ou tcom e in cran ioplast y: crit ical review in long-term follow -u p.
J Cran iofac Su rg 2003;14(2):144153
5. Lara WC, Sch w eit zer J, Lew is RP, et al. Tech n ical con siderat ion s in
th e use of polym ethylm eth acr ylate in cranioplast y. J Long Term
E Med Im plan t s 1998;8(1):4353
6. Verheggen R, Merten HA. Correction of skull defects using hydroxyapatite cem ent (HAC)evidence derived from anim al experim ents
and clinical experience. Acta Neurochir 2001;143(9):919926
7. Tadros M, Cost an t in o PD. Advan ces in cran iop last y: a sim p li ed
algorith m to guide cran ial recon st ruct ion of acqu ired defect s.
Facial Plast Su rg 2008;24(1):135145
8. Hanasono MM, Goel N, DeMonte F. Calvarial reconstruction w ith
polyetheretherketone im plants. Ann Plast Surg 2009;62(6):653655
9. Lin AY, Kin sella CR, Rot tgers SA, et al. Cu stom p orou s p olyethylen e im plan t s for large-scale pediat ric skull recon st r uct ion : early
ou tcom es. J Cran iofac Surg 2012;23(1):6770
10. Liu JK, Got tfried ON, Cole CD, et al. Porous polyethylen e im plan t
for cran ioplast y an d sku ll base recon st r u ct ion . Neu rosu rg Focu s
2004;16(3):ECP1
11. Wellisz T, Dough ert y W, Gross J. Cran iofacial applicat ion s for the
Med por p orou s p olyethylen e exblock im p lan t . J Cran iofac Su rg
1992;3(2):101107
12. Cabraja M, Klein M, Leh m an n TN. Long-term resu lt s follow ing
t it an ium cran ioplast y of large sku ll defect s. Neurosurg Focus
2009;26(6):E10

443

27

Surgery for Frontal Sinus Injuries


Abilash Haridas and Peter J. Taub

Introduction
Extern al force directed to th e an terior por t ion of th e foreh ead
can result in injur y to th e front al sin us. Th e fron t al bon e is th e
st rongest com p on en t of th e cran iofacial skeleton an d can w ith st an d bet w een 800 an d 2200 lb of force before fract u ring.1,2 Th e
sin u s is rough ly pyram idal in sh ape an d often divided by a m idlin e or p aram idlin e sept u m of bon e. Th e sin us is absen t at birth ,
but begin s to act ively pn eum at ize bet w een 7 an d 8 years of age
to reach an adult volum e after pubert y. By th eir m ech anism ,
m ost inju ries p rodu ce p osterior disp lacem en t of th e bon e in to
th e fron t al sin us, alth ough bon e at th e periph er y of th e injur y
can prot rude out w ard. Depen ding on th e force an d direct ion
of th e injur y, fract ures can involve eith er th e an terior t able of
th e sin us, both th e an terior an d posterior t ables, or solely th e
p osterior table.

Indications

Sin ce th e et iology is t raum a, an d is often of sign i can t force, a


fu ll t rau m a w orku p sh ou ld be p erform ed. In it ial con rm at ion
th at th e air w ay is paten t , th e pat ien t is breath ing, an d th ere is
adequ ate circu lat ion is p aram ou n t . Th e m ech an ism of fron t al
sin u s fract u re p laces th e cer vical spin e at risk for inju r y. Carefu l
p hysical exam in at ion of th e cer vical spin e as w ell as app ropriate im aging st udies is in dicated. Adequate plain lm s sh ou ld be
obt ain ed an d CT added if th e in it ial lm s are eith er in adequate
or in con clusive.

Su rgical t reat m en t , if in dicated, sh ou ld be in st it u ted w ith in

444

abscess. Som e au th ors elect to closely obser ve p at ien ts w ith


a p osterior table fract u re an d associated leakage of cerebrosp in al u id (CSF) for a de n ed period of t im e, su ch as 7 days.1
For n on displaced posterior t able fract u res, th e m an agem en t
is m ore con t roversial. Som e auth ors suggest th at all p osterior
t able fract ures sh ould un dergo explorat ion an d be exam in ed
directly via sin uscopy. Oth ers t reat th ese inju ries w ith close
obser vat ion an d explore if com plicat ion s develop.
Persisten t rh in orrh ea in dicates leakage of cerebrospin al u id
du e to injur y to th e dura th at h as n ot h ealed w ith obser vat ion
alon e an d requ ires in ter ven t ion .
Secon dar y correct ion is in dicated for w ou n ds th at w ere ob ser ved in lieu of op erat ive in ter ven t ion an d h ave h ealed w ith
n ot iceable deform it y.

th e rst 12 to 48 h ours after th e injur y, depen ding on th e


overall h ealth of th e p at ien t . Early t reat m en t redu ces th e in ciden ce of long-term com plicat ion s.3,4
With resp ect to th e an terior t able, depressed fract u res th at
w ill produce n ot iceable deform it y after th e resolut ion of
edem a or th at cou ld poten t ially resu lt in m u cocele form at ion
require repair. If th ere is n o com p uted tom ograp hy (CT) eviden ce of n asofron tal out ow t ract obst ruct ion (opaci ed sin u s, associated an terior eth m oid com plex fract u re, or fron tal
sin u s oor fract u re), obser vat ion m ay be recom m en ded w ith
less likelih ood of fut u re com p licat ion s developing.4
With resp ect to th e p osterior table, th e p resen ce of pn eu m oceph alu s h as been an in dicat ion for repair by som e auth ors.5
Th e pn eum oceph alus represen ts com m un icat ion bet w een
th e sterile m en ingeal space an d th e extern al environ m en t ,
w h ich cou ld lead to poten t ially life-th reaten ing in t racran ial
com plicat ion s, such as m en ingit is, en ceph alit is, an d brain

Preprocedure Considerations

Radiographic Imaging
CT is th e gold st an dard im aging m odalit y for th e cran iom a xillofacial skeleton . Historically, plain lm s w ere obt ain ed,
w h ich w ere able to iden t ify th e presen ce of uid in th e fron t al sin us, but presen ted di cult y w h en t r ying to determ in e
th e presen ce of an terior, posterior, or th rough -an d-th rough
injuries. CT scan s are able to provid e axial, coron al, an d sagitt al im ages th at can separately evaluate th e an terior an d posterior aspects of th e sin us (Figs. 27.1, 27.2, an d 27.3).

27

Fig. 27.1 CT demonstrating an isolated fracture of the anterior table of


the frontal sinus.

Surgery for Front al Sinus Injuries

Fig. 27.2 CT demonstrating an isolated fracture (arrow) of the posterior


table of the frontal sinus. Note the presence of pneumocephalus.

Fig. 27.3 CT demonstrating a fracture involving both the anterior and


posterior tables of the frontal sinus.

445

V Reconstructive Surgery

Operative Procedure
Bicoronal Incision (Fig. 27.4)

446

Figure

Procedural Steps

Fig. 27.4

A bicoronal incision several centimeters behind the hairline provides the best
access for exposure of the anterior forehead and frontal sinus. The residual scar is
inconspicuous if attempts to minimize alopecia are taken. Super cial electrocautery
should be avoided. A stair-step incision is designed along the w ound to break up the
w ound and prevent the hair, especially w hen w et, from falling all in one direction.
A strip of hair over the area of the incision is shaved for exposure and to facilitate
ultimate closure. The incision is in ltrated w ith 1%or 0.5%lidocaine w ith 1:100,000
or 1:200,000 epinephrine, respectively. After prep and drape, the incision is made
w ith a scalpel blade in the direction of the hair follicles. The deeper subcutaneous
tissues may be divided w ith electrocautery dow n to the level of the periosteum.

27

Surgery for Front al Sinus Injuries

Subperiosteal Dissection (Fig. 27.5a, b)

Figure

Procedural Steps

Fig. 27.5

(a) Dissection superior to the fractured area may proceed in either a subgaleal
or subperiosteal plane. How ever, once the fracture fragments are encountered,
dissection in a subperiosteal plane is required to mobilize and reduce the fracture
fragments. If the entire supraorbital rim needs to be visualized, the supraorbital
nerves may need to be taken out of their foramina. This does not need to be done if
the nerves merely rest w ithin a notch.
(b) To easily convert each foramen into a notch, a 2-mm osteotome is placed inside
the medial and lateral aspects of the foramen and directed inferiorly. Once the
nerves are free, the soft tissues on the orbital rim and roof can be dissected in a
subperiosteal plane for exposure.

447

V Reconstructive Surgery

Fragment Removal and Cataloguing (Fig. 27.6)

448

Figure

Procedural Steps

Pearls

Fig. 27.6

An elevating tool (Freer, bone hook, etc.) can be


inserted betw een the fragments to reduce them into a
more anatomic position or remove them for access to
the sinus and posterior table.

If the fragm ents are loose and exposure of deeper


structures is required, the fragm ents should be labeled
and catalogued so that they m ay be replaced in the correct
position and alignm ent.

27

Surgery for Front al Sinus Injuries

Con rming Frontonasal Duct Patency (Fig. 27.7)

Figure

Procedural Steps

Fig. 27.7

Placing a clean cotton sw ab in each of the nostrils and instilling a dilute


solution of methylene blue in saline via a syringe and catheter into each
of the ducts can rapidly con rm frontonasal duct patency. Transmission
of dye dow n the ducts, into the nose at the anterosuperior aspect of the
middle meatus, and onto the cotton sw ab indicates patency.

Pearls

449

V Reconstructive Surgery

Removal of the Posterior Table, if necessary (Fig. 27.8)

450

Figure

Procedural Steps

Pearls

Fig. 27.8

In the presence of pneumocephalus or displacement


of the posterior table fracture fragments, the entire
posterior table can be removed, allow ing the sinus to
be cranialized (see Fig 27.10).

The bone fragm ents rem oved from the posterior table can
then be used for autogenous graft m aterial to plug the
frontonasal ducts. Alloplastic m aterial should be avoided.
When possible, dural breaches should be repaired either
prim arily or with a dural patch.

27

Surgery for Front al Sinus Injuries

Burring the Sinus Mucosa (Fig. 27.9)

Figure

Procedural Steps

Fig. 27.9

The sinus mucosa does not stretch at against the w all of the sinus but
rather follow s small invaginations across the surface. Therefore, adequate
removal of the mucosa requires obliteration of the super cial depressions
in the bone w ith a pow er bur. Every surface and facet of the sinus should
be debrided to remove the mucosa.

