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54321
ISBN 978-1-60406-368-4
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
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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.
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Contents
Fo rew o rd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Ackno w ledgm en ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Co ntributo rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Objectives
1. Iden t ify n eurosurgical con dit ion s w h ich require em ergen t or urgen t in ter ven t ion
2. 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.
3. 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
4. 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.
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.
viii
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ix
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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 Leon E. Moores, MD, FAANS
P. David Adelson , MD, FAANS Corey Mich ael Mossop
Faiz U. Ah m ad, MD Soriaya Mot ivala, MD
Rocco A. Arm on da, MD, FAANS Mich ael S. Mu h lbau er, MD, FAANS
Nelson Ast u r, MD Ch ristoph er J. Neal, MD FAANS
Josh u a B. Bederson , MD, FAANS Kalm on D. Post , MD, FAANS
M. Ross Bu llock, MD, Ph D Craig H. Rabb, MD, FAANS
Lau ren ce Davidson , MD, FAANS Pat ricia B. Raksin , MD, FAANS#
Don iel Gabriel Drazin , MD Pal Ran dh aw a, MD
Yakov Gologorsky, MD Jon ath an Rasou li, MD
Mark R. Harrigan , MD, FAANS Dan iel K. Resn ick, MD, FAANS
Odet te Alth ea Harris, MD, MPH, FAANS Roberto Rey-Dios, MD
Brian Jam es Hood, MD Boyd Rich ards, DO
Josep h C. Hsieh , MD Mich ael K. Rosn er, MD, FAANS
Mich ael C. Hu ang, MD Ali Sh irzadi, MD
Ash a Mu th uram an Iyer, MD Bran ko Skor vlj, MD
Joh n A. Jan e, Jr., MD, FAANS Peter J. Tau b, MD, FACS, FAAP
Ar th u r L. Jen kin s III, MD, FAANS Rolan d A. Torres, MD, FAANS
Bow en Jiang, MD Jam ie S. Ullm an , MD, FAANS#
J. Pat rick Joh n son , MD, FAANS An an d Veeravagu , MD
Erin Kieh n a, MD William C. Warn er, Jr., MD
Pau l Klim o, Jr., MD, FAANS Nirit Weiss, MD, FAANS
Math ieu Laroch e, MD Sanjay Yadla, MD
An d rew Stew ard Levy, MD Benjam in M. Zussm an , MD
Ju st in Robert Mascitelli, MD Casey Madu ra, MD
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Educat ion al Con ten t Plan n ers.
x
Forew ord
Th is at las ed ited by Drs. Ullm an an d Raksin is clearly a ver y able guide for both residen ts as w ell as for m ore experien ced
valu able con t r ibu t ion to t h e n eu rosu rgical literat u re an d neurosurgeons. It w ill ser ve as a quick referen ce before one
m ay be best d escr ibed as a qu ick referen ce at las. Bot h of em barks on treating a patient w ith a traum atic neurosurgi-
t h e ed itors are exp er ien ced n eu rosu rgeon s w h o h ave h ad cal disorder, or in preparing to take an exam ination.
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 Alth ough th ere are oth er texts th at deal w ith n eurot raum a,
m any exp er t s in th e eld to d escr ibe t h eir ap p roach to t h e n on e of th em are as digest ible as th is on e. I could w ax elo-
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 quen t on th e m any m erit s of th is book. I dont n eed to. As
sp in e. 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
Th e illust ration s are m agn i cen t an d th e text is direct an d booksh elf, bu t to keep h an dy an d to u se on an ever yday ba-
easy to follow. Th is st yle ensures that this book w ill be a valu- sis. You w ill h ave n o t rouble pu t t ing it to good use.
xi
Acknow ledgments
We w ould like to ackn ow ledge an d th an k th e auth orskin d I (JSU) w an t to, p erson ally, dedicate th is book to m y daugh ter
colleagues, m en tors, an d dedicated residen t s an d fellow sfor Sara (fu t u re singer/dan cer, p ediat rician , an d/or n eu rosu rgeon )
len ding th eir ext raordin ar y expert ise an d experien ce to th is an d m y h u sban d Mark for th eir love an d pat ien ce; m y d ear
project . fam ily; an d to th e AANS/CNS Sect ion on Neurot rau m a an d Crit-
ical Care, of w h ich I have been an Execut ive Com m it tee m em ber
We w ou ld like to th an k Dr. Mark Lin skey, past ch air of th e AANS for m ore th an 16 years an d prou d to be its Ch air (2014-2016).
Publicat ion s Com m it tee, for support ing th e con cept of th is at- I w ou ld also like to th an k m y co-ed itor, P.B. Raksin , for h er
las, an d Dr. Jam es Rutka, th en AANS secretar y, for ch am p ion - collaborat ion , pat ien ce, an d diligen ce th rough ou t th e books
ing th is atlas to th e AANS Board of Directors. We are grateful to product ion a perfect m eld of m in d an d spirit . Fin ally, I w ould
th e AANS for it s gen erous gran tm atch ed by Th iem e Publish - like to th an k m y colleagues an d residen t s at th e Icah n Sch ool
ers (to w h om w e are also gratefu l)to fu n d th e illu st rat ion s. of Medicin e at Moun t Sin ai for th eir support an d con t ribut ion s
Th an ks also go to th e Execut ive Com m it tee of th e AANS/CNS to th is atlas an d over th e years; an d th e n e at ten ding an d
Sect ion on Neu rot rau m a an d Crit ical Care for its su p port an d resid en t st a of th e Hofst ra Nor th Sh ore-LIJ Sch ool of Medicin e
from w h ich m any of th e au th ors w ere selected . We are gratefu l w h o spen d long n igh t s on call t reat ing em ergen cy n eurosurgi-
to Dr. Mich ael Feh lings for h is review an d cou n sel regarding th e cal pat ien t s.
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 I (PBR) w ou ld like to ackn ow ledge th e m any pat ien t s w h ose
th is project . 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
Illu st rat ion s form th e backbon e of th is book an d, so, a sp ecial th e past t w o decades. I w ou ld also like to th an k m y co-editor,
th ank you goes to Jen n ifer Pr yll, our n e illust rator, for h er Jam ie Ullm an , for invit ing m e to p ar t n er w ith h er in th is p roject
t ireless e ort s in producing h igh -qualit y art w ork. Ms. Pr yll an d en t ru st ing m e to h elp execu te h er vision . An d, to m y w ife
dem on st rated an ext raordin ar y level of at ten t ion to detail an d Lisaw h o h eld dow n th e for t w h ile I pored over m an u script s
resp on siven ess to th e editors an d au th ors. 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).
xii
Preface
Neu rosu rger y is n ot so sim ple. Drilling bu r h oles in th e em er- Th e book is divided in to six sect ion s. Sect ion I (Ch apters 110)
gen cy depart m en t m ay relieve pressu re from an expan d- covers th e basic procedures th at form th e bread an d but ter of
ing epidu ral h em atom a, but the ensuing un cont rolled arte- cran ial n eu rosurger y for t raum a an d st roke, in cluding cran i-
rial bleeding m ay resu lt in sign i can t blood loss, hypoten sion , otom ies for in t ra- an d ext ra-axial h em atom a, m an agem en t of
an d death if on e is n ot skilled in h an dling th is sit u at ion . An d, p en et rat ing inju ries, an d decom pressive cran iectom y. Excellen t ,
alth ough traum a m ay be on e of th e m ore com m on reason s com preh en sive review s of n eurom on itoring an d m an agem en t
for em ergen t n eurosu rgical in ter ven t ion , acute care for n eu - of n eurovascular inju ries com plem en t th ese ch apters.
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 di- Sect ion II (Ch apters 1118) focu ses on sp in al em ergen cy pro-
t ion s cont in ually ch allenges the skills obtain ed during the long ceduresboth t raum at ic and n on t raum at ic. Th e im port an t role
n eu rosu rger y residen cy t rain ing period, dem an ding n ot on ly of early surger y for acute t raum at ic spin e an d spin al cord in -
broad kn ow ledge and evolving techn ical skills, but pre-, in tra-, ju ries is in creasingly recogn ized; several ch apters are devoted
an d p ostoperat ive clin ical ju dgm en t th at can t ake a lifet im e to to operat ive m an agem en t of th ese injuries. W h ile open proce-
m asterall for th e goal of im proving pat ien t outcom es. du 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 -
Appreciat ion of th is w eigh t y t ask m ust be cou pled w ith th e idea n iqu es in th is set t ing can n ot be ign ored. Ch apter 16 ou tlin es
th at learn ing in n eurosurger y is a decidedly visual pursuit . th e m in im ally invasive approach to th oracolum bar t rau m a.
Neu rosu rgeon s-in -t rain ing st u dy an atom ic rep resen t at ion s, Non t rau m at ic em ergen cies, in clu ding ep id u ral sp in al com pres-
dissect cadavers, an d obser ve th eir m en tors in th e operat ing sion an d cau da equ in a syn drom e, are also addressed .
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 Sect ion III (Ch apters 1922) discu sses th e su rgical m an agem en t
w ords in a textbook in to m en t al im ages, or to im agin e on es of n on t rau m at ic em ergen cies in cluding spon t an eous in t racra-
w aystep -by-step an d w ith variat ion sth rough a procedu re n ial h em orrh age, in t racran ial in fect ion , p it u it ar y apop lexy, an d
before en tering th e operat ing th eater. 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
The true value of a surgical atlas, then, lies in the presentation: the su rgical in ter ven t ion , de n it ive m an agem en t often is u n der-
telling of a procedure in pictures. Historically, atlases h ave been t aken m ore elect ively w ith in a 12- to 72-h our period. Th e tech -
designed to guide the learner through interventions in a step - n iqu e of an eu r ysm clip ping is th e su bject of several im p or tan t
w ise fashion. In 1960, Jam es Leonard Poppen, MD, published his tom es an d is beyon d th e gen eral scope of this atlas. Sim ilarly,
fam ed atlas entitled, An Atlas of Neurosurgical Techniques. This w h ile su rger y for rupt ured arterioven ous m alform at ion s is of-
tom e presen ted procedures in diagram m atic fashionuseful ten deferred for a period of t im e to perm it resorpt ion of h em or-
to any neurosurgeon beginning to hone h is or her craft. In th at rh age, p at ien ts m ay presen t w ith life-th reaten ing acute bleed s
spirit, and in the spirit of great surgical atlases such as Zollingers th at n ecessitate em ergen t in ter ven t ion for relief of m ass e ect .
Atlas of Surgical Operations, w e have set out to create a sim ilar Th ese clin ical scen arios are addressed in Ch apter 19.
volum e devoted to em ergen cy n eurosurgical procedures.