451

V Reconstructive Surgery

Packing the Frontonasal Ducts (Fig. 27.10)

452

Figure

Procedural Steps

Fig. 27.10

If the posterior table is removed and the sinus allow ed to cranialize, the
frontonasal ducts must be obliterated to avoid an ascending infection
from the nonsterile respiratory tract. Plugging of the ducts has been
described using muscle, fat, or alloplastic material. How ever, morselized
bone graft from the remnants of the posterior table provides excellent
graft material. The bone is crushed w ith a rongeur on a back table and
packed into the ducts.

27

Surgery for Front al Sinus Injuries

Elevation and Rotation of Pericranial Flap (Fig. 27.11a, b)

Figure

Procedural Steps

Fig. 27.11

(a) A ap of pericranial tissue provides further separation of the nasal mucosa and
meningeal space. The ap is harvested from the deep surface of the bicoronal ap
and based inferiorly along the supraorbital rim.
(b) The pericranium should be elevated as large as possible to w rap over the
inferior aspect of bone and dow n into the anterior fossa. It can be incised w ith the
electrocautery and dissected free w ith a scissors.

453

V Reconstructive Surgery

Application of Fibrin Sealant (Fig. 27.12)

454

Figure

Procedural Steps

Fig. 27.12

Final separation is achieved w ith brin sealant placed over the


pericranial ap.

27

Surgery for Front al Sinus Injuries

Replacement of Cranial Bone Flap Components (Fig. 27.13)

Figure

Procedural Steps

Pearls

Fig. 27.13

The anterior table fracture fragments can be reconstituted on


a back table w ith plates and screw s made of either titanium or
resorbable material. The entire construct is then replaced over the
forehead and xated in the same manner.

Low pro le plates are preferable since the


bone is not weight bearing and any super cial
irregularit y m ay be noticeable.

455

V Reconstructive Surgery

Closing

Special Considerations

Cranial Incision

Persisten t leakage of u id from th e n ose m u st be evalu ated


for CSF. An t ibiot ic prop hylaxis is con t roversial in fron tal sin u s t rau m a. On e recen t ret rosp ect ive st u dy by Devaiah et al
sh ow ed n o ben e t w ith resp ect to th e rate of p ostop erat ive
in fect ion s w ith addit ion al an t ibiot ics, but suggested th at an t ibiot ic usage m ay be w arran ted in th e presen ce of severe facial
t raum a an d m u lt iple open fract ures.3,6 Alth ough sign i can t
brain injur y m ay accom pany fron tal sin us injuries, th e use of
steroids is n ot recom m en ded to redu ce in t racran ial p ressu re,
an d, in fact , is con t rain dicated.7 Alth ough an em erging tech n iqu e, th e role of en doscopic repair h as been lim ited to con tou ring of m in im ally displaced an terior t able fract u res.1,8

Th e w oun d is irrigated w ith copious w arm n orm al salin e

w ith or w ith out an t ibiot ics.


A at su ct ion d rain is placed across th e ver tex of th e sku ll.
Th e scalp is closed in layers. Depen ding on th e age of th e pat ien t , th e galea is reapproxim ated w ith in terrupted 3-0 ab sorbable su t u res.
Th e skin is closed w ith run n ing locked 4-0 plain gut sut ures
or altern at ive tech n iques, such as st aples.
A dressing con sist ing of pet roleu m gau ze, in dividu al dr y
gau ze, an d a h ead w rap is app lied.

Postoperative Management
Th e pat ien t is kept in th e h ospital u n t il aw ake an d alert . Th e
drain is kept to self-suct ion an d th e out put follow ed for quan t it y an d color. If it is n oted to be too sanguin eous, th e scalp
sh ou ld be carefu lly in sp ected for eviden ce of h em atom a an d a
seru m h em atocrit ch ecked. Eviden ce of ongoing bleed ing w arran ts ret urn to th e op erat ing room for evacu at ion an d h em ost asis. W h en drain age is m in im al, it m ay be rem oved.

Radiographic Imaging
Postop erat ive im aging w ith CT can be obt ain ed at th e discre

456

t ion of th e surgeon .
Pat ien t s sh ou ld be follow ed closely in t h e early p ostop erat ive p eriod for th e develop m en t of m en ingit is, en cep h alit is,
brain abscess, osteom yelit is of th e fron t al bon e, n on u n ion ,
caver n ou s sin u s th rom bosis, CSF leak, m u copyocele, an d
m en in goen cep h alocele.
Mu coceles h ave an in sid iou s cou rse over m any years, w arran t ing long-term follow -u p w ith im aging.1,4

References
1. Man olid is S, Hollier LH Jr. Man agem en t of fron t al sin u s fract u res.
Plast Recon st r Surg 2007;120(7 Suppl 2):32S48S
2. Strong EB, Kellm an RM. Endoscopic repair of anterior tablefrontal
sinus fractures. Facial Plast Surg Clin North Am 2006;14(1):2529
3. Bu llock MR, Ch esn u t R, Gh ajar J, et al. Su rgical m an agem en t of
dep ressed cran ial fract u res. Neu rosu rger y 2006;58(3 Su p p l):
S5660; discussion Si-iv
4. Rodrigu ez ED, St anw ix MG, Nam AJ, et al. Tw en t y-six-year experien ce t reat ing fron t al sin us fract ures: a n ovel algorith m based
on an atom ical fract ure pat tern an d failure of conven t ion al tech n iques. Plast Recon st r Surg 2008;122(6):18501866
5. Tedaldi M, Ram ieri V, Forest a E, et al. Exp erien ce in th e m an agem en t of fron t al sin u s fract u res. J Cran iofac Su rg 2010;21(1):
208210
6. Lau der A, Jalisi S, Spiegel J, et al. An t ibiot ic prophylaxis in th e
m an agem en t of com plex m idface and fron t al sin us t raum a.
Lar yngoscope 2010;120(10):19401945
7. Brat ton SL, Ch est n u t RM, Gh ajar J, et al. Gu idelin es for th e m an agem en t of severe t raum at ic brain injur y. XV. Steroids. J Neurot raum a 2007;24(Suppl 1):S9195
8. Rontal ML. State of the art in craniom axillofacial traum a: frontal
sin us. Curr Opin Otolaryngol Head Neck Surg 2008;16(4):381386

VI

Special Considerations in Pediatric


Emergency Neurosurgery

28

Special Considerations in the Surgical


Management of Pediatric Traumatic
Brain Injury
Anthony Figaji and P. David Adelson

Introduction
Ch ildren an d adults are physiologically di eren t . Even w ith in
th e pediat ric populat ion , th ere is a w ide range of physiological
n orm at ive valu es across th e age sp ect ru m . Th is is p erh aps m ost
relevan t in th e n eurosu rgical set t ing for th e m an agem en t of in t racran ial pressure (ICP) an d blood pressure. Path ophysiology
after t rau m at ic brain inju r y (TBI) is also di eren t in ch ild ren .
Di u se brain inju r y is m ore com m on . Focal inju r y an d ext raaxial h em atom as are less com m on . Th ere also are di eren ces in
th e pressurevolum e relat ion sh ips w ith in th e skull, m et abolic
resp on ses to inju r y, an d cerebral h em odyn am icsall of w h ich
h ave clin ical im p licat ion s for t reat m en t . Fu r th erm ore, th e tech n ical asp ect s of op erat ive m an agem en t in th e p ediat ric pop u lat ion w ith regard to an esth et ic con t rol, operat ive plan n ing,
an d t issu e h an dlingrequ ire sp ecial con siderat ion . Alth ough it
is beyon d th e scope of th is ch apter to cover all th e det ails of
ever y sp eci c em ergen cy op erat ion perform ed in ch ildren , key
p rin cip les com m on to th e m ost im por tan t of th ese procedures
are addressed .

Indications
Insertio n o f parenchym al m o nito rs (ICP, brain oxygen , m i-

458

crodialysis, etc.). It is th e auth ors pract ice to place (at m in im u m ) an ICP m on itor for all p at ien t s w h o requ ire ven t ilat ion
after TBI an d w h o h ave an abn orm al h ead com pu ted tom ograp hy (CT) scan . Invasive m on itoring m ay also be con sidered
for pat ien t s w ith di u se inju ries, as a n orm al CT does n ot preclude a pat ien t from poten t ially h aving in t racran ial hyperten sion . In t racran ial m on itoring also m ay be con sidered for
p at ien t s w ith oth er acute n eurologic path ologies th at result
in com a an d th at m ay be associated w ith brain sw elling an d
brain isch em ia. Open sut ures an d fon tan els in young ch ildren
sh ou ld n ot discou rage m on itoring, as th ese pat ien t s rem ain
at risk for in creased ICP.
Insertio n o f ventricular drainage cathete rs. Extern al ven t ricular drain (EVD) placem en t en ables accurate m onitoring
of ICP an d allow s for th erapeut ic drain age of cerebrospin al
u id (CSF) in th e set t ing of in creased ICP. Ap prop riate in dicat ion s for EVD placem en t in clude a n eed for ICP m on itoring
in pat ien t s w ith severe TBI (Glasgow Com a Scale [GCS] 8)

an d th e presen ce of hydrocep h alu s. W h ile th ere is Class III


eviden ce for u se of lu m bar d rain s w ith a con cu rren t EVD an d
open cistern s on CT, it h as n ot been th e pract ice of th e auth ors to use such devices because of con cern of h ern iat ion .
Operative treatm ent o f depressed skull fractures. Not all
closed, depressed fract ures require surger y. Min or depression s often w ill rem old over t im e, esp ecially in th e you ng
ch ild. In dicat ion s for operat ive repair in clude depressed fract ures associated w ith sign i can t m ass e ectw ith or w ith out subadjacen t h em atom a; com poun d, depressed fract ures;
an d fract u res in cosm et ically im p or t an t areas.
Cran io to m y/cran ie cto m y fo r extra- o r in tra-axial h e m ato m as. Th e in d icat ion s for evacu at ion of in t racran ial h em atom as con form largely to t h e corresp on ding pr in cip les in
ad u lt t rau m a. Hem atom as associated w it h sign i can t m ass
e ect are rem oved . Con t u sion s are m ost su it able for rem oval
ifin ad d it ion to d em on st rat in g m ass e ect t h ey are d iscrete an d close to t h e cor t ical su rface. Hem atom as of t h e
tem p oral lobe an d p osterior fossa p resen t t h e greatest r isk
for sign i can t m ass e ect .
Deco m pressive cranie cto m y. Th e in dicat ion s for decom p ressive cran iectom y are sim ilar to th ose in adult s. Th e exp ect at ion of clin ical ben e t from th e procedu re, h ow ever,
m ay be greater in ch ildren th an in adu lt s. Cran iectom y, if
con tem plated, sh ould be perform ed early rath er th an lateas
a secon d t ier th erapy in th e m an agem en t of in creased ICP refractor y to m edical t reat m en t .
Cranio plasty. Delayed cran ioplast y m ay be n ecessar y to rep lace th e bon e ap after decom pressive cran iectom y or to
address oth er t rau m a-related cran ial defects.
Re pair o f grow ing skull fractures. A grow ing sku ll fract u re,
or leptom en ingeal cyst , is a poten t ial com plicat ion of skull
fract u res in you ng ch ildren . Leptom en ingeal cysts u su ally
st art to develop w ith in a few m on th s of th e inju r y. Pu lsat ion
of th e brain again st an un recogn ized dural tearw ith in terp osit ion of t issue bet w een th e edges of th e fract u releads
to progressive w iden ing of th e fract ure an d in creasing size
of th e du ral defect . Th e diagn osis becom es clin ically eviden t
as a p rogressively en larging, p u lsat ile m ass in th e region of
th e previou s fract ure. Sur veillan ce is w arran ted for all young
ch ildren w ith skull fract ures. Clin ical follow -up at 24 w eeks
p ost-injur y, w ith or w ith ou t fur th er radiograph ic im aging, is
in dicated to assess for persisten t or in creasing sw elling in th e
region of th e fract u re. If a grow ing fract u re is diagn osed, it
requires op erat ive repair.

28

Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury

Preprocedure Considerations

X-ray
Plain sku ll radiograph s are obt ain ed on ly on rare occasion .

Radiographic Imaging
CT
CT scan s of th e h ead (6 cer vical spin e) sh ou ld be acquired

as soon as th e ch ild is h em odyn am ically stable. Abdom in al


or th oracic CT can be perform ed at th e sam e t im e for polyt raum a pat ien t s if th ere is a clin ical in d icat ion . Rou t in e u se of
body scan s is n ot advocated for several reason s, in cluding th e
in creased dose of radiat ion .
Op en su barach n oid cistern s on a h ead CT do n ot in dicate
n orm al ICP.
Part icu lar at ten t ion sh ou ld be p aid to th e p osterior fossa on
h ead CT. It is easy to m iss h em atom as h ere, an d th e con sequen ces m ay be severe, given th e relat ively com pact size an d
im p or tan t an atom ical con ten t of th e com par t m en t . Brain stem com pression an d hydrocep h alu s are com m on com p licat ion s. Such h em atom as are often associated w ith a fract u re in
th e occipital or suboccipital region an d m ay occur in conjun ct ion w ith a ven ous sin us injur y.
Th e low est axial cut s sh ould be review ed for eviden ce of an
ext ra-axial h em atom a ven t ral to th e low er brain stem . Hem atom a in th is locat ion m ay be a m arker for clival fract ure an d/
or a ligam en tous injur y at th e cran iocer vical jun ct ion .

Anesthetic Considerations in
Children
It is essen t ial th at th e an esth esiology team h ave both p ediat-

MRI
Magn et ic reson an ce im aging (MRI) of th e brain is rarely in -

dicated in th e set t ing of acu te t raum a, w ith th e except ion of


st u d ies perform ed to exclu de associated spin al or cran iocervical inju ries.
Su sp icion of SCIWORA (spin al cord injur y w ith ou t rad iograp h ic abn orm alit y) requires an MRI of th e spin e.

A n orm al skull radiograph does n ot exclu de an in t racran ial


injur y, an d a sku ll fract ure detected on radiograp hs does n ot
n ecessarily in dicate an associated in t racran ial h em atom a;
th erefore, sku ll radiograph s do n ot ch ange th e in dicat ion for
h ead CT. Plain radiograp h s m ay h ave a role in th e follow -u p
of fract ures in you ng ch ildren an d as part of th e bone su r vey
in th e set t ing su spected n on acciden t al inju r y.
Plain radiograph s of th e cer vical spin e are st ill used rout in ely
for severe TBI pat ien ts, w ith the addit ion of MRI if ligam en tou s
injur y or SCIWORA is suspected. Even in absence of suspected
SCIWORA th ough , it is recom m en ded to practice basic spin al
caut ion ar y m easures an d keep th e head in th e m idline posit ion for children w ho have a depressed level of con sciousness.
Preoperat ive im aging (Fig. 28.1a, b).

ric an d p olyt rau m a exp erien ce. Secon dar y in su lt s con t ribu te
su bstan t ially to w orse ou tcom e an d so sh ou ld be aggressively
avoided.
In adequ ate m an agem en t of th e resp irator y an d circu lator y
system s m ay lead to secon dar y in su lt s su ch as hyp oxia an d
hypoten sion . Brain sw elling m ay be exacerbated by hypo- or
hyperten sion , hypercarbia, an d in adequate pain con t rol.
Th e en dot rach eal t u be m ust be fasten ed securely, part icu larly if th e ch ilds h ead is to be t urn ed. Loss of th e air w ay is
of greater con sequen ce in ch ildren because th ey deteriorate
rap idly. Th e TBI pat ien t , in p art icu lar, h as a redu ced capacit y
to tolerate hypoxic in sults. Hypocarbia m ay exacerbate th e

Fig. 28.1a, b Axial CT (a) bone and (b) soft tissue windows demonstrating a bony defect with protrusion of meninges. This patient fell from a bed,
striking his head on the concrete oor, and presented approximately 8 months later with a tender, pulsatile postauricular mass.

459

VI Special Considerations in Pediatric Em ergency Neurosurgery

decreased cerebral blood ow often seen early after TBI, an d


hypercarbia m ay in crease cerebral blood volum e an d, con sequen tly, ICP.
In du ct ion of an esth esia m u st be sm ooth ; cough ing or bu cking m ay h ave fat al con sequ en ces in pat ien t s w h o already
h ave life-th reaten ing increased ICP.
Often , an esth esiologists are accu stom ed to m ain t ain ing p at ien t s at blood pressures in th e low er range of n orm al during elect ive su rger y. Th is pract ice m ay be h azardou s w h en
m an aging th e TBI ch ild at risk of early brain isch em ia. Also,
im p airm en t of p ressure autoregulat ion m ay resu lt in reduced
capacit y to accom m odate a blood pressure in th e low er range
of n orm al. Large bore in t raven ou s access allow s adequate
respon se to h em odyn am ic in st abilit y, especially w h en th ere
m ay be occu lt abdom in al or th oracic inju r y.
To estim ate w hat blood pressure is adequate, the anesthesiologist m ust have access to ch arts for n orm al m ean arterial pressure ranges for age (and, preferably, h eigh t and gender as w ell).
If a cran iotom y or cran iectom y is p lan n ed, en su re th at blood
is cross-m atch ed for possible t ran sfusion , especially in th e
ver y you ng. Th e circu lat ing blood volu m e of a ch ild is on ly
7085 m L/kg depen ding on age, so relat ively sm all volum es
of blood loss in th ese pat ien ts m ay rapidly lead to h em odyn am ic in st abilit y.
Placem en t of cen t ral ven ou s an d arterial lin es is recom m en ded for severe TBI p at ien ts, n ot on ly for adequ ate in t raop erat ive h em odyn am ic con t rol, but also to facilitate in ten sive care
u n it m an agem en t th ereafter.
If m an n itol is requ ired in t raop erat ively to assist th e redu ct ion of brain sw elling, th e an esth esiologist m ust en sure th at
th e pat ien t rem ain s euvolem ic th rough ou t an d th at th ere is
an adequ ate resp on se to th e m an n itol in fu sion by m on itoring
u rin e ou t put .
Do n ot u se hypoton ic or glu cose-con t ain ing u ids.

Operative Management
An exh aust ive descript ion of th e full range of em ergen cy procedures perform ed in pediat ric pat ien t s presen t ing w ith TBI
w ou ld exceed th e scop e of th is p u blicat ion . Th erefore, w e review som e basic prin ciples th at d ist ingu ish th e su rgical ap proach to pediat ric pat ien t s an d o er operat ive pearls relevan t
to speci c procedures. Fin ally, w e provide m ore detailed guid an ce regarding th e rep air of grow ing sku ll fract u resan en t it y
th at is un ique to th e pediat ric populat ion .

General Surgical Principles


Take care w h en incising skin overlying open fon t an els an d

su t u res.
Con t rol bleeding from th e scalp ap early w ith th e applicat ion of scalp clips. Con t in ued ooze during th e operat ion can
lead to sign i can t blood loss in young ch ildren . On ce th e
scalp ap h as been t u rn ed, rem em ber to ch eck in term it ten tly
th at th e ap rem ain s dr y th rough ou t th e operat ion .
Th e skin an d scalp of young ch ildren is th in n er th an in adult s.
Treat th e t issues gen tly an d do n ot cru sh th em bet w een
pick-ups. Avoid acute ben ds in th e re ected scalp ap as th is
m ay cu t o its blood su p p ly. Th is p oses a greater risk th an in
adu lt s becau se th e scalp ap is th in n er an d th e blood p ressu re is low er.
Th e du ra is often adh eren t w h ere cran ial su t ures are st ill
open . Use a dissector to separate th e dura from th e bon e carefu lly an d th orough ly ben eath su t u re lin es.