W h ile on ly a select few neurosurgeon s h ave part icipated in th e
Th is book w as w rit ten for n eurosurgeon s-in -t rain ing, as w ell th eater of w ar, w e felt it w ould be valuable to in clu de a sect ion
as for th ose already in p ract ice w h o desire to m eet th e ch al- addressing em ergen cy in ter ven t ion s for n eu rologic inju ries in
lenge of w h atever com es in to th e em ergen cy depar t m en t . com bat (Sect ion IV, Ch apters 23 an d 24). Key lesson s learn ed
Crit ical care pract it ion ers m ay also n d th is book ben e - over th e past t w o decades of con ict h ave led to in creased su r-
cial to un derstan ding th e surgical m an agem en t of n eurologic vival from th ese d evast at ing inju ries. With th e loom ing th reat
con dit ion s th at w ill dem an d th eir m edical expert ise in th e of terrorism , w e m ust be prepared to apply th ese tech n iques in
p ostop erat ive p eriod. 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 re- add it ion , m any step s are rep eated across ch apters (w ith varia-
con st ruct ive su rger y. Th e m an agem en t of fron tal sin us inju- t ion ) to keep m ost of th e ch apters self-con t ain ed. Many of th e
ries requ ires a com bin at ion of acu te care an d recon st ru ct ive procedural steps are accom pan ied by pearlsaddit ion al w is-
ap proach es. Any con sid erat ion of decom pressive cran iectom y dom from th e su bject exper ts, geared tow ard en h an cing an
w ou ld n ot be com plete w ith ou t a discu ssion of it s n at u ral con - operat ions success an d avoiding com plicat ion s. Each ch apter
sequ en ce: th e n eed for addit ion al, m ostly elect ive, su rger y con cludes w ith a discussion of postoperat ive m an agem en t an d
to restore th e cran iu m to it s origin al p rotect ive p u rpose. Th e special con siderat ion s relevan t to th at top ic. Referen ces are kept
in form at ion p rovided is design ed to h elp th e su rgeon n ish to a m in im um .
th e job.
As th e pract ice of n eu rosurger y is as m uch an ar t as it is a sci-
Fin ally, Sect ion VI (Ch apters 28 an d 29) con siders con cern s spe- en ce, th ere w ill be n u an ces an d app roach es p referable to each
ci c to th e t reat m en t of h ead an d spin al injuries in th e pediat ric in dividu al surgeon , an d th ere are often several w ays to ac-
popu lat ion , in cluding steps for th e recon st ru ct ive repair of lep - com plish th e sam e goal. Th e procedures outlin ed in th is book
tom en ingeal cyst s. Th ese ch apters are d esign ed to h igh ligh t key represen t th e best pract ices of th e various au th ors an d can be
di eren ces in th e acute, an d delayed, m an agem en t of injuries in m odi ed based on su rgeon exp erien ce, preferen ce, an d p at ien t
ch ildren as com pared w ith adu lt s. 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
Th e ch apters follow a st an dardized form at . In t roductor y en cou n tered em ergen cy p rocedu res, it is in evit able th at oth er
com m en t ar y for each topic is follow ed by an accoun t ing of em ergen cy con dit ion s w ill arise th at fall ou t side th e scope of
in dicat ion s for n eurosurgical in ter ven t ion an d preprocedu ral th is project . It is our h ope th at th e in form at ion presen ted in
con siderat ion s. Th e operat ive procedure form s th e core of each th is book w ill ser ve as a platform upon w h ich to build st rat-
sect ion . For th e readers conven ien ce, w e design ed th is book to egies for t reat ing m ore com p lex or less com m on em ergen cy
keep illu st rat ion s an d p rocedu ral step s in close proxim it y. In presen t at ions.
xv
xvi Contributors
Medications
Indications Preoperat ive an t ibiot ics: eith er a ceph alosporin or van com y-
cin (if pen icillin allergic) sh ould be given .
Su rgical in ter ven t ion is app ropriate for epidural hem atom as Th e pat ien t sh ould be given seizure prophylaxis at earliest
(EDH) w ith th e follow ing ch aracterist ics 2 opport un it y after arrival to th e h ospit al. Eviden ce-based
Glasgow Com a Scale (GCS) score 8 an d an isocoria gu id elin es su p p or t th e u t ilizat ion of an t iconvu lsan ts for
operat ing room as soon as p ossible 7 days in pat ien t s follow ing t raum at ic brain injur y.4
Hem atom a volu m e 30 cm 3 Fresh frozen plasm a an d/or oth er blood product s/factors
Hem atom a volu m e , 30 cm 3 bu t accom p an ied by: sh ou ld be adm in istered p reop erat ively an d in t raop erat ively
Th ickn ess 15 m m as n eeded to correct coagu lopathy.
Midlin e sh ift 5 m m
GCS 8
Focal m otor de cit
E aced cistern s
Operative Field Preparation
Deteriorat ing n eu rologic st at u s Th e h ead m ay be posit ion ed on a dough n ut or h orsesh oe
Su rgical in ter ven t ion is ap prop riate for subdural hem atom as h ead h old er, rath er th an a th ree-pin ion h ead h older, to facili-
(SDH) w ith th e follow ing characterist ics 3 t ate m ore rapid progression to brain decom pression .
Th ickn ess 10 m m The operative eld should be prepared using an iodine-based
Midlin e sh ift 5 m m sterile prep solution, provided the patient has no iodine allergies.
Th ickn ess , 10 m m an d m idlin e sh ift , 5 m m but accom - Th e use of ch lorh exidin e is con t roversial; product in ser t in -
p an ied by: form at ion bars th e u se for p rocedu res exp osing th e cerebral
Neu rologic w orsen ing by 2 or m ore poin t s on th e GCS m en inges. In cases w ith kn ow n bet adin e or iodin e allergies,
Asym m et ric pupils ch lorh exidin e or alcoh ol prep can be u sed.
Fixed an d dilated pupils Th e in cision s are m arked an d, after n al sterile draping, in l-
In t racran ial pressure (ICP) 20 m m Hg t rated w ith 1% lidocain e w ith epin eph rin e 1:100,000.
2
1 Surgery for Epidural and Subdural Hem atom as
a b
c d
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.
3
I Cerebral Traum a and Stroke
Operative Procedure
Positioning (Fig. 1.2a, b)
Fig. 1.2 (a, b) The head is turned so Discuss positioning with the anesthesiology team . The endotracheal tube (ETT) should
as to expose the operative exit the contralateral side of the m outh if placed orally, and should be secured in place
hemicranium. The patient using tape, ETT collar, etc. The eyes should be protected from corneal abrasion by placing
whose neck has not yet been ointm ent under each lid and taping the lids shut.
cleared can be positioned Allowance for central venous catheters, peripheral intravenous catheters, and arterial
in the cervical collar by lines should be m ade, with these positioned toward the anesthesiology team if possible.
placing a bolster under the Foley catheters should always be placed and should be accessible to the anesthesia team .
ipsilateral shoulder and the Pin xation may also be used, but positioning on a doughnut or horseshoe head holder
ipsilateral arm across the m ay expedite decompression of the brain.
chest. Pressure points should The head should be positioned just at or slightly overhanging the end of the table and the
be padded appropriately. sterile craniotomy drape placed so that it hangs vertically to facilitate drainage of irrigation
The head may be placed on by gravit y. Final draping should exclude the anesthesia setup, using a vertical drape.
a foam or gel doughnut to An exit site for a subgaleal drain should be included in the area exposed by the sterile draping.
expedite positioning. Reverse Trendelenburg positioning m ay be used to provide elevation of the head to help
reduce cerebral edem a.
4
1 Surgery for Epidural and Subdural Hem atom as
Fig. 1.3 The skin incision Other skin incisions m ay be utilized to evacuate sm aller hematom as. However, before
should be planned to com mit ting to a m ore lim ited exposure, consideration should be given to the degree of brain
create a craniotomy swelling anticipated.
su cient to access When using a question m ark incision, care should be taken not to place the incision too close to
the entire hematoma. the pinna of the ear. A m argin of at least 1 cm should be used. Likewise, the vertical lim b of the
The question mark incision should be placed at least 1 cm anterior to the tragus. The scalp m ay be elevated o of
or reverse question the underlying bone and retracted out of the way.
mark incision Scalp clips m ay be applied to the scalp edges to aid in hem ostasis.
(illustrated here) Prior to opening the scalp over the temporalis m uscle, an instrum ent m ay be passed over
is used commonly the m uscle fascia and the skin divided down to the level of the instrum ent with a scalpel. The
to access large temporalis m ay then be divided in parallel with the incision using Bovie cautery.
traumatic extra-axial Branches of the super cial and m iddle temporal arteries may be encountered and m ay be
hematomas. ligated and divided sharply, or cauterized with the bipolar cautery.
5
I Cerebral Traum a and Stroke
Fig. 1.4 For rapid opening, the The temporalis m uscle m ay be elevated o of the underlying bone using a sharp
temporalis muscle may be periosteal elevator, such as a Langenbeck, or using the Bovie cautery.
elevated simultaneously The musculocutaneous ap should be protected from strangulation by placing dry
w ith the scalp ap. 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.
6
1 Surgery for Epidural and Subdural Hem atom as
a b
Fig. 1.5 (a) Bur holes are placed at the perimeter of the planned After creation of the bur holes using a high-speed
bone ap, leaving su cient bony margins so that the plating drill, bone wax is applied to the raw bone edges
hardw are is not located immediately under the skin incision where necessary. Excess wax is rem oved, along with
at closure. any obstructive bone edges deep in the bur holes,
with a cup curet te.
A no. 3 Pen eld dissector is used to strip the dura o of the A larger instrum ent, such as a Langenbeck periosteal
undersurface of the bone at each bur hole. If possible, the elevator, m ay be used to elevate the ap, as long
Pen eld should be used to make a communication, in this as the underlying dura is protected from the sharp
same plane, betw een adjacent bur holes. The high-speed drill edge of the instrum ent. The explanted bone ap
attachment is converted to a cutting bit w ith a footplate and should be cleared of hem atom a and blood and
used to connect each pair of bur holes circumferentially. placed in irrigation infused with antibiotics on the
back table until ready to be replaced.
The bone ap should be secured in place w ith a nger prior to Center holes may be m ade later in the bone ap for
making the nal cut. epidural tack-up sutures.
7
I Cerebral Traum a and Stroke
Fig. 1.6 As the bone ap is elevated, an epidural Evacuation of an epidural hem atom a will often yield both organized
hematoma w ill be appreciated immediately hem atom a and liquid blood. The hem atom a is often adherent to the
in the extradural space. This may be bleeding vessel, com monly the m iddle m eningeal artery in the anterior
removed using irrigation and suction. temporal area. This, in turn, m ay be associated with a fracture of the
squam ous portion of the temporal bone.
The source of bleeding should be
addressed as quickly as possible, utilizing Other sources of epidural hem atom as m ay be handled sim ilarly. Venous
bipolar cautery on the vessel itself, and/or epidural hem atom as sometim es require application of gel foam soaked
bone w ax on the foramen spinosum w here in throm bin and gentle pressure, or Bovie cautery or bone wax to
the vessel enters the cranium. bleeding bone edges.