ICP and Other Parenchymal Brain


Monitors
ICP an d oth er invasive p robes (e.g., brain t issu e oxygen ) m ay

Operative Field Preparation


The child is positioned according to the t ype of procedure

460

planned. If the spine has not been cleared, pay careful attention
to protecting the cervical spin e w hile positioning for surgery.
An t ist aphylococcal an t ibiot ics are given rou t in ely at th e t im e
of skin in cision .
Th e h ead of th e operat ive t able is sligh tly elevated to prom ote
ven ou s ret u rn .
Blood pressure sh ould be w ell m ain tain ed th rough out surger y. At n o t im e sh ou ld th e blood p ressu re be allow ed to d rop .
If brain sw elling an d in creased ICP are su sp ected, a dose of
m an n itol can be given ju st after in du ct ion .
En sure th at th e plan n ed skin ap allow s adequate access for
th e path ology con cern ed. As a gen eral prin ciple of t raum a
su rger y, a w ider exp osu re is preferred .
Prepare th e skin w idely to allow for an in crease in th e exposu re sh ou ld th is becom e n ecessar y du ring th e operat ion .
Th e plan n ed skin in cision is in lt rated w ith 0.25%local an esth et ic an d epin eph rin e 1:400,000.
Drap e an d p osit ion th e pat ien t so th at th e an esth esiologist
h as adequ ate access to th e air w ay.
Th e surgeon sh ould h ave a clear view of th e an esth esiology
m on itors d u ring th e operat ion .

be in t roduced via single or double lum en bolt s or in serted


via a sm all bu r h ole an d t u n n elled to exit th e skin . Bolt system s can be u sed even in ver y young ch ildren ; m easure th e
th ickn ess of th e skull from th e h ead CT an d plan in ser t ion
accordingly.
Un less th ere is a com pelling reason to do oth er w ise, m on itors
are p laced in th e fron tal region on th e n on dom in an t side.
For probes th at require accurate placem en t in w h ite m at ter
(e.g., brain oxygen m on itors), m easurem en t s can be m ade
from th e h ead CT. In p ract ice, p lacem en t of th e probe t ip
2.5 cm ben eath th e cort ical surface is usu ally adequ ate.
Con siderat ion sh ould be given to th e locat ion of any invasive
probes (an d th e scalp in cision used) relat ive to th e possibilit y
th at th e ch ild m ay n eed furth er surger y.

External Ventricular Drains


Typically, an EVD is placed in a st an dard fron tal locat ion on

th e n on dom in an t side, th rough a precoron al bur h ole in th e


m idp u p illar y lin e.
Th e cath eter is passed w ith a t rajector y th at is angled tow ard
th e ipsilateral in n er can th us in th e coron al plan e an d just an terior to th e ipsilateral extern al auditor y m eat us in th e sagittal plan e.

28

Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury

Th e cath eter sh ould be passed slow ly, an t icipat ing th e t act ile

Epidural h em atom as overlying a ven ous sin us presen t a

feedback w h en th e ep en dym a of th e ven t ricle is p en et rated.


If th e ven t ricle is n ot en tered w ith th e rst p ass, a sligh tly
m ore m ed ial t rajector y m ay be at tem pted .
No m ore th an th ree p asses sh ou ld be at tem pted .
TBI-related brain sw elling in ch ildren m ay resu lt in com p ression of th e lateral ven t ricle; h ow ever, w ith experien ce,
th e ven t ricle st ill can be can n ulated in m ost cases. If n euron avigat ion is available, in t rodu ct ion of th e n avigat ion p robe
th rough th e lu m en of th e ven t ricu lar cath eter m ay assist
accu rate p lacem en t in di cu lt cases.
An t ibiot ic-im pregn ated cath eters an d periprocedural an t ibiot ics are opt ion s th at m ay reduce th e in ciden ce of
ven t ricu lostom y-related in fect ion s.

p ar t icu lar h azard in ch ildren due to th e poten t ial for rapid


blood loss in th e set t ing of an already sm all tot al blood volu m e. If th e h em atom a m ust be evacuated, prepare for blood
loss from th e sin us an d m on itor for possible air em boli. Plan
a skin an d bon e ap th at allow s for ad equ ate exp osu re an d
con t rol of th e sin us both proxim ally an d distally. If a sin us
tear is iden t i ed, th is m ust be con t rolled w ith im m ediate
p ressure over th e sin us to stem bleeding, sur veillan ce for
air em boli, an d repair of th e sin u s u sing a pericran ial patch
graft . If bleeding is too vigorou s to allow ad equ ate visu alizat ion , m ain t ain pressure over th e tear an d tem porarily con t rol
th e sin us proxim ally an d distally to en able sut uring of th e
p atch . Main t ain a paten t sin us to preven t add it ion al ven ou s
engorgem en t of th e brain .

Craniotomy
Th e skin in cision sh ould be plan n ed based on th e locat ion of

th e lesion .
Typically, for a un ilateral lesion , an ipsilateral quest ion m ark
or T-sh aped in cision is perform ed to en able w ide access to
th e h em isph ere.
In gen eral, aim for as large a ap as p ossible. Th e base of th e
skin ap sh ou ld be broad en ough to en su re adequ ate perfusion to th e skin .
W h en th e ap is t urn ed, w rap an d t u ck an an t ibiot ic-soaked
sw ab or cot ton sp onge ben eath th e ap to preven t th e creat ion of an acu te angle th at m igh t com p rom ise perfu sion
to th e ap. Th is m ay be a par t icular problem in ver y you ng
ch ildren . In term it ten tly m oisten th e sponge during th e
p roced ure.
Dissect th e ap in a su bgaleal p lan e to p rep are a free bon e
ap. Preser ve th e p ericran iu m as th is can be u sed later for a
dural graft if n eeded.
Th e exten t of th e bony open ing is plan n ed according to th e
u n derlying lesion . If th ere is gen eralized sw elling, th e bon e
sh ou ld be rem oved dow n to th e tem p oral base to m axim ize
th e space ach ieved at th e level of th e ten torial hiat us.
If du ral op en ing is n ecessar y to evacu ate a h em atom a, a cru ciate in cision is perform ed over th e h em isph ere. Any su bdural h em atom a th en m ay be evacu ated.
If evacu at ion of a con t u sion is p lan n ed, carefu l preoperat ive plan n ing or n euron avigat ion is required to opt im ize th e
locat ion of th e cort icectom y. Often a subdu ral h em atom a is
associated w ith a bu rst lobe in w h ich th e con t u sion can
be iden t i ed at th e surface. A discrete h em atom a can be
evacu ated aggressively. A con t u sion m ixed w ith brain t issu e
sh ou ld be h an dled w ith greater cau t ion , d ep en ding on several factors, in clu ding th e eloqu en ce of th e involved brain an d
th e degree of brain sw elling. Th e con ser vat ive approach of
allow ing th e con t u sion /h em atom a to decom p ress it self m ay
be all th at is required.
If th e brain is sw ollen , th e du ra sh ou ld be exp an ded w ith a
dural graft h ar vested from local pericran ium . Use n on absorb able su t u res an d close th e du ra in a w atert igh t fash ion .
Th e decision of w h eth er to replace th e bon e ap depen ds on
th e preoperat ive im aging, in t raoperat ive n dings, an d an t icip ated postop erat ive risk for ongoing in creased ICP. If th e bon e
ap is left ou t , it sh ou ld be m an aged as below for decom pressive cran iectom y.

Surgery for Depressed Fractures


Th e prin ciples of depressed fract ure m an agem en t in ch ildren

are sim ilar to th ose of ad u lt s, w ith a few except ion s.


If th e depressed fract u re is closed, th e skin in cision is p lan n ed
based on th e locat ion of th e depressed fragm en t , blood sup p ly to th e ap, an d cosm esis. If th e fract ure is com pou n d,
th e w oun d m ust be debrided an d exten ded in a cu r vilin ear,
S-sh ap e to exp ose th e exten t of th e fract u re.
Bon e is m u ch th in n er an d softer in ch ildren . Often a pingp ong t ype fract ure can be elevated by drilling a bu r h ole to
th e side of th e fract ure an d by posit ion ing a sligh tly angled
in st rum en t (e.g., a n o. 3 Pen eld or sm all periosteal elevator)
th rough th e bur h ole, elevat ing th e fract ure from in side.
If th e du ra is torn , a bu r h ole sh ou ld be placed at th e m argin
of th e depressed fract ureover in t act dura. Th en th e cran iectom y, or cran iotom y, can be perform ed to u n cover th e area
of dural violat ion . Th e dural tear is sut ured, an d bon e fragm en t s, if clean , m ay be laid over th e defect .
Bony defect s in ch ild ren u su ally h eal ver y w ell w ith n ew
bon e grow th , as long as th e du ra is in t act . Larger lesion s m ay
require later cran ioplast y if adequate rem odeling does n ot
occur an d th e resu lt is a sign i can t cosm et ic an d/or fun ct ion al defect . Th e u se of autologous bon e is opt im al. Th e
best bon e is split calvarial bon e, preferably t aken from th e
correspon ding locat ion on th e opposite side. Th e h ar vested
bon e can be split th rough th e diploic space, creat ing t w o
p ieces: on e for th e defect an d th e oth er to be rep laced at th e
d on or site. In you ng ch ildren , th is m ay n ot be possible. Rib
graft or cran ioplast ic m aterialresorbable or n on resorbable,
p refabricated or n ot (i.e., m ethylm eth acr ylate)m ay also
be con sidered.
Du ral d efects m u st alw ays be rep aired to avoid th e p oten t ial
com plicat ion s of a CSF leak an d/or a grow ing skull fract ure.
Devit alized skin m u st be d ebr id ed an d t h e w ou n d t h orough ly ir r igated . If t h e skin can n ot be closed p rim ar ily, t h e h elp
of a p last ic su rgeon m ay be valu able to p lan a rot ated skin
ap .

Decompressive Craniectomy
Several di eren t ap p roach es h ave been d escribed for decom p ressive cran iectom y (DC). Th e follow ing re ects a com bin at ion of gen eral prin ciples an d person al pract ice.