8
1 Surgery for Epidural and Subdural Hem atom as
Fig. 1.7 The dura is opened w idely enough to allow For curvilinear incisions, at least 1 cm of dura should be left bet ween the
access to as much of the subdural space as durotomy and the bone edge to prevent retraction, causing di cult y
possible in the craniotomy exposure. 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
The initial dural opening may be made to prevent strangulation of the underlying brain by the dural edge.
w ith a no. 11 scalpel. The dural edges The dural edges should be secured with 4-0 braided nylon sutures, and
may then be grasped w ith ne -toothed held in place with m osquito hem ostats, either to gravit y or secured to
forceps, elevated, and the remainder of the the drapes without undue tension.
opening performed w ith ne Metzenbaum The dural ap or aps should be weighted with hem ostats in order to
or tenotomy scissors. Occasionally, if the prevent shrinkage during the procedure as m uch as possible.
brain is very edematous, the opening Dural vessels m ay be coagulated with the bipolar at the edges of the cut
may be made w ith a no. 11 scalpel over a dura.
groove director.
9
I Cerebral Traum a and Stroke
Fig. 1.8 The subdural The source of any SDH should be sought. The source is often a cortical surface vein or artery.
hematoma (SDH) is SDHs occasionally m ay em anate directly from a surface contusion.
seen overlying the Gentle irrigation with sterile saline should be used and the entire perim eter of the
surface of the brain dural exposure explored with adequate lighting to ensure that the hem atom a has been
and is evacuated w ith completely evacuated. A brain retractor blade m ay be used to gently depress the brain
irrigation and suction. 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.
10
1 Surgery for Epidural and Subdural Hem atom as
Fig. 1.9 After adequate evacuation of Closure of the dura should be a ected in a watertight fashion if possible. Over the
the hematoma, the dura is convexit y, watertight closure is not imperative. The dura may be closed with simple
closed w ith 4-0 braided nylon running, running-locking, or interrupted sutures.
suture. 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
Epidural tack-up sutures are substitute m aterials are available. The dura m ay be patched with suturable graft
placed through small drill m aterials or autograft from the patients own galea or m uscle fascia, or closed with
holes placed around the graft m aterials alone.
perimeter of the craniotomy. Prior to placing the nal few sutures, the subdural space should be irrigated a nal
A central epidural tacking tim e. When a large subdural potential space rem ains (as in the case of an elderly
stitch may be brought out patient and/or one with a slack brain), a sm all am ount of irrigation m ay be left in the
through tw o holes drilled in subdural space to lessen the risk of extensive postoperative pneum ocephalus.
the bone ap.
11
I Cerebral Traum a and Stroke
Fig. 1.10 Follow ing evacuation of either an Many t ypes of cranial plating system s, with a variet y of plate shapes
epidural or subdural hematoma, the and sizes, are available. These are generally m ade of titanium , which is
bone ap is replaced in its anatomic nonm agnetic, allowing for later m agnetic resonance im aging.
position, using a cranial plating Resorbable plates and screws are available for children. Alternatively, the
system. The central epidural tacking bone ap m ay be replaced with silk suture to avoid rigid xation in the
stitch is secured. growing skull.
12
1 Surgery for Epidural and Subdural Hem atom as
Fig. 1.11 For large aps, a subgaleal drain The drain should exit from a separate stab incision, formed with a trocar or
may be used to lessen the risk of no. 11 knife, and should be secured at its skin exit site with a nylon stitch.
postoperative subgaleal hematoma. The drain is at tached to bulb suction.
13
I Cerebral Traum a and Stroke
Pat ien ts w ith severe inju ries w ill likely h ave addit ion al in -
Closing 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
If m ass e ect h as been relieved adequ ately an d th e brain is gu ide m an agem en t . Invasive h em odyn am ic m on itoring (ar-
slack (creat ing dead sp ace in w h ich blood m ay accu m u late
terial lin e, cen t ral ven ous lin e, Sw an -Gan z cath eter) m ay be
postoperat ively), th e pat ien ts en d-t idal CO2 level sh ould be
in dicated to assist m an agem en t in crit ically ill pat ien t s.
allow ed to rise gradu ally to 30 to 35 m m Hg (rough ly equ iva-
Drain s sh ou ld be m on itored for ou t pu t ever y 4 h ou rs for th e
len t to p CO2 of 35 to 40 m m Hg) d u ring closu re.
rst 8 h ou rs an d th en ever y 8-h ou r sh ift .
If ongoing coagu lopathy is obser ved, m easu res sh ou ld be t ak-
Th e in cision an d/or dressing sh ould be m on itored for bleed-
en to correct clot t ing p aram eters in t raop erat ively.
ing in it ially, an d for er yth em a, exudate, an d /or edem a subse-
Sterile salin e irrigat ion is ut ilized in th e in t radu ral space.
quen t to th e in it ial postoperat ive period.
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. Medication
Tem poralis m uscle and fascia are reapproxim ated w ith 0-gauge
braided absorbable suture. The galea is closed w ith interrupted, Postop erat ive an t ibiot ics are con t in u ed for 24 h ou rs u n less
inverted, 2-0 braided absorbable suture. As the scalp closure th ere w as gross con t am in at ion presen t at th e t im e of surger y,
proceeds, the scalp clips m ay be rem oved successively, by in w h ich case th is period m ay be exten ded.
spreading w ith the scalp clip applier or a hem ostat. Seizu re prop hylaxis sh ou ld be con t in u ed for a total of 7 days
Th e skin m ay be closed w ith nylon or oth er n on braided su- for p at ien ts w ith EDH or SDH. Th e presen ce of d ocu m en ted
t ure, or w ith st aples. Extern al su t ure is requ ired on th e scalp, seizu res m ay p rovide an in dicat ion to con t in u e th erapy be-
as th ere is n ot a w ell-develop ed su bcu t icu lar layer. yon d th is w in dow.
Th e w ou n d m ay be dressed in a variet y of w ays. Th e auth or Hyperosm olar th erapym an n itol an d/or hyper ton ic salin e
prefers to apply a st rip of n on adh eren t pet rolat um gauze over m ay be in dicated for ICP con t rol dep en d ing on th e clin ical
su t u res or st ap les to p reven t p u lling. Th is base dressing, in pict ure.
t urn , is covered w ith n arrow gau ze ban dages to absorb m in or Sedat ion an d /or n eu rom u scu lar p aralyt ics m ay be in dicated
oozing postoperat ively. Th e dressing is secured w ith st retchy to assist ICP con t rol depen ding on th e clin ical pict ure.
dressing t ape, applied un der sligh t tension to assist in cision al Pressor support m ay be n ecessar y to m ain tain adequate cra-
h em ostasis. St rip s of dressing tape m ay be u sed to follow th e n ial perfu sion pressu re d ep en ding on th e clin ical pict u re.
cur vat ure of th e h ead parallel to th e in cision for close adh er- Ongoing coagu lopathy sh ou ld be corrected w ith fresh frozen
en ce. Th e dressing is rem oved after 24 h ou rs, an d th e pat ien t plasm a or oth er appropriate blood product s/factors.
is allow ed to clean se th e w oun d w ith m ild soap an d w ater.
Radiographic Imaging
Postop erat ive im aging (Fig. 1.12).
Postoperative Management
Further Management
Monitoring 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 input h as slow ed su cien tly. If th ere is sign i can t out p ut , re-
u n it (recover y room ), progressive care un it , or in ten sive m oval m ay be d elayed an oth er 1 to 2 days.
care un it w ith frequen t n eurologic ch ecks, occurring at least Th e dressing is rem oved an d th e w oun d is clean sed w ith
h ou rly in it ially. Th e p at ien ts preoperat ive st at us an d p ost- w arm w ater an d m ild soap or sh am p oo after 24 h ou rs.
operat ive course w ill dict ate th e t im ing of t ran sit ion to less Skin su t u res or st ap les are rem oved on or abou t p ostop era-
in ten sive m on itoring. t ive day 10 to 14.
14
1 Surgery for Epidural and Subdural Hem atom as
a b
Fig. 1.12a, b Axial CT images demonstrating resolution of (a) epidural hematoma and (b) subdural hematoma.
15
2 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
All Procedures
Am erican Associat ion of Neurological Surgeons procedural sur- Su bacu te or ch ron ic su bdu ral h em atom a w ith m axim u m
vey rep or ted over 43,000 bu r h oles perform ed for th e evacu a- th ickn ess . 10 m m an d/or m idlin e sh ift . 7 m m
t ion of ext ra-axial (subdural/epidural) h em atom as.1 Th e m ost Su bacu te or ch ron ic su bd u ral of any th ickn ess cau sing m ass
com m on pat ien t ch aracterist ics are elderly m ales w ith or w ith - e ect , m idlin e sh ift , or n eu rologic sign s an d sym ptom s.
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 e-
sis.4 CSDHs are often u n ilateral, bu t p resen t as bilateral in ap -
Minimally Invasive
p roxim ately 16 to 25%of cases.3,5 Th e m ost com m on presen t ing Favorable CT im aging ch aracterist icsa un iform ly isoden se
sym ptom s in clu de h eadach e, ataxic gait , con fu sion , ap h asia, or hypoden se collect ion in th e subdural spaceare presen t .
an d variou s n on speci c com p lain t s. If th e CSDH is large an d Th is suggest s th e subdural h em atom a is su cien tly lique ed
causes sign i can t m ass e ect , paresis, seizure, an d com a m ay to perm it drain age via a ven t riculostom y cath eter.
en su e. Mort alit y st at ist ics var y am ong in st it u t ion s, bu t gen er- The presence of an isodense, or even slightly hyperdense,
ally range from 5 to 16%.6,7 ground glass appearance is not necessarily a contraindication
Several th eories exist to exp lain th e p ath ogen esis of CSDH. to catheter drainage. This ph enom enon is seen som etim es in
The prevailing hypoth esis is th at m ost start as acute subdural the set ting of a subacute or acute on chronic subdural hem a-
bleeds th at t rigger a local in am m ator y respon se in th e sur- tom a, often w ith a gradual gradient from anterior hypodensit y
roun ding m en inges. In am m at ion t riggers th e m igrat ion of - to posterior hyperdensit y (re ecting dependen t acute blood
broblast s, w hich th en create m em bran es th at organ ize th e clot m ixed w ith th e predom inantly ch ronic hem atom a). These
an d secrete vascu lar en doth elial grow th factor (VEGF) th at , in usually can be drained e ectively w ith a bedside catheter or
t urn , prom otes th e form at ion of capillaries w ith in th ese m em - suction evacuation procedure.
bran es.8 Over t im e, th ese m em bran e capillaries bleed an d pre- A sm all am oun t of acute, hyperden se subdural blood w ith in a
ven t th e blood from being reabsorbed. Hem oglobin even t u ally larger, m ostly ch ron ic, hypoden se collect ion is n ot n ecessar-
is broken dow n in to h em osiderin , leading to th e ch aracterist ic ily a con t rain d icat ion .
ap p earan ce of CSDH on com pu ted tom ograp hy (CT)/m agn et ic W h ile adequate drain age can be ach ieved even in th e pres-
reson an ce (MR) im aging (Fig. 2.1). en ce of a few su bdu ral m em bran es, exten sive m em bran es
Man agem en t of CSDH t yp ically involves su rgical evacu at ion an d m u lt iple layers of su bdu ral h em atom a (SDH) of d i eren t
of th e clot an d placem en t of post surgical drains to preven t reac- ages or den sit ies m ay p ose a ch allenge. Bur h ole drain age or
cum ulation of blood in th e subdural space. In part icular, th e use cran iotom y sh ould be con sidered in th is set t ing.
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 aliza-
t ion of th e subdural space. W hen th e radiograph ic appearan ce
Preprocedure Considerations
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 Radiographic Imaging (Figs. 2.1,
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
2.2, and 2.3)
therapy m igh t sh ow som e prom ise in t reat ing CSDH.10,11 New er X-ray: In gen eral, X-ray is a poor diagn ost ic tool for CSDH.
p h arm acological t reat m en t , such as th e u se of t ran exam ic acid Occasion ally, a p lain lm of th e sku ll m ay reveal a calci ed
(an an t ith rom bolyt ic agen t), is invest igat ion al.12 CSDH recu r- CSDH.15
ren ce rates var y am ong in st it u t ion s, bu t gen erally range from CT: CT is t h e gold -st an dard im agin g m odalit y for d iagn osin g
8 to 16%.13,14 Several st udies h ave suggested that CSDH recur- CSDH. SDHs classically d e m on st rate a crescen t ic con gu ra-
ren ce rates are h igh er w ith bilateral CSDH, w ith large volum es t ion , as t h e ir d ist r ibu t ion over t h e cor t ical convexit y is n ot
of pn eum oceph alus after evacuat ion , an d w ith use of an t ico- 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).
agu lat ion th erapy.13,14 Mass e ect , cor t ical b u cklin g, an d m id lin e sh ift m ay also
16
2 Chronic Subdural Hem atom as
a 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
Table 2.1 CT appearance of subdural blood over time 17 Table 2.2 MR appearance of subdural blood over time 18
18
2 Chronic Subdural Hem atom as
Operative Procedure
Bur Hole Drainage
Positioning and Skin Incision (Fig. 2.4a, b)
19
I Cerebral Traum a and Stroke
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.
20
2 Chronic Subdural Hem atom as
21
I Cerebral Traum a and Stroke
22
2 Chronic Subdural Hem atom as
23
I Cerebral Traum a and Stroke
24
2 Chronic Subdural Hem atom as
25
I Cerebral Traum a and Stroke
Operative Procedure
Tw ist Drill Craniostomy
Positioning and Skin Incision (Fig. 2.9)
Fig. 2.9 The patients head is positioned on a rm surface, such Soft restraints are often necessary to prevent the
as a folded blanket or gel donut, and turned 15 to patient from inadvertently reaching into the sterile eld.
30 degrees to the contralateral side (60 degrees if a An assistant may be useful to stabilize the patients
more posterior parietal entry point is required). Make head during the procedure, with hands placed gently on
a small stab incision at the desired insertion site w ith a either side of the patients jaw, under the drapes.
no. 15 blade. The entry point for the catheter insertion The ideal entry point is usually sim ilar to a
is chosen over a relatively thick part of the SDH that is ventriculostomy entry point, but m ore lateral.
safely accessible, usually in the frontal region, about 2 cm Occasionally, a predom inantly posterior SDH will require
in front of the coronal suture and 4 to 8 cm o midline. a parietal entry point.
26
2 Chronic Subdural Hem atom as
27
I Cerebral Traum a and Stroke
28
2 Chronic Subdural Hem atom as
29
I Cerebral Traum a and Stroke
a b
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 post-
operat 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
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 . Fig. 2.14 Postoperative CT scan of the patient in Fig. 2.1 undergoing
Barring a ch ange in n eu rologic st at us, addit ion al CT scan s are bur hole drainage with drain in place. There is pneumocephalus and
u su ally obtain ed at 2 to 4 w eeks, 2 to 3 m on th s, an d th en as improvement in m ass e ect. The patient also has a smaller subacute
n eeded u n t il th e SDH is com pletely resolved. right parietal subdural collection which was treated conservatively.
30
2 Chronic Subdural Hem atom as
a 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 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
Su bdu ral reaccu m u lat ion is a kn ow n risk of op erat ive t reat-
surger y. Th e rat ion ale for th e u se of cort icosteroids is based on
m en t . Reop erat ion m ay be n ecessar y. A secon d reaccu m u lat ion
the ant iangiogenic propert ies an d inh ibit ion of the in am m ator y
m ay requ ire su bd u ralperiton eal sh u n t ing (w ith ou t a valve),
react ion , presum ed to play a key role in h em atom a form at ion
w h ich m ost often resolves th is di cult problem .
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 avail-
able. 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 lace-
m 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 edi-
ate relief of p ressu re if a p at ien t becom es severely let h argic
or obt u n d ed .
References
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
Fig. 2.16 Post-drainage CT of patient in Fig. 2.3 shows a signi cant 2. Mori K, Maeda M. Su rgical t reat m en t of ch ron ic su bdu ral h em a-
decrease in the size of the chronic subdural hematoma, and decreased tom a in 500 con secu t ive cases: clin ical ch aracterist ics, surgical
midline shift. The tip of the subdural catheter can be seen in the subdural ou tcom e, com plicat ions, an d recurrence rate. Neurol Med Ch ir
space (arrow). 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. 12. Kageyam a H, Toyooka T, Tsu zu ki N, Oka K. Non su rgical t reat m en t
St at ist ical an alysis of chron ic subdu ral h em atom a in 309 adu lt of ch ron ic subdu ral h em atom a w ith t ran exam ic acid. J Neuro-
cases. Neurol Med Ch ir 1972;12(0):7183 surg 2012;119:331337
4. Kaw am at a T, Takesh ita M, Ku bo O, Izaw a M, Kagaw a M, Takaku ra 13. Takayam a M, Ter u i K, Oiw a Y. Ret rospect ive st at ist ical an alysis
K. Man agem en t of in t racran ial h em orrh age associated w ith an t i- of clinical factors of recurren ce in ch ron ic subdural h em atom a:
coagulan t th erapy. Surg Neurol 1995;44(5):438442 correlat ion bet w een un ivariate an d m u lt ivariate an alysis. No
5. Robin son RG. Ch ron ic su bdu ral h em atom a: su rgical m an agem en t Sh in kei Geka 2012;40(10):871876
in 133 pat ien t s. J Neurosurg 1984;61(2):263268 1 4 . St an ii M, Hald J, Rasm u sse n IA, et al. Volu m e an d d e n si-
6. Miran da LB, Braxton E, Hobbs J, Qu igley MR. Ch ron ic su bdu - t ies of ch ron ic su bd u ral h ae m at om a obt ain e d from CT im ag-
ral h em atom a in th e elderly: n ot a ben ign disease. J Neurosurg in g as p re d ict ors of p ostop e rat ive re cu r re n ce: a p rosp ect ive
2011;114(1):7276 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 ):
7. Ram ach an d ran R, Hegd e T. Ch ron ic su bdu ral h em atom ascau ses 323333
of m orbidit y an d m ort alit y. Surg Neurol 2007;67(4):367372 15. Pap p am ikail L, Rato R, Novais G, Bern ardo E. Ch ron ic calci ed
8. Shono T, Inam ura T, Morioka T, Matsum oto K, Suzuki SO, Ikezaki K, subdural h em atom a: Case repor t an d review of the literat ure.
Iw aki T, Fukui M. Vascular endothelial grow th factor in chronic Surg Neu rol Int 2013;4:21
subdural haem atom as. J Clin Neurosci 2001;8(5):411415 1 6 . Se n t u rk S, Gu zel A, Bilici A, Takm a z I, Gu zek E, Alu clu U,
9. Santarius T, Kirkpatrick PJ, Ganesan D, et al. Use of drains versus no Ceviz A. CT an d MR im agin g of ch ron ic su b d u ral h ae m ato -
drains after bur-hole evacuat ion of chronic subdural hem atom a: a m as: a com p arat ive st u dy. Sw iss Me d W kly 2010;140(23-24):
random ized controlled trial. Lancet 2009;374(9695):10671073 335340
10. Delgado-Lop ez PD, Mar t in -Velasco V, Cast illa-Diez JM, et al. 17. Coh n DF, Avrah am i E, Ried er- Grossw asser I. Radiograp h ic
Dexam eth ason e t reat m en t of ch ron ic su bdu ral h em atom a. isoden se subdural h em atom as in com puterized tom ography.
Neuroch irugia (Ast ur) 2009;20:346359 Sch w eiz Med Woch ensch r 1981;111(12):427429
11. Su n TF, Boet R, Poon WS. Non -su rgical p rim ar y t reat m en t of 18. Tu rh im S. In t racerebral h em orrh age. In : Fron tera JA, ed. Deci-
ch ron ic subdural h em atom a: prelim inar y result s of using dexa- sion Making in Neurocrit ical Care. New York: Th iem e Medical
m eth ason e. Br J Neu rosu rg 2005;19:327333 Publish ers; 2009:3652
32
3 Surgery for Cerebral Contusions of
the Frontal and Temporal Lobes,
Including Lobar Resections
Pal S. Randhaw a and Craig Rabb
Indications
Preprocedure Considerations
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:
Radiographic Imaging
A fron t al or tem p oral con t u sion of greater th an 20 cm 3 in Non con t rast h ead CT is vit al in th e evalu at ion of all severe
volu m e an d associated w ith any of th e follow ing: t raum at ic brain injuries. CT allow s for an atom ic localizat ion of
Glasgow Com a Scale (GCS) score 6 to 8 su rgical path ology an d, in t u rn , facilitates p lan n ing of p at ien t
Midlin e sh ift at least 5 m m posit ion ing an d operat ive approach .
Cistern al com pression Pre o pe rative im aging (Fig 3.1).
a b
Fig. 3.1a, b Axial CT images demonstrating (a) frontal and (b) temporal lobe cerebral contusions.
33
I Cerebral Traum a and Stroke
34
3 Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
Operative Procedure
Bicoronal Approach
Positioning (Fig. 3.2)
Fig. 3.2 The patient is positioned supine, w ith the head in a Consider using a horseshoe headrest to facilitate m ore
neutral, upright position. The head is stabilized w ith rapid decompression in the em ergency set ting, or if a skull
May eld three -point xation. The head of bed is fracture prevents use of a May eld three-point xation.
elevated slightly.