461

VI Special Considerations in Pediatric Em ergency Neurosurgery


Th e m ost im port an t surgical prin ciples of DC are: select a

462

u n ilateral or bilateral app roach as approp riate, m ake th e cran iectom y as large as possible, an d con t rol th e brain sw elling
before open ing th e dura.
Th e ch oice of a bifron t al or h em icran iectom y depen ds both
on person al preferen ce an d th e n at ure of th e injur y. Predom in an tly un ilateral h em isph eric injur y m ay be bet ter
su ited to h em icran iectom y, w h ereas di u se inju r y or fron tal con t usion s m ay be bet ter suited to bifron t al cran iectom y.
Th ough th e speci cs of each tech n ique di er, th e prin ciples
of decom pression are th e sam e.
Du rap last y in creases th e com p licat ion s associated w ith cran iectom y; h ow ever, open ing an d expan ding th e dura leads
to su bst an t ially low er ICP, an d com p licat ion s are gen erally
avoidable if don e correctly.
Th e h em icran iectom y is perform ed sim ilar to th e h em isph eric
cran iotom y. Maxim izing th e bony open ing h elps m in im ize
th e degree to w h ich th e sw ollen brain push es again st th e
bony lim it s. Pressure at th e bony edges m ay fu rther injure
th e sw ollen brain an d con st rict ven ou s out ow of th at segm en t . Th e tem poral bon e is rem oved as low as possible d ow n
to th e base to m axim ize th e decom pression at th e level of th e
ten torial in cisura. Th e du ra is open ed an d expan ded w ith a
large pericran ial graft , th e edges of w h ich can be sut ured so
th at th ey lie w ith in th e dural edge, to m in im ize th e risk of th e
sh arp du ral edge cu t t ing in to th e sw ollen brain .
Th e bifron tal cran iectom y is perform ed th rough a bicoron al
skin in cision , posit ion ed beh in d th e h airlin e. Th e scalp is
re ected an teriorly, preser ving th e pericran ium for a dural
graft . Keyh ole an d p aram edian bu r h oles lateral to th e sagittal sin us are used to create a large bifron tal, single-piece bon e
ap exten ding posteriorly to th e coron al su t u re. Pay part icu lar at ten t ion w h en separat ing th e dura from th e bon e, esp ecially over th e m idlin e, to avoid injur y to th e sagit t al sinu s
an d it s bridging vein s. Th e du ra is in cised in a U-sh ap e from
lateral to m edial. Th e m idlin e sagit tal sin us is t ied o at th e
fron t al base an d th e falx is sect ion ed from an terior to p osterior along th e skull base to allow for m a xim al expan sion

of th e brain . W h en doing th is, t ake care to preser ve cort ical


vein s, esp ecially bridging vein s leading to th e sagit tal sin u s.
Th e h ar vested pericran ial graft is used to expan d th e dura.
Regardless of approach , it is of ut m ost im port an ce th at th e
dura n ot be open ed abruptly if ten se to th e tou ch . Oth er w ise,
m assive brain sw elling m ay p rodu ce rap id , u n con t rolled h ern iat ion of th e brain th rough th e du ral op en ing w ith resu lt an t
com pression of super cial drain ing vein s an d progressive en gorgem en t of th e en t rapp ed brain . Alth ough , by de n it ion ,
th e pat ien t is in surger y for refractor y in t racran ial hyper ten sion , it is n early alw ays p ossible to con t rol th e sw elling for th e
sh ort period of t im e it t akes to open th e du ra an d secu re th e
graft in p lace. Th e su rgeon m u st w ork w ith th e an esth esiologist to m axim ize brain relaxat ion by th e t im e of du ral op en ing. Poten t ial in ter ven t ion s in clude con t rolling blood pressu re, adm in istering m an n itol an d/or hyp erton ic salin e at th e
t im e of skin in cision , elevat ing th e h ead of th e bed, an d low ering th e ar terial CO2 (w h ile in creasing th e FiO2 ). Th e pericran ial graft m u st be p rep ared p rior to th e du ral open ing. W h en
pressu re m an agem en t h as been opt im ized, th e du ra sh ould
be open ed quickly an d th e graft in corporated w ith sut ure.

Repair of Grow ing Skull Fractures (Leptomeningeal Cyst)


Th ough n ot requiring em ergen t in ter ven t ion , grow ing skull

fract u res do rep resen t a late con sequ en ce of t rau m a an d, as


su ch , deser ve m en t ion h ere.
Opt im al t reat m en t of a grow ing sku ll fract u re requ ires u n derst an ding of th e path ology (see In dicat ion s).
Th e du ra is alw ays torn ; th is tear w iden s w ith t im e as th e
bon e edges separate. Usually th e dural edges ret ract w ell beyon d th e bon e edge so th at th e du ral defect is larger th an th e
bony defect .
Th e a ected pat ien t s are young, so th ere m ust be adequ ate
preparat ion for blood loss. Do n ot un derest im ate th e poten t ial for blood loss in th ese operat ion s.

28

Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury

Operative Procedure
Repair of Grow ing Skull Fractures
Positioning (Fig. 28.2)

Figure

Procedural Steps

Fig. 28.2

Positioning w ill be dictated by the anticipated need for anatomic access.

463

VI Special Considerations in Pediatric Em ergency Neurosurgery

Incision (Fig. 28.3)

464

Figure

Procedural Steps

Pearls

Fig. 28.3

A curvilinear, S-shaped, or U-shaped incision is made


to access the cranial defect.

The extent of necessary exposure is planned from the CT


head ndings and palpation of the edges of the defect.

28

Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury

Subcutaneous Dissection (Fig. 28.4a, b)

Figure

Procedural Steps

Fig. 28.4

(a) Subgaleal dissection of the scalp ap is used to expose the full extent
of the defect. (b) The periosteum is incised, follow ing the edges of the
cranial defect. The periosteum is re ected inw ard, tow ard the defect.
Using a sharp periosteal dissector, the periosteumdura junction is freed
circumferentially from the edges of the bone margin.

465

VI Special Considerations in Pediatric Em ergency Neurosurgery

Craniotomy (Fig. 28.5a, b)

Figure

Procedural Steps

Pearls

Fig. 28.5

(a) Several bur holes are placed at the periphery of the bony
defect, overlying normal dura. The exact position of the bur
holes in relation to the defect depends on the anticipated dural
retraction beneath the bone edges. Typically, larger lesions
are associated w ith greater retraction of the dura beneath the
bone edges. Preserve the periosteum overlying the bone to use
as a dural graft.

The m argin should be several centim eters

(b) A dissector is introduced through each bur hole and used to


separate the dura from the overlying bone. A craniotome then
is used to connect the bur holes, creating a ring bone ap
(including the defect) that, in turn, is elevated aw ay from the
underlying dura.

466

from the edge of the bony defect or


approxim ately 50% of the width of the defect,
to create a bone ap that can be used to cover
the defect.
Prior MRI m ay give the surgeon an
approxim ation of this distance; however, often
it is the surgeons judgm ent based on the size
of the defect.
The dural edges are adherent to the
underlying gliotic brain and m ust be separated
from it circum ferentially.

28

Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury

Closure of the Dural Defect (Fig. 28.6)

Figure

Procedural Steps

Fig. 28.6

A periosteal graft from normal bone is harvested to close the dural


defect. The graft is incorporated circumferentially w ith 4-0 braided
nylon stitches.

Pearls

467

VI Special Considerations in Pediatric Em ergency Neurosurgery

Repair of the Bony Defect (Fig. 28.7a, b)

468

Figure

Procedural Steps

Pearls

Fig. 28.7

(a) The harvested bone ap can be divided into tw o halves. If possible, each
half then can be split w ith an osteotome (though the diploic space) into
inner and outer tables, yielding a total of four pieces that may be used to
cover the defect. (b) The bone graft is secured to the surrounding bone
using resorbable or permanent mini plates. If the bone can be secured w ith
sutures, this is preferable. Alternatively, mini plates are used.

If the dural defect has been closed


adequately, any residual bony
defect will usually close over tim e.

28

Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury

Closing
If th e bon e is replaced, it is secu red w ith absorbable or n on -

absorbable p lates an d screw s. Th e size of th e screw s sh ou ld


be m atched to th e th ickn ess of th e bon e. Long screw s risk
p erforat ion of th e d ura. On th e oth er h an d, screw s m u st be of
a su cien t length to ach ieve adequ ate bony pu rch ase.
If th e bon e is left ou t , it sh ou ld be h an dled an d p rocessed for
freezing in accordan ce w ith th e in st it u t ions bon e ban k protocol. Altern at ively, th e bon e can be placed in a subcut an eous
abdom in al pocket . Th e follow ing caveats ap ply: com orbid ab dom in al t raum a m ay preclude access to th is site; it m ay be
di cult to create an adequate pocket in a you ng ch ild; an d, if
a bifron t al ap h as been elevated, it m ay be n ecessar y to sp lit
th e bon e dow n th e m idlin e an d superim pose th e h alves to
create th e opt im al con tour th at w ill t in th e pocket .
Th e skin is closed w ith a 4-0 m on o lam en t sut ure or st aples.

Postoperative Management
Monitoring

Further Management
Con cern s about ongoing injur y to th e unprotected brain h ave

Invasive ICP m on itoring is u su ally rou t in e in ch ildren w ith

severe TBI. Ben ign h ead CT feat u res do n ot exclu de in creased


ICP or th e risk th at ICP w ill in crease in th e su bsequ en t days.
ICP m on itoring is st an dard at th e au th ors in st it u t ion for any
ch ild requiring ongoing ven t ilat ion , w ith out im m ediate plan s
for ext u bat ion , after TBI.
Th e m on itoring of brain t issue oxygen an d oth er m easures
of cerebral h em odyn am ics or m et abolism is less w ell est ab lish ed in ch ildren th an in adult s, but is in creasingly com m on
in clin ical p ract ice an d research .
Typically, ICP is m ore fragile, or brit tle, in ch ildren th an in
adu lt s. Becau se th ese obser ved dyn am ic ch anges are largely
h em odyn am ic in n at u re, invasive m on itoring of blood p ressu re an d volu m e st at u s m ay allow for bet ter ch aracterizat ion of th e path ophysiology in in dividual pat ien t s, an d, in so
doing, perm it m ore targeted t reat m en t of elevat ion s in ICP.

w as p erform ed ver y early after t rau m a (e.g., w ith in th e rst


2 h ou rs), repeat im aging m ay be in dicated to detect h em atom as th at w ere n ot dem on st rated in it ially. W h en th ere is a
h em atom a on th e in it ial scan th at is t reated n on op erat ively,
rep eat im aging m ay be n ecessar y to en su re th at th e h em atom a h as n ot en larged. For lesion s w ith m ass e ect in th e
p osterior fossa, repeat im aging m ay be requ ired to exclu de
th e developm en t of hydroceph alu s. Also, if th e pat ien t is
m an aged w ith ou t in t racran ial m on itoring, th ere is a low er
th resh old for repeat ing im aging.
A planned follow -up head CT m ay be considered to look for optim al position of intracranial m onitors, evolution of hem atom as/
contusions, and brain swelling. At our institution, this is done
2448 hours after adm ission, depending on stabilit y of the intracranial variables and nature of the initial scan. Decisions are individualized; however, in general, earlier scans are indicated w hen
there is greater concern about the initial im aging ndings and
w hen there are signi cant perturbations in ICP or brain oxygen.
Postoperat ive im aging (Fig. 28.8).

driven th e t ren d tow ard early replacem en t of bon e aps after cran iectom y. Reim plan t at ion m ay be appropriate w ith in
4 w eeks of th e in it ial surger y, provided th e brain sw elling h as
su bsided, th e w ou n d is h ealed, an d th e p at ien t is free of in fect ion . How ever, th e t im ing of reim p lan t at ion sh ou ld n ot be
accelerated if con dit ion s are su bopt im al, as bon e ap sep sis
can create subst an t ial problem s.
Th e bon e m ust n ot be au toclaved. It is rem oved from sealed
bags an d allow ed to soak in a diluted solut ion of betadin e at
th e st ar t of surger y.
Th e pat ien ts bon e is alw ays preferred to ar t i cial subst it utes,
n ot on ly becau se of th e bet ter t bu t also becau se ad dit ion al
grow th of th e sku ll is exp ected in you nger ch ildren .
Ver y you ng ch ildren m ay be at in creased risk for bon e ap
resorpt ion problem s.

Wound Management
Su bgaleal drain s m ay be u sed in th e im m ediate postoperat ive

p eriod but sh ould be rem oved w ith in 12 h ou rs, if possible, or


w h en th e drain age is below 25 m L per 1224 h ours.
Com pression , cot ton w rap t ype dressings used for w oun d
h em ost asis p ostop erat ively m ay requ ire loosen ing or cu t t ing.

Radiographic Imaging
As a gen eral prin ciple, th e frequen cy of CT im aging of ch il-

dren sh ould be lim ited because of th e long-term risk of radiat ion . Un n ecessar y follow -up im aging also exposes th e ch ild
w ith severe injur y to poten t ial secon dar y in sult s associated
w ith t ran spor t out of th e in ten sive care un it environ m en t .
How ever, if in dicated, ap p rop riate im aging m ay be lifesaving. Th ere sh ou ld alw ays be a clear in dicat ion for rep eat
im aging, su ch as clin ical deteriorat ion . W h en th e in it ial scan

Fig. 28.8 Axial CT im age demonstrating repair of the dural tear and
bony defect.

469

29

Special Considerations in Pediatric


Cervical Spine Injury
Paul Klim o Jr., Nelson Ast ur Neto, W illiam C. W arner Jr., and Michael S. Muhlbauer

Introduction
Sp in e t rau m a in th e p ediat ric pop u lat ion is a relat ively u n com m on occu rren ce (12% of all p ediat ric fract u res 1 ), but h as been
obser ved m ore frequen tly w ith im provem en t s in em ergen cy
care, t ran spor t ser vices, an d t raum a life support .2 Ch ildren differ from th eir adu lt cou n terp ar t s w ith regard to spin e an atom y,
p hysiology, an d body propor t ion s:
Ligam en ts an d join ts can st retch an d expan d con siderably
w ith out tearing
Facet join t s are sh allow an d h orizon t ally orien ted
Vertebral bodies are w edged an teriorly
Un cin ate processes, w h ich lim it rotat ion , do n ot form u nt il
age 10
Disp rop or t ion ately larger h ead in conju n ct ion w ith w eaker
an d in com p letely d evelop ed m u scu lar an d ligam en tou s su p p or t ing st ru ct ures
Th ese u n ique di eren ces resu lt in a spin e th at is m ore m alleable th an th at of an adult . Pediat ric cer vical spin al injuries
follow a p redict able pat tern related to th e ch ilds age. Sp in al in ju ries in ch ildren younger th an 810 years of age are m ore likely
to involve th e upper cer vical spin e, from th e occiput to th e th ird
cer vical ver tebra. Most injuries in th is age group are ligam en tous axis-atlan to-occipit al dislocat ion s or spin al cord injuries
w ith ou t radiograph ic abn orm alit y (SCIWORA). Ch ildren older
th an 810 years of age are m ore vuln erable to cer vical spin e
inju ries involving th e low er segm en t s (C3C7); th e pat tern of
inju r y in th is group is sim ilar to th e adu lt popu lat ion .3,4
Sp in al cord inju r y (SCI) is a rare occu rren ce in th e pediat ric
p op u lat ion an d accou n t s for less th an 4% of th e tot al an n u al
in ciden ce of SCI (Nat ion al Spin al Cord Inju r y St at ist ical Cen ter,
2004). Neurologic recover y in ch ildren w ith SCI ten ds to be bet ter th an in adult s.5 SCI occurring before th e adolescen t grow th
sp u rt is a great risk factor for th e developm en t of p ost t rau m at ic
scoliosis.5

Indications
Pediat ric cer vical spin e inju ries can be divided in to inju ries th at
a ect th e u p p er cer vical sp in e (occip u tC2) an d th ose th at affect th e su baxial sp in e (C3C7). Below is a list of th e inju ries
th at are m ore com m on ly en coun tered in children . As st ated
p reviou sly, older ch ildren w ill h ave a physiologically developed
adu lt spin e, an d th u s, th e sp in e inju ries are sim ilar to th ose
seen in adu lt s. Th ere is a m yriad of congen it al cer vical an om alies th at m ay cause or place a ch ild at risk for spin al cord inju r y.

470

A det ailed review of th ese en t it ies is beyon d th e scope of th is


ch apter.
Upper cer vica l spin e in ju r ies
Atlan to-occipit al dislocat ion (AOD)
Atlan toaxial dislocat ion (AAD)
Atlan toaxial rot ator y su blu xat ion (AARS)
Tran slat ion al atlan toaxial su blu xat ion (TAAS)
Od on toid fract u res, in clu ding syn ch on drosis fract u res
Trau m at ic spon dylolisth esis of th e axis (i.e., h angm ans
fract u re)
Pu re ligam en tous/soft t issue injur y (previously kn ow n as
SCIWORA)
Com bin at ion of th e above path ologies
Low er cer vica l spin e in ju r ies
Pu re ligam en tous/soft t issue injur y (previously kn ow n as
SCIWORA)
Osseous anterior and/or posterior colum n injuries (e.g., com pression and burst fractures, lam inar/pedicle/facet fractures)
Sp in al cord disru pt ion
Biom ech an ical in stabilit y resu lt ing from any of th e above inju ries m ay p rovide an in dicat ion for op erat ive in ter ven t ion .
The appropriate surgical approach is dictated by th e speci c
injur y:
Occipit ocer vica l a r t h r odesis
Atlan to-occipit al dislocat ion s, atlas fract u res, congen ital
occipitocer vical an om alies
At la n t oa xia l a r t h r odesis
Atlas fract ures, odon toid fract ures, t raum at ic C1C2 ligam en tou s disrupt ion s, an d congen ital atlan toaxial in stabilit y
Su ba xia l cer vica l post er ior a r t h r odesis
Posterior ligam en tous disrupt ion , un ilateral an d bilateral
facet dislocat ion s, bu rst fract u res, an d sp on dylolisth esis
An t er ior cer vica l a ppr oa ch
An an terior approach is rarely in dicated (except possibly
for decom p ression of a bu rst fract u re) before th e age of 12.
Th ereafter, children assum e a m ore adult spin e and becom e m ore suscept ible to adult-t ype inju ries.

Preoperative Considerations
Field and Emergency Room
Management
Field m an agem en t follow s th e basic prin ciples of th e Advan ced
Trau m a Life Suppor t (ATLS). Air w ay, breath ing, an d circu lat ion (ABCs) m ust be addressed. Because of a relat ively larger

29

Special Considerations in Pediatric Cervical Spine Injury

Fig. 29.1a, b Pediatric backboard. Given a relatively larger head size, (a) use of a recessed head backboard or (b) elevation of the trunk by
approxim ately 25 mm should be considered to maintain neutral alignment.

h ead size, th e cer vical sp in e w ill be exed w h en th e ch ild is


p laced sup in e on a st an dard h orizon t al backboard.6 A recessed
h ead backboard, or elevat ion of th e t ru n k by ap proxim ately
25 m m , m ust be con sidered prim arily in ch ildren aged less
th an 8 years of age w ith suspected n eck injur y (Fig. 29.1a, b).6,7
On ce th e ch ild arrives in th e em ergen cy room , th e ABCs m u st
be repeated, and disabilit y an d exposure sh ou ld be added. In
p at ien ts presen t ing w ith hypoten sion in th e presen ce of bradycardia, n eu rogen ic sh ock m u st be di eren t iated from hypovolem ic sh ock. If a sp in al cord inju r y is p resen t , m an agem en t
sh ou ld p roceed w ith vasop ressors an d m od est u id resu scitat ion . Neurologic im pairm en t sh ould focus th e em ergen cy team
on a possible h ead or spin e injur y or both .

Radiographic Imaging
After a careful n eurologic evaluat ion , cer vical spin al im aging
sh ou ld be obt ain ed . Plain radiograph s, com p u ted tom ograp hy
(CT), an d m agn et ic reson an ce im aging (MRI) m ay be con sidered. On ce a sp in e inju r y is detected, clearan ce an d im aging of
all sp in e segm en ts sh ou ld be u n dert aken , con sidering a sign i can t prevalen ce of n on con t igu ous fract u res.4,8
Som e varian t s of th e n orm al an atom y or congen ital an om alies
m ay be m isin terp reted as t rau m at ic inju r y.9,10 An an terolisth esis of C2C3 is a ver y com m on n ding an d cou ld be m isdiagn osed as a ligam en tou s inju r y w h en , m ost of th e t im e, it is a
p hysiologic pseu dosublu xat ion cau sed by th e hyper exibilit y of th e im m at ure cer vical spin e. A syn ch on drosis bet w een
th e odon toid an d th e body of C2w h ich m ay persist un t il a
ch ild is 12 years of agem ay be m isin terpreted as an odon toid

fract u re. Fu rth erm ore, a persisten t n eu rocen t ral syn ch on drosis
of C2 can be m isdiagn osed as a h angm ans fract ure. Th e atlan toden tal in ter val (ADI) in th e ch ild spin e is greater th an in th e
adu lt , bu t sh ou ld n ot exceed 5 m m ; th is lim it is becau se of th e
th icker ch ild cart ilage th at does n ot appear in radiograph s. Any
p ersist ing doubt w ith st an dard radiograph s sh ould be furth er
evalu ated w ith CT an d MR.
Preoperat ive im aging (Fig. 29.2a c).

Medication
Steroid adm inistration in the set ting of a spinal cord injury is still
controversial and should be based on the institutional protocol.
A recent system atic review of the literature found no evidence
supporting the use of neuroprotective interventions for the treatm ent of spinal cord injury in children, including hypotherm ia and
steroids.7 Furtherm ore, all studies that have evaluated steroids in
spinal cord injury have speci cally targeted the adult population.