35
I Cerebral Traum a and Stroke
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
3 Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
37
I Cerebral Traum a and Stroke
38
3 Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
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
b c
Fig. 3.7 Pilot holes are drilled circumferentially at the periphery of the Dural tacking stitches help prevent the
craniotomy to create dural tack-up sites. 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.
(b) It may be necessary to divide the superior sagittal sinus and falx The sinus should be targeted for ligation and
in order to achieve adequate decompression of the frontal lobes. division at a point well forward of the coronal
After release of the sinus, use a double ligature technique to occlude suture (along the anterior one-third of the sinus).
the sinus, using a 2-0 polypropylene or nylon suture. Make a double The second needle pass should be m ore
circular course across the falx, just below the level of the sinus, super cial (within the falx) than the rst.
and cinched tightly to occlude the sinus. Repeat this process w ith a
second stitch, anterior to the rst.
(c) Sever the sinus between the ligatures and divide the subadjacent falx Alternatively, ligation may be performed with
in its entirety to complete the exposure. 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.
40
3 Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
Fig. 3.8 (a) Inspect the cortical surface. Select your site for entryan If the cortical surface appears undisturbed, consider
area of obvious contusion or cortical disruption is ideal. the use of ultrasound to localize the m ost super cial
extent of the hem atom a.
Cauterize the super cial vessels and pia mater at the A handheld m alleable retractorintroduced over
planned entry site. Use a no. 11 or no. 15 blade to open the a saline-moistened 1- 3 3-cm cot ton pat tie (to
pia. Approach the hematoma cavity in the subpial plane w ith protect the friable tissue along the cavit y wall)m ay
a combination of gentle suction and bipolar electrocautery. assist visualization during contusion resection and
hem ostasis.
(b) Upon entry to the hematoma, suction out any liquid Always be mindful of position relative to the anterior
clot and remove solid clot in a piecemeal fashion. Continue horn of the lateral ventricular while evacuating
evacuation of hematoma until gliotic brain is visible on all sides. hem atom a from deep subcortical spaces. Avoid entry
to the ventricle if feasible.
41
I Cerebral Traum a and Stroke
42
3 Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
43
I Cerebral Traum a and Stroke
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
3 Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
45
I Cerebral Traum a and Stroke
46
3 Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
47
I Cerebral Traum a and Stroke
The dural opening is initiated over the frontal area with a no. 15 Allow a dural m argin of at least 0.5 cm with respect
blade and enlarged with tenotomy scissors. A strip of moistened to the craniotomy edge to perm it prim ary closure
nonadherent bandage or a cotton pattie may be introduced into after decompression.
the subdural space to protect the underlying cortex. The dural ap Keep the re ected dural ap m oistened with a damp
is secured under modest tension with 4-0 braided nylon stitches. sponge to minimize shrinkage.
48
3 Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
49
I Cerebral Traum a and Stroke
50
3 Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
fash ion .
Th e skin is closed eith er w ith staples or w ith 3-0 nylon (in a
Further Management
vert ical m at t ress or ru n n ing fash ion ). Skin su t u res or staples are rem oved after 2 w eeks.
a 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 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
1. Bullock MR, Chesnut R, Ghajar J, et al. Surgical m anagem ent 7. Mandera M, Zralek C, Krawczyk I, Zycinski A, Wencel T, Bazowski P.
of traum atic parenchym al lesions. Neurosurger y 2006;58(3): Surgery or conservative treatm ent in children w ith traum atic intra-
S2546 cerebral haem atom a. Childs Nervous System 1999;15(5):267269
2. Singou n as EG. Severe h ead inju r y in a p aediat ric pop u lat ion . 8. Miller JD, Bu t ter w or th JF, Gu dem an SK, et al. Fu r th er experi-
J Neu rosu rg Sci 1992;36:201206 en ce in th e m anagem en t of severe h ead inju r y. J Neurosurg
3. Gallbraith S, Teasdale G. Pred ict ing th e n eed for op erat ion in th e 1981;54:289299
pat ien t w ith an occult t raum at ic in t racran ial h em atom a. J Neu- 9. Nordst rom C, Messeter K, Su n dbarg G, Wah lan der S Severe t rau -
rosurg 1981;55:7581 m at ic brain lesion s in Sw eden. Par t I: Aspect s of m anagem en t in
4. Gen n arelli T, Spielm an GM, Lang t t T, et al. In u en ce of th e t yp e n on -n eu rosurgical clin ics. Brain Inj 1989;3:247265
of in t racran ial lesion on outcom e from severe h ead inju r y. J Neu- 10. Solon iu k D, Pit t s LH, Lovely M, Bar tkow ski H. Trau m at ic in t ra-
rosurg 982;56:2632 cerebral hem atom as: Tim ing of appearan ce and in dicat ion s for
5. Jallo J, Narayan RK. Gen eral prin cip les of cran iocerebral t rau - operat ive rem oval. J Traum a 1986;26:787794
m a an d t raum at ic hem atom as. In : Sekhar LN, Fessler RG, eds. 11. Sujit S. Prabh u , Zau n er A, Bu llock MRR. In t racerebral h em atom a
Atlas of Neurosurgical Tech n iques. New York: Th iem e; 2006: an d cerebral con t u sion . In : Win n HR, ed . You m an s Neu rological
895905 Surger y. Ph iladelph ia: Elsevier; 2010:51595162
52
4 Decompressive Craniectomy for
Intracranial Hypertension and Stroke,
Including Bone Flap Storage in
Abdominal Fat Layer
Roberto Rey-Dios and Dom enic P. Esposito
53
I Cerebral Traum a and Stroke
a b
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.
54
4 Decom pressive Craniectom y for Intracranial Hypertension and Stroke
Operative Procedure
Decompressive Hemicraniectomy (Frontotemporoparietal [Occipital]
Craniectomy)
Positioning (Fig. 4.2)
55
I Cerebral Traum a and Stroke
Fig. 4.3 For a standard hemicraniectomy, the incision In m any patients, the super cial temporal artery (STA) can be
w ill start at the level of the zygomatic arch, 1 cm palpated, and the incision designed to avoid it. Maintaining a
in front the tragus, and extend superiorly and patent STA will increase the viabilit y of the ap. The posterior
posteriorly in a reverse question mark fashion. The portion of the question m ark should be kept uniform in width
incision w ill end anteriorly at the hairline, close to with the frontotemporal base of the ap to avoid a narrow,
midline. poorly vascularized distal end of the ap. This is achieved
by allowing the reverse question mark to turn superiorly all
The skin opening technique varies w ith surgeon the way to m idline rather than directing it inferiorly into the
preference. The most expedient method that territory m ainly supplied by the occipital artery. A narrow or too
still minimizes blood loss should be used, since caudally directed distal portion of the ap can result in tenuous
trauma patients often have already su ered severe perfusion, poor wound healing, or frank skin necrosis.
hemorrhage and may be acutely anemic and In cases of traum a, the ap should extend as posteriorly as
hypovolemic. The authors prefer to open the skin possible to include the parietal em inence. In cases of ischem ic
w ith a no. 10 blade and to advance through the stroke, the decompression area should be tailored to the
subcutaneous tissue w ith the monopolar. Focal m argins of the infarcted area, allowing only the devitalized brain
bleeding points are controlled w ith both mono- to bulge through the defect.
and bipolar electrocautery. Scalp clips are applied Once the whole incision is open and hemostasis has been
immediately to the skin edges to assist hemostasis. 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.
56
4 Decom pressive Craniectom y for Intracranial Hypertension and Stroke
57
I Cerebral Traum a and Stroke
58
4 Decom pressive Craniectom y for Intracranial Hypertension and Stroke
59
I Cerebral Traum a and Stroke
60
4 Decom pressive Craniectom y for Intracranial Hypertension and Stroke
61
I Cerebral Traum a and Stroke
62
4 Decom pressive Craniectom y for Intracranial Hypertension and Stroke
a b
63
I Cerebral Traum a and Stroke
64
4 Decom pressive Craniectom y for Intracranial Hypertension and Stroke
65
I Cerebral Traum a and Stroke
66
4 Decom pressive Craniectom y for Intracranial Hypertension and Stroke
67
I Cerebral Traum a and Stroke
b c
68
4 Decom pressive Craniectom y for Intracranial Hypertension and Stroke
69
I Cerebral Traum a and Stroke
Monitoring
Im m ed iately p ostop, th e blood p ressu re m u st be m on itored Further Management
closely an d kept w ith in a t igh t rangeh igh en ough to guar-
an tee good cerebral p erfu sion pressu re bu t n ot so h igh as to Th e ICP m on itor can be rem oved if th e values h ave been sta-
risk h em orrh age. ble an d th e n eurologic st at us of th e pat ien t is st able.
Placem en t of an invasive pressu re m on itor is st rongly recom - Post t rau m at ic hydrocep h alu s is a w ell-described p h en om -
m en ded, if n ot already don e, to p erm it accu rate assessm en t en on , an d th e in cid en ce h as been rep or ted to be h igh er in
of ICP in th e postop period. pat ien t s un dergoing decom pressive cran iectom y.20
JP drain ou t pu t sh ou ld be m on itored . Th e drain is u su ally Du ring th e early postoperat ive period, pat ien ts experien ce a
left in p lace for up to 48 h ou rs. CSF in th e drain is n orm al dist urbance in CSF dynam ics th at m ay result in the appearance
an d act u ally ben e cialboth for ICP con t rol an d to preven t of extra-axial e usionsm ost often ipsilateral, but som et im es
leakage from th e in cision . Focal p oin t s of leakage along th e cont ralateral or in terhem isphericw ith or w ithout an asso-
in cision lin e sh ou ld be addressed prom ptly w ith sut ure rein - ciated increase in ventricular size. This early presentat ion of
forcem en t an d, if persisten t , prom pt con sid erat ion of fur th er extern al hydroceph alu s is often ben ign an d ten ds to resolve
radiograp h ic invest igat ion . on ce the bone ap is replaced. Th e integrit y of the w oun d in
Nu rsing st a m u st be in st ru cted to exercise st rict cran iecto- th ese cases can be protected by tem porar y CSF diversion. In
m y p recau t ion s, in cluding posit ion ing of th e h ead to preven t som e patien ts, resolut ion of th e extra-axial e u sion s after
any pressu re on th e defect , avoidan ce of t igh t dressings, an d cran ioplast y is follow ed by the onset of sym ptom atic hydro-
rem oval of any equ ipm en t in th e vicin it y th at could injure th e cephalus, w ith an associated increase in vent ricular size. This
u np rotected brain . 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 neuro-
Medication
logic recover y and usually require shunting.
Sut ures are usually rem oved 14 days after surgery. Th e inci-
Adequ ate sedat ion an d an algesia sh ou ld be p rovided du ring sion should be m onitored closely for any leaks, especially in
th e postoperat ive period, w h ile th e pat ien t rem ain s in t u bat- patients know n to have posttraum atic hydrocephalus. If CSF
ed an d at risk for in t racran ial hyp erten sion . Neu rom u scu lar continues to leak despite suture reinforcem ent, hydro cephalus
blockade can be in t roduced for pat ien t s w ith h igh er ICP val- and infection should be ruled out. It is im portant to rem em -
u es or severe respirator y com plicat ion s. ber that patients w ith hydrocephalus w ho have an active leak
Hyperosm olar th erapyw ith m an n itol or hyper ton ic salin e m igh t not h ave ventricular en largem ent in im aging studies.
is app ropriate if th e ICP rem ain s h igh after decom pression W h en ready for m obilizat ion , pat ien t s sh ould be t ted for
an d rep eat CT iden t i es n o sp ace-occu pying lesion s am en a- a protect ive h elm et to be w orn w h en ou t of bed an d d u ring
ble to surgical th erapy. t ran sport .
Periop erat ive an t im icrobial prop hylaxis is given for 24 h ou rs Th e pat ien t sh ou ld be evaluated for recon st ruct ion of th e
(or un t il th e JP drain is rem oved). cran ial vault approxim ately 4 to 6 w eeks post injur y. Re-
If th e pat ien t p resen ted w ith an op en sku ll fract u re, pen e- placem en t of th e bon e ap is addressed in Ch apter 25. Ad -
t rat ing brain inju r y, or degloving injur y of the scalp, a lon - dit ion al alloplast ic tech n iques for cran ial recon st ruct ion are
ger cou rse of t riple an t ibiot ic th erapy sh ou ld be con sidered . discussed in Ch apter 26.
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4 Decom pressive Craniectom y for Intracranial Hypertension and Stroke
a b
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.
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 expedi- m ay p resen t a p ar t icu lar ch allenge in th e set t ing of t rau m a.
en tly to prevent herniation of the brain and shearing against In su ch sit u at ion s, collaborat ion w ith a p last ics or h ead an d
the dural and bone edge. Earlier in this chapter w e explained n eck su rgeon is essen t ial. Art i cial graft s often are u sed as
our technique of slow ly opening the dura as the duraplast y a tem p orar y m easu re u n t il t issu es h eal su cien tly an d are
graft is being sut ured in place to allow for gradual expan sion clean enough to receive a perm an en t graft , if n eeded.
of the brain. If the surgeon instead has opened the dura com - Th e so-called syn drom e of th e t reph in ed (or sin king scalp
pletely and brain herniation occurs, the follow ing m easures ap syn drom e) in clu des a com bin at ion of n eu rologic sym p -
should be taken : tom s th at can be directly related to th e presen ce of a cran iec-
1. Positioning: Elevate the head of the bed to im prove venous tom y defect an d th at even t ually im prove after cran ioplast y.
drainage. Rule out kinking of the endotracheal tube and/ or Pat ien t s u su ally becom e sym ptom at ic w h en th ey start to sit
neck. u p or am bu late. Most com m on sym ptom s are h eadach e, dis-
2. Ven t ilat ion : Ch eck th e air w ay pressure. Th e an esth esiolo- com fort in th e region of th e cran ial defect , dizzin ess, seizu res,
gist sh ou ld u se th e ven t ilat ion m ode th at ach ieves th e low - an d p sych iat ric alterat ion s. Som e p at ien ts w ill exp erien ce
est air w ay p ressu res possible. m ore severe sym ptom s, in clu d ing orth ostat ic veget at ive dys-
3. PCO2 : Ch eck th e en d-t idal PCO2 . Hyper ven t ilat ion can be fu n ct ion an d focal cran ial n er ve or m otor de cit s. Sym ptom s
p erform ed for a brief p eriod of tim e w ith out det rim en t al are u su ally t riggered or aggravated by th e u p righ t posit ion .
e ects, an d it can buy som e t im e. Sym ptom at ic pat ien t s sh ou ld be evaluated for a cran ial vault
4. Hyperosm olar th erapy: Man n itol, hyperton ic salin e, an d recon st ruct ion as soon as possible.
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
References
t apping th e ven t ricle th rough th e exposed an terior fron tal
1. Horsley V. Address in Su rger y: Delivered at th e seven t y-fou r th
lobe if a ven t riculostom y w as n ot previou sly in serted. an n ual m eet ing of th e brit ish m edical associat ion . Br Med J
6. Low ering of CMRO2 : Con sid er a bolu s of barbit u rates or 1906;2(2382):411423
etom idate. 2. Cu sh ing H. Tech n ical m eth ods of p erform ing cer t ain cran ial op -
7. Undiagnosed m ass lesion: Bear in m ind that a hem atom a erat ion s. Surg Gyn ecol Obstet 1908;3(6):227246
either extra-axial or intraparenchym alm ay develop as a result 3. Kjellberg RN, Prieto A Jr. Bifron t al d ecom p ressive cran iotom y for
of reperfusion achieved by opening the cranial compartm ent. 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 13. Sch irm er CM, Hoit DA, Malek AM. Decom p ressive h em icra-
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 ): n iectom y for th e t reat m en t of in t ract able int racranial hyper-
429433 ten sion after an eur ysm al subarach n oid h em orrh age. St roke
5. Gaab MR, Rit t ierodt M, Loren z M, Heissler HE. Trau m at ic brain 2007;38(3):987992
sw elling an d operat ive decom pression : a prospect ive invest iga- 14. Ste n i R, Lat ron ico N, Corn ali C, Rasu lo F, Bollat i A. Em ergen t
t ion . Act a Neu roch ir Suppl (Wien ) 1990;51:326328 decom pressive cran iectom y in p at ien t s w ith xed dilated p u p ils
6. Aarabi B, Hesdor er DC, Ah n ES, Aresco C, Scalea TM, Eisen - du e to cerebral ven ou s an d du ral sin u s th rom bosis: rep or t of
berg HM. Ou tcom e follow ing decom p ressive cran iectom y for th ree cases. Neu rosu rger y 1999;45(3):626629
m align ant sw elling du e to severe h ead injur y. J Neurosurg 15. Adam o MA, Desh aies EM. Em ergen cy decom pressive cran i-
2006;104(4):469479 ectom y for fulm in at ing infect ious en ceph alit is. J Neu rosurg
7. Morgalla MH, Will BE, Roser F, Tat agiba M. Do long-term resu lt s 2008;108(1):174176
ju st ify decom pressive cran iectom y after severe t raum at ic brain 16. Coloh an AR, Gh ost in e S, Esp osito D. Exploring th e lim it s of su r-
injur y? J Neurosu rg 2008;109:685690 vivabilit y: rat ion al in dicat ion s for decom p ressive cran iectom y
8. Weiner GM, Lacey MR, Mackenzie L, et al. Decom pressive craniecto- an d resect ion of cerebral con t u sion s in adu lt s. Clin Neu rosu rg
my for elevated intracranial pressure and its e ect on the cum ulative 2005;52:1923
ischem ic burden and therapeutic intensity levels after severe trau- 17. Flan n er y T, McCon n ell RS. Cran iop last y: w hy th row th e bon e ap
m atic brain injury. Neurosurgery 2010;66(6):11111118 out? Br J Neurosurg 2001;15(6):518520
9. Eberle BM, Sch n riger B, In aba K, Gr u en JP, Dem et riades D, Bel- 18. In am asu J, Ku ram ae T, Nakat su kasa M. Does di eren ce in th e
zberg H. Decom pressive cran iectom y: su rgical con t rol of t rau - storage m eth od of bon e ap s after d ecom p ressive cran iectom y
m at ic in t racranial hyper ten sion m ay im prove outcom e. Injur y a ect th e in ciden ce of su rgical site in fect ion after cran iop last y?
2010;41(7):934938 Com parison bet w een su bcu t an eou s p ocket an d cr yopreser va-
10. Bu llock MR, Ch esn u t R, Gh ajar J, et al. Gu idelin es for th e Su rgical t ion . J Traum a 2010;68(1):183187; discussion 187
Man agem en t of Traum at ic Brain Inju r y Auth or Group. Neurosur- 19. Jiang JY, Xu W, Li W P, et al. E cacy of st an dard t rau m a cran i-
ger y 2006;58(3):S262 ectom y for refractor y in t racran ial hyper ten sion w ith severe
11. Kakar V, Nagaria J, Kirkp at rick JP. Th e cu rren t st at u s of d ecom - t raum at ic brain injur y: a m ult icenter, prospect ive, ran dom ized
pressive cran iectom y. Br J Neurosurg 2009;23(2):147157 cont rolled st udy. J Neurot rau m a 2005;22(6):623628
12. Vah edi K, Hofm eijer J, Ju et tler E, et al. Early decom pressive su r- 20. Ch oi I, Park HK, Ch ang JC, Ch o SJ, Ch oi SK, Byu n BJ. Clin ical
ger y in m align an t in farct ion of th e m iddle cerebral ar ter y: a factors for th e develop m en t of p ost t rau m at ic hydrocep h a-
pooled an alysis of th ree ran dom ised con t rolled t rials. Lan cet lus after decom pressive cran iectom y. J Korean Neurosurg Soc
Neurol 2007;6(3):215222 2008;43(5):227231
72
5 Surgery for Cerebellar Stroke and
Suboccipital Trauma
Faiz U. Ahm ad and Ross Bullock
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 gyback [IVPB]) m ay be given if clin ical deteriorat ion occurs.
to th e op erat ing room directly, w ith ou t a rep eat CT scan . Th e Oth er w ise, a bolu s is adm in istered prior to skin in cision in
t im e requ ired to com plete an addit ion al diagn ost ic st u dy m ay th e operat ing room .
n ot be w or th th e diagn ost ic yield in th is set t ing. Th ere is n o role for preoperat ive an t iepilept ics un less th ere is
Preo perative im aging (Fig. 5.1). 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
Ventriculostomy h osp it al p rotocol.
74
5 Surgery for Cerebellar Stroke and Suboccipit al Traum a
a b
c d
75
I Cerebral Traum a and Stroke
Operative Procedure
Positioning (Fig. 5.2a, b)
76
5 Surgery for Cerebellar Stroke and Suboccipit al Traum a
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
a b
78
5 Surgery for Cerebellar Stroke and Suboccipit al Traum a
Fig. 5.5 The bony exposure should extend from the inion to the foramen Care should be taken to avoid stripping the
magnum. A w ide exposure is needed for cerebellar infarcts, muscles o the spinous process and lam ina of
extending laterally to a centimeter from the mastoid process. C2 as this is a m ajor insertion point for m any
This essentially means incorporating the w hole of the w ide of the stabilizing m uscles of the neck.
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.