Surgical Timing
Th e opt im al t im ing for surgical decom pression an d xat ion is
also con t roversial. A recen t system at ic review st ates th at early
su rgical d ecom p ression (i.e., in less th an 72 h ou rs) m ay im p rove
n eu rologic ou tcom esespecially in th e set t ing of in com plete
SCI an d w h en p erform ed in less th an 24 h ou rs.11 W h ile th is
review suggest s early decom pression m ay ben e t th e gen eral
SCI p opu lat ion , n eu rologic recover y seem s to be bet ter in th e
pediat ric popu lat ion th an in adults.

471

VI Special Considerations in Pediatric Em ergency Neurosurgery

Fig. 29.2ac (a) Lateral radiograph and (b) sagit tal and (c) coronal CT
reconstructions demonstrating an atlanto-occipital dislocation. Note
the widened intervals bet ween C0C1 and C1C2.

Operative Management
Su ccessfu l in t raop erat ive m an agem en t of th e ch ild w ith a cervical spin e inju r y dep en d s on a team ap p roach w ith th e sp in al
su rgeon , pediat ric t rau m a su rgeon , an esth esiologist , an d su rgical an d radiology tech n ician s.

Anesthesia
In cervical spin e injuries w ith gross in stabilit y, the neck m ust be
m ain tained in a n eutral position throughout the procedure; in tubation m ay be challenging. In-line beroptic intubation should
be considered, followed by induction of general anesthesia. Care
to prevent both sublu xation an d distraction is im perative w h en
intubating, turning, or transferring. Preoperatively, antibiotics
are adm in istered at least 30 m inutes before the procedure; the
authors prefer van com ycin an d cefazolin. If neurom onitoring
(e.g., m otor-evoked potentials [MEPs] and som atosensory-evoked
potentials [SSEPs]) is used, the anesthesia team should be alert

472

that alterations in anesthetic depth can a ect the abilit y to ob tain useful signals; the use of bispectral index (BIS) m onitoring
can m inim ize this e ect. It is im perative that the anesthesiologist
avoid hypotension and hypovolem ia during surgery.

Positioning
Anterior Cervical Approach

Su pin e p osit ion


Pad or tow el roll bet w een scap u las for sligh t n eck exten sion
St abilize h ead w ith a ch in or foreh ead st rap
Neck in n eu t ral p osit ion or rot ated to con t ralateral su rgical
ap p roach site
Pull both arm s togeth er caudally an d t ape th em on th e sh oulders for bet ter uoroscopic view of th e cer vical spin e
Use in t raoperat ive u oroscopy to m ark th e correct level on
th e skin
Som e su rgeon s advocate a left-sided ap proach becau se of
th e low er rates of recurren t lar yngeal n er ve inju ries 12

29
Longit u din al in cision p rovides a greater exp osu re (u su ally

w h en th ree or m ore levels are exposed) w h ereas a t ran sverse in cision h eals w ith bet ter cosm esis
Care m ust be taken not to dist ract the injured spine w ith either
m anipulat ion or inadvertent elevat ion of the head of bed w hen
the pat ient is in Mayf eld f xat ion.

Posterior Cervical Approach


Pron e posit ion
Use chest rolls (or a spine table for older children) and a three

pinion skull clam p or Gardner-Wells tongs in neutral position


St rap arm s dow n at th e p at ien ts side
Sligh t reverse Tren delen bu rg p osit ion ing allow s for bet ter exp osu re, if th e pat ien t does not d ist ract
Pad all bony prom inences and apply tight straps over the patient
Th e crit ical period during w h ich th e spin e is at greatest risk is
th e t ran sfer to pron e posit ion ; a t igh tly applied rigid collar or
h alo m ay be u sed to redu ce th is risk.

Special Considerations in Pediatric Cervical Spine Injury

Occipitocervical Arthrodesis
Indications
Atlan to-occipit al dislocat ion s, atlas fract u res, congen it al occip itocer vical an om alies.

Atlantoaxial Arthrodesis
Indications
Atlas fract u res, odon toid fract u re, t rau m at ic C1- C2 ligam en tou s
disru pt ion s, an d congen it al atlan toaxial in st abilit y.

Subaxial Cervical Posterior Arthrodesis


Indications
Posterior ligam en tous disrupt ion , un ilateral an d bilateral facet
dislocat ion s, burst fract ures, an d spon dylolisth esis.

473

VI Special Considerations in Pediatric Em ergency Neurosurgery

Operative Procedure
Occipitocervical Arthrodesis w ith Contoured Rod and Segmental Wire
Positioning and Preparation (Fig. 29.3)

Figure

Procedural Steps

Pearls

Fig. 29.3

Position the patient prone on a spine table,


w ith the head xed to the table in a neutral
position using either three -pinion head holder
xation or Gardner-Wells tongs. Alternately,
a standard operating tablew ith chest rolls
oriented transversely across the chest and
hipsmay be used.

Do not use traction in AOD cases, especially when ipping

474

the patient and in this nal position. When in slight reverse


Trendelenburg, use a bolster at the feet to prevent the body from
sliding down. As the head is elevated, use uoroscopy to check
alignm ent.
Con rm proper neutral positioning of the occiput over the atlas
with uoroscopy. If fused in hyper exion, the child m ay have
di cult y swallowing; if fused in excessive lordosis, the child m ay
have di cult y am bulating because he cannot see his feet, and
lower levels may have to be in continual kyphosis to compensate.
Fusion in neutral or slight exion m ay o set the possibilit y of
continued anterior growth causing hyperlordosis if a posterior
fusion is perform ed in a young child.
The surgical elds are prepared and draped to include the posterior
inferior one-third of the skull and all the posterior part of the neck.
Include preparation of the bone graft harvest site at the region of
the posterior iliac crest.

29

Special Considerations in Pediatric Cervical Spine Injury

Skin Incision (Fig. 29.4)

Figure

Procedural Steps

Pearls

Fig. 29.4

Make a posterior midline, longitudinal skin


incision from the base of the occiput to the
most caudal spinous process desired for the
cervical fusion.

Use lateral uoroscopy for cervical spine level con rm ation.


For a short occipitocervical fusion (occiputC1 or C2) stop the

incision at C3 level.
Do not expose m ore than needed because there is a high rate of
fusion in the child spine just by exposing the posterior elements.

475

VI Special Considerations in Pediatric Em ergency Neurosurgery

Subcutaneous Dissection (Fig. 29.5)

Figure

Procedural Steps

Pearls

Fig. 29.5

Extend the dissection deep w ithin the


relatively avascular intermuscular septum
(aka ligamentum nuchae). The suboccipital
regionas w ell as the entire posterior
arch of C1, C2, and other desired levelsis
exposed subperiosteally.

Cerebrospinal uid leak is not an unusual nding while dissecting. It is

476

very di cult to repair the dural tear prim arily. Use gelatin sponge or
onlay dural graft substitutes. Lam inectomy is not recomm ended for
repair.
While dissecting bet ween C1 and C2 laterally, there is often a robust
perivertebral artery venous plexus. Bleeding from this plexus may be
brisk but easily controlled with gelatin sponge.
Exercise caution while exposing the C1 posterior arch: do not to expose
m ore than 12 m m to 20 mm laterally, depending on age and anatomy,
to reduce the risk of vertebral artery injury. (Always stay on bone!) In
young children, there m ay be a brous union in the m idline of the arch,
which can be easily breached with monopolar electrocautery.

29

Special Considerations in Pediatric Cervical Spine Injury

Fixation Points and Rod and Wire Preparation (Fig. 29.6a, b)

Figure

Procedural Steps

Pearls

Fig. 29.6

(a, b) A template of the intended shape and size of the


rod is made w ith a Luque w ire. Tw o bur holes are made
on each side of the occiput: 2 cm lateral to the midline
and 2.5 cm above the foramen magnum. An additional
pair of bur holes also may be placed above and lateral
to the foramen magnum. Titanium cables are passed in
an extradural plane from each bur hole to the adjacent
bur hole or to the foramen magnum. Sublaminar cables
are passed around C1 and C2. Thus, for an occiput to C2
fusion, there are a total of six cables (three on each side).
The rod is contoured to match the template, creating a
U-shape that w ill t the occipitocervical region.

Som e children m ay have a low-lying tentorium, which

would put their sinovenous structures lower than


norm al. The suboccipital dura is often quite thin and
can be easily torn when m aking the bur holes.
A m inim um of 1 cm of cortical bone should be left
intact bet ween the holes for good xation.
A bending instrum ent m ay be helpful in bending the
rod.13
Usually a 135-degree headneck angle and a slight
cervical lordotic bend will t the rod to the surgical
site.

These six cables w ill secure and tighten the rod w ith
ongoing uoroscopy. A cross-link may be added at the
caudal extent of the xation, below the spinous process.

477

VI Special Considerations in Pediatric Em ergency Neurosurgery

Bone Graft (Fig. 29.7)

Figure

Procedural Steps

Pearls

Fig. 29.7

The w ound is irrigated w ith copious amounts


of antibiotic solution.

Dem ineralized bone matrix m ay be m ixed in with the autograft,

The spine and occiput are then decorticated


and prepared for autogenous, onlay, and
corticocancellous bone graft harvested from
the posterior iliac crest.

478

as well as som e allograft bone chips, to m ake a slurry that is then


applied to all decorticated surfaces. Bone m orphogenetic protein
(BMP), if used, should be applied sparingly and only out laterally,
away from the dural portion of the spinal canal. Occasionally, if
anatomy perm its, decortication and fusion m ass m ay include the
facet joints at C1C2 and occipital condyleC1.

29

Other Options for Occipitocervical


Fixation
Technique : Occipital Plate
Th is tech n iqu e is best in skelet ally m at u re p at ien t s. After su b p eriosteal d issect ion an d exp osu re of t h e su boccip it al bon e
w ith Bovie elect rocau ter y, p lace th e p late in p osit ion an d m ark
m id lin e u sin g on e of t h e p late ap er t u res. Th e p late sh ou ld be
p laced closer to th e in ion th an to th e foram en m agn u m so

Special Considerations in Pediatric Cervical Spine Injury


t h ere can be en ough su r face area for ap p rop riate fu sion . Th e
su boccip it al bon e m ay n eed con tou rin g to allow th e p late to
lay u sh . Care m u st be t aken n ot to d isr u pt t h e ou ter cor tex
fu lly (th ereby, d est abilizin g t h e con st r u ct ). Carefu lly, m ake
t h e rst p reviou sly m arked bicor t ical h ole w it h a p ow er d rill
an d t ap it . Rep lace t h e p late an d secu re it w it h an ap p rop riate screw . Place th e ot h er screw s w it h t h e p late in p lace in ord er to gu id e t h em . Con n ect th e p late w it h rod s to th e cer vical
xat ion . Th e occip it al p late sh ou ld be fu lly covered by m u scle
w h en closing.

Technique : C1 Lateral Mass Screw s 13 (Fig. 29.8a, b)

Figure

Procedural Steps

Fig. 29.8

After posterior approach to the arch of C1, use blunt dissection to expose the posterior arch of C1 and C2. Use
the bipolar and hemostatic agents to control bleeding from the atlantoaxial perivertebral venous plexus. Using a
Pen eld no. 4, retract the C2 nerve root caudally in order to expose the C1 lateral mass and the C1C2 joint space
just inferior to its arch. Find the medial and lateral borders of the C1 lateral mass by palpation. The inferior aspect
of the posterior arch of C1 often needs to be drilled dow n to gain further access to this region and to allow the
screw to sit ush w ith the proper angulation. (a) For the screw entry point, make a small hole w ith a drill at the
center of C1 lateral mass. (b) With the aid of a uoroscopic lateral view of the high cervical spine, aim the drill
tow ard the anterior tubercle of C1 and medialize the trajectory by 5 to 10 degrees, depending on the anatomy of
the lateral mass of C1. Stop drilling w hen the drill tip is just short of posterior margin of the anterior tubercle or
you feel that you have gone through the anterior cortical margin of the lateral mass of C1. Tap the hole and insert
a partially threaded screw so that the shaft of the screw in contact w ith the C2 nerve root does not have any
threads. The screw length is typically 34 to 36 mm. For particularly unstable or immature spines, bicortical screw
xation is paramount and requires controlled tapping to penetrate the anterior cortical surface w ithout risking
vascular injury. A probe is helpful in determining depth and length of screw.

479

VI Special Considerations in Pediatric Em ergency Neurosurgery

Technique : C2 Pedicle Screw (Fig. 29.9)

Figure

Procedural Steps

Fig. 29.9

After exposure of the posterior arch of C2, palpate the medial portion of the C2 pedicle w ith a nerve hook or
a small Pen eld and make reference of its trajectory. The entry point w ill be in the pars interarticularis of C2,
lateral to the superior margin of the C2 lamina. (a) Medial and (b) cranial angulation of the screw trajectory
is dependent on careful evaluation of the preoperative imagingusually 15 to 20 degrees and 20 degrees,
respectively. Again, the course of the vertebral artery on the preoperative CT w ill dictate w hether placement
is advisable ; the risks of vascular injury are low.

Technique : C2 Pars Screw 14


Th e tech n ique for placem en t of a C2 pars screw is sim ilar to th at
for a C1C2 t ran sar t icular screw (see below ), except th e t arget
an d t rajector y do n ot exten d to th e C1C2 art icu lat ion . Th e en t r y poin t is ju st above th e in ferior art icular facet of C2 (3 m m
cran ial an d 3 m m lateral to th e in ferior m edial th ird of th e in ferior art icu lar su rface of C2). Drilling an d screw t rajector y sh ou ld
be parallel to th e angle of th e pars in terart icularis, w ith 45 to

480

60 degrees of cran ial an d eith er st raigh t up or 15 degrees of


m ed ial angu lat ion . Th e opt im al d rilling t rajector y is eith er th e
an terior t u bercle or a few m illim eters su perior. Preop erat ive
review of th e CT is essen t ial, w ith focu s on th e sagit t al recon st ru ct ion to id en t ify th e vertebral ar ter y foram en . Th e length of
th e screw m u st be determ in ed on th e preoperat ive CT scan . Th e
screw m u st stop before reach ing th e t ran sverse foram en (u su ally 1420 m m ). See also Ch apter 12, Fig. 12.15..

29

Special Considerations in Pediatric Cervical Spine Injury

Technique : C2 Translaminar Screw (Fig. 29.10)

Figure

Procedural Steps

Fig. 29.10

After subperiosteal dissection of the C2 posterior arch, the entry point w ill be identi ed at the base of the
spinous process (i.e., the spinolaminar line), contralateral to the lamina intended for xation. The lamina itself
w ill de ne the screw trajectory; make a slight dorsal angulation to avoid vertebral canal breach. When using
this technique bilaterally, one entry point must be higher than the other so that one screw w ill not intersect
w ith the other. The lamina must be thick enough to allow the placement of 3.5 mm screw s. Frequently, the
anatomy requires a hybrid construct w ith di erent instrumentation on left and right. The C2 translaminar
screw head location in longer constructs may require o set xation and may pose occasional rod bending
challenges.

481

VI Special Considerations in Pediatric Em ergency Neurosurgery

Atlantoaxial Arthrodesis
Technique : Brooks and Jenkins 15 (Fig. 29.11)

482

Figure

Procedural Steps

Pearls

Fig. 29.11

Brooks and Jenkins xation. C1-C2 sublaminar w ires are secured


over bilateral interposition bone grafts to provide a measure of
stability. A standard midline longitudinal posterior approach is
used to expose the arch of the atlas and lamina/spinous process
of the axis. Tw o double 20-gauge w ires should be inserted under
each side of the posterior arch of C1 and the lamina of C2. Tw o
tricortical structured bone autografts are harvested from the iliac
crest and shaped to the size of the posterior space betw een C1 and
C2. The w ires, once positioned, are tightened over the graft.

Postoperative rigid im mobilization is required

with a Minerva cast or halo brace.


Despite the appearance and the feeling of
being very stable at placem ent, the wiring
constructs lack the rigidit y and stabilit y of the
Harm s or transarticular con gurations.16

29

Special Considerations in Pediatric Cervical Spine Injury

Technique : Gallie 17 (Fig. 29.12)

Figure

Procedural Steps

Pearls

Fig. 29.12

Gallie xation. A posterior w ire construct is bolstered w ith


a notched interposition bone graft shaped to t above the
lamina of C2 and over the C1 posterior arch.

This technique avoids the need for sublaminar C2

The posterior arch of the atlas and the lamina of C2 are


exposed no further than 1.5 cm lateral to the midline in order
to prevent injury to the vertebral arteries. A w ire loop is
passed upw ard under the arch of the atlas (1). Then, the free
ends of the w ire are passed into the loop, notching the arch
of C1 (2, 3). An interpositional, notched corticocancellous
graft is harvested from the iliac crest and shaped to t the
space above the lamina of C2 and over the arch of C1. The
free ends (4) of the w ires are passed over the graft, securing
it. One end w ill pass around or through the spinous process
of C2 and then should be tw isted and tightened to the other
end. Postoperative rigid immobilization is required w ith a
Minerva cast or halo brace.

wires, which m ay be advisable in cases of congenital


or acquired spinal stenosis.
This technique is one of the least stable constructs,
which could result in wire breakage and delayed
deform it y.
Also, because the wire is sublam inar at C1 and
around the spinous process at C2, overtightening
of the wires will cause a posterior translation of C1
on C2.
Multiple other wiring techniques have been
described, including Sonntags m odi ed Gallie
technique.18

483

VI Special Considerations in Pediatric Em ergency Neurosurgery

Technique : Posterior C1C2 Transarticular Screw Fixation (Fig. 29.13a, b)

484

29

Special Considerations in Pediatric Cervical Spine Injury

Figure

Procedural Steps

Pearls

Fig. 29.13

Reduction of C1C2 to anatomic or near anatomic alignment must


be achieved preoperatively and con rmed w ith radiographs. A CT of
the upper cervical spine is mandatory to rule out an aberrant position
of the vertebral artery. Slight exion of the neck helps the exposure.
A routine midline longitudinal posterior approach is performed to
expose the posterior elements of C1 to C3. Identi cation of the C2C3
facet joint w ill determine the entry point: 2 to 3 mm lateral and 2 to
3 mm rostral to the inferior, medial portion of the C2C3 facet joint.
(a) A small angulation of 1015 degrees to medial is also made. (b)
Lateral view uoroscopy is used to direct the trajectory tow ard the C1
posterior tubercle (approximately 60 degrees), running just below and
parallel to the dorsal aspect of the pars interacrticularis. The assistant
w ill use a tow el clamp on the spinous process of C2 to manually
reduce the C1C2 articulation before the drill crosses the joint.

Frequently, a separate stab incision is

Once the screw is in place and reduction is achieved, the contralateral


screw is placed, keeping the same reduction. Each screw should pass
through four cortical surfaces (the entry point just above the inferior
C2 face, each surface of the C12 joint space, and the anterior C1
lateral mass), making it a very strong construct. If a vertebral artery
injury is suspected, continue placing the w orking screw and abort
placement on the contralateral side.

A unilateral transarticular screw,

If there is no concern for an arterial injury, then proceed w ith


placement of the contralateral screw w ith the same technique.
The arthrodesis is reinforced w ith a corticocancellous bone graft
harvested from the iliac crest and xed w ith sublaminar w ires around
the posterior elements of C1 and C2.

There is no need for halo or Minerva

made caudal to the operative opening


to allow the proper angulation of the
drill bit.
Tapping with an appropriately sized
tap is recom m ended, especially with
grossly unstable spines to prevent
distraction of the C1C2 joint space.

married with contralateral wire


construct, is preferable where a
suspected or known preexisting
vertebral artery injury is present.

cast postoperatively. A rigid cervical


collar only is used.

485

VI Special Considerations in Pediatric Em ergency Neurosurgery

Technique : Harms Posterior C1-C2 Fusion w ith Polyaxial Screw and Rod Fixation 14
(Fig. 29.14a, b)

Figure

Procedural Steps

Fig. 29.14

Harms posterior C1C2 fusion w ith polyaxial screw and rod xation. C1 lateral mass xation is coupled w ith C2
pars or pedicle screw s. The construct is held together w ith a rod, providing rigid xation bilaterally.
A standard midline longitudinal posterior approach is used to expose the C1C2 complex. First, 3.5-mm polyaxial
screw s are inserted in the lateral masses of C1. Next, polyaxial screw s are placed bilaterally into the C2 pars
interarticularis or pedicle (as described above). Manipulation of the implants allow s reduction of C1 onto C2 w hen
necessary. A 3.2- to 3.5-mm rod is placed to connect the screw s and provide rigid xation. Bone graft is then
placed over the decorticated posterior elements for de nitive fusion. Intraoperative reduction of subluxation can
be achieved w ith placement of the screw s either recessed or proud in spite of their polyaxial nature.
(a) Figure demonstrates the desired entry point and (b) the optimal screw trajectory.

486

29

Special Considerations in Pediatric Cervical Spine Injury