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
a b
Fig. 5.6 (a) Bur holes are placed at the level of the transverse sinus (approximately Protect the drill from slipping
1 cm below the inion), to either side of midline. We typically use a perforator into the foram en m agnum region
drill; alternately, a matchstick or acorn bur may be employed. A second set of during initial stages of the drilling.
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.
80
5 Surgery for Cerebellar Stroke and Suboccipit al Traum a
81
I Cerebral Traum a and Stroke
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
5 Surgery for Cerebellar Stroke and Suboccipit al Traum a
83
I Cerebral Traum a and Stroke
Fig. 5.10 In case of an intracerebellar hematoma, a 2- to 3-cm corticectomy is Ultrasound can be useful for sm aller
made over the site of clot presentation w ith a bipolar and microscissors/ and/or deeply located hem atom as,
no. 11 blade. White matter is gently suctioned in the direction of the clot or if the hem atom a is not found
until the hematoma cavity is accessed. A brain cannula (e.g., Dandy) can be at the anticipated site after the
passed into the clot to assist in localization. corticectomy.
The clot is gently suctioned out using no. 9 or no. 12 suction tips. Discrete Surgical loupes and a headlight are
bleeding points are identi ed and coagulated. Self-retaining brain useful adjuncts at this point.
retractors assist the exposure during hemostasis. Fukushima (teardrop side
port) suction tips (e.g., no. 7) may be useful during the hemostasis stage.
The brain w ill usually be slack after clot removal. If not, cerebrospinal uid Always keep in m ind the location of
drainage from the cisterna magna should be attempted prior to resection the fourth ventricle while suctioning
of edematous cerebellum. the depths of the hem atom a cavit y.
84
5 Surgery for Cerebellar Stroke and Suboccipit al Traum a
Fig. 5.11 In the case of surgery for infarction, w ide decompression is the primary In som e cases, severe cerebellar swelling
objective. The posterior rim of the foramen magnum should alw ays be due to autonom ic dysregulation can
opened. Resection of infarcted cerebellum is required only if closure is occur.
di cult. Release of cerebrospinal uid from the cisterna magna is more
useful for infarcts than for hematoma.
85
I Cerebral Traum a and Stroke
86
5 Surgery for Cerebellar Stroke and Suboccipit al Traum a
Epidural tacking stitches are not necessary except in the setting of If epidural tacking stitches are placed, care
epidural hematoma. must be taken (in particular, along the
superior edge) to avoid the venous sinuses.
87
I Cerebral Traum a and Stroke
a b
c 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
5 Surgery for Cerebellar Stroke and Suboccipit al Traum a
Monitoring 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
Th e pat ien t is obser ved in a m on itored set t ing (in ten sive care Ner v Sys 1993;9:224228
u n it), at least overn igh t . 6. Berker M, Cat altepe O, Ozcan OE. Trau m at ic epid u ral h aem atom a
No sedat ion is given if th e p at ien t is ext u bated. 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
Medication 1999;22:3440
Prophylact ic an t ibiot ics are con t in ued for 24 h ours, regard- 8. Moh an t y A, Kollu ri VR, Su bbakrish n a DK, Sat ish S, Mou li BA,
less of th e p resen ce of ven t ricu lostom y. 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 fac-
tors in th e t reat m en t of cerebellar h aem orrh age. Act a Neuroch ir
Radiographic Imaging (Wien ) 1994;131:5966
A n on con t rast CT scan is obt ain ed in th e early postopera- 10. Mah ajan RK, Sh arm a BS, Kh osla VK, Tew ari MK, Math uriya
t ive period to assess th e st at us of th e h em orrh age, decom - 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
p ression , an d ven t ricular size. Th e early postoperat ive st udy
1993;22:410413
also allow s screen ing for th e develop m en t of a delayed epi-
11. Auer LM, Auer T, Sayam a I. In dicat ion s for surgical t reat m en t of
dural or in t racerebral h em orrh age at a dist an t , supraten torial
cerebellar h aem orrh age and in farct ion . Act a Neuroch ir (Wien )
locat ion w h ich is n ot un com m on . 1986;79:7479
Po sto perative im aging (Fig 5.14). 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
Further Management 13. Kirollos RW, Tyagi AK, Ross SA, van Hille PT, Marks PV. Man age-
m en t of spon t an eous cerebellar h em atom as: a prospect ive t reat-
Th e drain (if presen t) is rem oved over th e n ext 24 to 48 h ours. m en t protocol. Neurosurger y 2001;49:13781386
Skin su t u res or st aples are rem oved after 1 to 2 w eeks. 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. Cer-
References ebellar in farct ion w ith obst r uct ive hydroceph alus. J Neurosurg
1982;57:8391
1. Hayash i T, Kam eyam a M, Im aizu m i S, Kam ii H, On u m a T. Acu te 16. Kh an M, Polyzoidis KS, Adegbite AB, McQueen JD. Massive
epidural h em atom a of the posterior fossacases of acute clin ical cerebellar infarct ion : con ser vat ive m an agem en t . St roke 1983;
deteriorat ion . Am J Em erg Med 2007;25:989995 14:745751
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 17. Wong CW. Th e CT criteria for con ser vat ive t reat m en tbu t
h e m or rh age: a clin ical review . An est h An alg 2010;110:1419 un der close clin ical obser vat ion of posterior fossa epidural
1427 h aem atom as. Act a Neurochir (Wien ) 1994;126:124127
3. Karasu A, Saban ci PA, Izgi N, Im er M, Sen cer A, Can sever T, 18. Bor-Seng-Sh u E, Aguiar PH, de Alm eida Lem e RJ, Man del M,
Can bolat A. Trau m at ic epid u ral h em atom as of th e p osterior An drade AF, Marin o R, Jr. Epidural h em atom as of th e posterior
cran ial fossa. Surg Neurol 2008;69:247251 cran ial fossa. Neu rosurg Focus 2004;16:ECP1
4. Koc RK, Pasaoglu A, Men ku A, Oktem S, Meral M. Ext radu ral 19. dAvella D, Ser vadei F, Scerrat i M, et al. Trau m at ic in t racerebellar
h em atom a of th e posterior cran ial fossa. Neu rosurg Rev h em orrh age: clin icoradiological an alysis of 81 pat ien t s. Neuro-
1998;21:5257 surger y 2002;50:1625
89
6 Elevation of Depressed
Skull Fractures
Anand Veeravagu, Bow en Jiang, and Odet te A. Harris
90
6 Elevation of Depressed Skull Fractures
a b
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
6 Elevation of Depressed Skull Fractures
a b
93
I Cerebral Traum a and Stroke
94
6 Elevation of Depressed Skull Fractures
95
I Cerebral Traum a and Stroke
96
6 Elevation of Depressed Skull Fractures
97
I Cerebral Traum a and Stroke
98
6 Elevation of Depressed Skull Fractures
Further Management t 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
Post t raum at ic an d postoperat ive m an agem en t are perform ed u n dergo skin debridem en t w ith out elevat ion of th e de-
in accordan ce w ith p ublish ed TBI gu idelin es. p ressed bon e segm en t . How ever, if th e pat ien t is n eurologi-
Skin su t u res or st ap les m ay be rem oved in 7 to 10 days, cally un st able, urgen t elevat ion m ay be required.
dep en ding on t ype of injur y an d w ou n d closu re. In the case of sinus throm bosis, the anterior one-third of the
Prophylact ic an t ibiot ics are given for 5 to 7 days to lessen th e superior sagit tal sinus usually can be ligated w ithout conse-
risk of cen t ral n er vou s system in fect ion . Th e au th ors p refer quence. However, injury to the posterior t w o-thirds of the sinus
in t raven ou s cefazolin or piperacillin -t azobact am . How ever, requires either prim ary repair or interposition grafting (w ith a
th ere is in su cien t eviden ce to support a speci c agen t or galeal or pericranial patch). Alternatively, a piece of m uscle or
durat ion of th erapy in th is set t ing. gelatin sponge can be sutured over the sinus as a bolster.
An t iconvulsan t s are often given to reduce risk of seizures, If the native bone cannot be replaced, either titanium cranioplas-
alth ough th e su pp or t ing eviden ce is equ ivocal. t y or a polyetheretherketone (PEEK) im plant m ay be considered.
a b
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 3. Con n olly ES. Fu n dam en t als of Op erat ive Tech n iqu es in Neu ro-
surger 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 .
1. Qu resh i N, Harsh G. Sku ll fract u re. Availab le on lin e at: h t t p :// New York: Th iem e Medical Publish ers; 2006
em e d icin e.m e d scap e.com /ar t icle /248108- ove r view 5. March er S, An dres RH, Fath i AR, Fan din o J. Prim ar y recon st ru c-
2. Bullock MR, Chesnut R, Ghajar J, et al. Surgical m anagem ent of de- t ion of open depressed skull fract ures w ith t it aniu m m esh . J Cra-
pressed cranial fract ures. Neurosurger y 2006;58(3 Suppl):S5660 n iofac Surg 2008;19(2):490495
100
7 Invasive Neuromonitoring Techniques
Mathieu Laroche, Michael C. Huang, and Geof rey T. Manley
101
I Cerebral Traum a and Stroke
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
7 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)
104
7 Invasive Neurom onitoring Techniques
105
I Cerebral Traum a and Stroke
106
7 Invasive Neurom onitoring Techniques
107
I Cerebral Traum a and Stroke
108
7 Invasive Neurom onitoring Techniques
109
I Cerebral Traum a and Stroke
a b
Fig. 7.8 (a) Using a trocar, the ventricular catheter is tunneled Secure the Luer lock connection with a 2-0 silk tie.
about 5 cm from the incision.
(b) After removing the trocar, a Luer lock and cap are A gentle loop of the external portion of the catheter perm its
applied. The EVD is secured to the skin at multiple stay sutures at 3, 6, 9, and 12 oclock. Failure to secure the EVD
points w ith 3-0 nylon stitches. adequately to the patient may leave the system vulnerable to
unintended, traumatic explantation.
110
7 Invasive Neurom onitoring Techniques
111
I Cerebral Traum a and Stroke
Intraparenchymal Monitor Visualization of the ICP waveform during insertion can assist
The probe then is introduced into the central in the placem ent. If no waveform or an unexpectedly high
opening of the bolt apparatus and advanced into pressure is observed, rem ove the probe temporarily, reassess
the brain parenchymadeep enough to obtain a the patency of the dural opening, and consider irrigation with a
reliable ICP measurement (no more than 2.5 cm). sm all am ount of sterile saline.
The pressure probe then is secured to the bolt The ICP m onitor can be tested after insertion with brief bilateral
system or tunneled and secured to the skin m anual compression of the jugular veins (Queckenstedt
depending on the system. m aneuver). This m aneuver reduces venous out ow and,
thereby, increases ICP.
Variation for Brain Tissue Oxygen Monitor There should be no resistance when the inner sleeve and the
After ensuring that the dura and the pia are brain tissue oxygen probe are inserted if the dura is widely open
opened, the inner sleeve is inserted into the bolt. and the pia has been pierced. Any signi cant resistance during
The brain tissue oxygen probe, in turn, is inserted placem ent of the inner sleeve indicates a need for wider dural
through the inner sleeve into its predetermined opening. Resistance during probe placem ent could m ean that
port. The inner sleeve then is secured to the bolt by the probe is m igrating in the epidural space or sliding over the
a screw. brain. An FiO2 challenge (rapid increase in inspired oxygen to
100%) should be used to verify that the probe is functioning.
112
7 Invasive Neurom onitoring Techniques
113
I Cerebral Traum a and Stroke
114
7 Invasive Neurom onitoring Techniques
115
I Cerebral Traum a and Stroke
116
7 Invasive Neurom onitoring Techniques
a b
c d e
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 p ract it ion er sh ould be aw are th at th e m easurem en t of SjVO2
w orse ou tcom e after severe TBI, w h ereas a h igh valu e (. 80%) is ext rem ely labor in ten sive because of th e frequ en t n eed to
m ay correlate eith er w ith hyp erem ia (w h ere in creased ow assess th e p osit ion of th e p robe an d to com pare blood sam -
redu ces th e sat u rat ion di eren ce) or w ith brain death (w h ere ples obtain ed from th e t ip of th e cath eth er to th e valu es ob -
im p aired m etabolism an d t issue death redu ce th e sat urat ion t ain ed by oxim et r y.
di eren ce). Th e obser ved value is sen sit ive to th e posit ion of Cerebral blo o d f ow (CBF) m o nitoring: An in t rap aren chy-
th e cath eter. Con t am in at ion by ext racerebral ven ous blood, m al p robe m easu res th e local blood ow u sing a th erm al
for exam p le, w ill lead to a low er valu e.12,13 As w ith brain t is- di usion tech n ique. Th e probe is in serted in th e w h ite m at -
su e oxygen m on itoring, p oten t ial system ic cau ses (hypoxia, ter (n orm al CBF 2035 m L/100 g/m in ). A valu e of less th en
hypoten sion , hypocarbia, an em ia) m ust be ruled out w h en a 9 m L/100 g/m in in dicates a degree of isch em ia th at w ill lead
low valu e is obser ved. Alth ough m u ch con t roversy exists re- to irreversible cellular dam age. It is im port an t to n ote th at th e
garding th e opt im al sid e for p lacem en t of th e SjVO2 probe, it m easu red valu e re ects th e st at u s of on ly th e sm all, sph eri-
is t yp ically in ser ted on th e righ t side becau se th e righ t t ran s- cal volu m e of brain t issue (27 m m 3 ) aroun d th e cath eter
verse sin u s is th e m ost frequ en tly th e dom in an t site for th e t ip an d th at th e m easurem en t is ext rem ely probe posit ion -
ven ou s drain age of th e brain . Th e jugu lar ven ou s sat u rat ion depen den t .1416 Proxim it y of th e probe to inju red t issu e w ill
m on itor, w h en u sed in com bin at ion w ith th e PbtO2 probe, produ ce a low er CBF valu e as com pared w ith th at m easured
p rovides both a global (SjVO2 ) an d a focal (PbtO2 ) assessm en t by a probe position ed w ith in n orm al-appearing cor tex.
of brain t issue oxygen at ion . Th is com bin at ion allow s for Micro dialysis: A m icrodialysis p robe allow s for th e st u dy of
th e dist in ct ion bet w een hyperem ia an d h ardw are failure if th e brain t issue ch em ist r y th rough m easurem en t s of cere-
a valu e seem s to be ou t of range. Moreover, th e t an dem u se bral m et abolism . Glucose, pyruvate, an d lact ate are m arkers
of SjVO2 an d PbtO2 m ay facilitate m odi cat ion of th erapy to of en ergy m et abolism . Glutam ate an d glycerol are m arkers
opt im ize CPP in th e set t ing of im paired autoregulat ion . Th e 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 4. Bellan der BM, Can t ais E, En blad P, et al. Con sen su s m eet ing
brain injur y. Microdialysis h as been used in th e set t ing of se- on m icrodialysis in neu roin ten sive care. In ten sive Care Med
vere TBI an d su barach n oid h em orrh age to p redict isch em ia 2004;30(12):21662169
an d vasosp asm .4 Th e use of m icrodialysis is labor in ten sive 5. OLear y ST, Kole MK, Hoover DA, Hysell SE, Th om as A, Sh a rey
an d n ecessitates a h igh ly t rain ed team . Resu lts w ill d i er de- CI. E cacy of th e Gh ajar Guide revisited: a prospect ive st udy.
J Neu rosurg 2000;92(5):801803
pen ding on w h eth er th e probe is posit ion ed w ith in n orm al
6. Tom a AK, Cam p S, Watkin s LD, Grieve J, Kitch en ND. Extern al
or con t used t issue.17
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
Special Considerations 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
ICP rem ain s th e corn erston e of invasive brain m on itoring. Ad- 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
van ced n eu rom on itoring tech n iqu es p rovide an op port u n it y
of th e tech n ique an d resu lt s of a feasibilit y st udy in 97 pat ien t s.
for bet ter u n derstan ding of cerebral path ophysiology; h ow ever,
J Neu rot raum a 2006;23(10):15101517
e ect ive u se of th is tech n ology requ ires an u n d erst an ding of
9. Narot am PK, Morrison JF, Nath oo N. Brain t issu e oxygen m on i-
h ow to both properly p lace th e p robe an d in terpret th e dat a. toring in t rau m at ic brain inju r y an d m ajor t rau m a: ou tcom e
Dat a derived from th ese m odalit ies are ext rem ely depen den t an alysis of a brain t issue oxygen -directed th erapy. J Neurosurg
on th e posit ion of each probe. Th erefore, veri cat ion of probe 2009;111(4):672682
posit ion is essen t ial prior in it iat ing sign i can t ch anges in clin i- 10. Rose JC, Neill TA, Hem p h ill JC, 3rd. Con t in u ou s m on itoring of th e
cal m an agem en t . Fu rth erm ore, pat ien t s requiring su ch m on i- m icrocircu lat ion in n eurocrit ical care: an update on brain t issue
toring t yp ically are com p lex an d m ay p resen t w ith a variet y of oxygen at ion . Cu rr Op in Crit Care 2006;12(2):97102
cerebral path ophysiologic abn orm alit ies. Th e pract it ion er m ust 11. Spiot t a AM, St iefel MF, Gracias VH, et al. Brain t issu e oxygen -
possess a deep an d clear un derst an ding of cerebral physiology directed m an agem en t an d ou tcom e in pat ien t s w ith severe t rau -
an d m et abolism in order to u se th e in form at ion e ect ively in m at ic brain injur y. J Neurosurg 2010;113(3):571580
th e pat ien t-speci c t reat m en t of TBI. In sum m ar y, w h ile th ere 12. Fan din o J, Stocker R. Cath eterizat ion of th e in tern al jugu lar vein
does exist a role for th e use of advan ced n eu rom on itoring tech - for jugular bulb oxygen sat urat ion m on itoring after brain injur y.
J In ten Care Med 1999;14:270290
n iques, th e resu lt s m ust be in terp reted an d ap plied crit ically.
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 sberg-
References er 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 )
1. Brat ton SL, Ch est n u t RM, Gh ajar J, et al. Gu idelin es for th e 2005;147(1):5156; discussion 56
m an agem en t of severe t rau m at ic brain injur y. VII. In t racran ial 15. Bh at ia A, Gu pt a AK. Neu rom on itoring in th e in ten sive care u n it . I.
pressure m on itoring tech n ology. J Neu rot raum a 2007;24 Suppl In t racran ial pressure an d cerebral blood ow m on itoring. In ten -
1:S4554 sive Care Med 2007;33(7):12631271
2. Brat ton SL, Ch est n u t RM, Gh ajar J, et al. Gu idelin es for th e m an - 16. Vajkoczy P, Roth H, Horn P, et al. Con t in u ou s m on itoring of
agem en t of severe t raum at ic brain injur y. VI. Indicat ion s for in - region al cerebral blood ow : experim en t al an d clin ical vali-
t racranial pressu re m on itoring. J Neurot raum a 2007;24 Suppl dat ion of a n ovel th erm al di usion m icroprobe. J Neurosurg
1:S3744 2000;93(2):265274
3. Brat ton SL, Ch est n u t RM, Gh ajar J, et al. Gu idelin es for th e m an - 17. Engst rom M, Polito A, Rein st ru p P, et al. In t racerebral m icrodialy-
agem en t of severe t raum at ic brain inju r y. X. Brain oxygen m on i- sis in severe brain t raum a: th e im por t an ce of catheter locat ion .
toring an d th resh old s. J Neu rot rau m a 2007;24 Su p pl 1:S6570 J Neu rosu rg 2005;102(3):460469
118
8 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 The totalit y of the obser ved injury re ects a com bination of
penet rat ing, n ot all su ch inju ries are alike. Th e term penet rat ing forces: (1) direct crush injur y in icted by the projectile along
inju r y tech n ically describes th e sit uat ion in w h ich a project ile its path; (2) cavitation produced by the centrifugal e ects of the
en ters th e sku ll bu t does n ot exit . A perforat ing injur y occurs projectile on the parenchym a; and (3) stretch injury resulting
w h en th e project ile passes en t irely th ough th e h ead, leaving from th e shock wave generated by the projectile in transit.
both an en t ran ce an d an exit w oun d. Th is dist in ct ion h as Each m ust be factored into the decision-m aking process.
progn ost ic im plicat ion s. In a series of project ile-related h ead Tw o fun dam en tal decision s drive m an agem en t: (1) w h eth er
inju ries du ring th e Iran -Iraq War, p at ien ts t reated for perforat- or n ot to operate an d, if so, (2) th e exten t of th e in ter ven t ion
ing w ou n d s h ad a poorer post su rgical outcom e (50% greater to be un der taken .
m orbidit y an d m ort alit y) th an th ose t reated for p en et rat ing Th e decision of w hether or not to operate is dict ated both by
w ou n ds.1 clin ical st at us an d th e obser ved radiograph ic path ology.
Pen et rat ing h ead inju ries m ay resu lt from in ten t ion al or Su pp ort ive, expect an t (n on operat ive) m an agem en t m ay be
un in ten t ion al even ts, in clud ing sh oot ings, st abbings, blast in - ap p rop riate for a pat ien t p resen t ing w ith a Glasgow Com a
ju ries, an d m otor veh icle or occup at ion al acciden t s (e.g., n ails). Scale (GCS) score 5 an d bilateral xed, dilated pupils
Stab w ou n ds are ch aracterized by a sm aller im pact area an d post-resuscit at ion .
low er velocit y th an m issile w oun ds. For th e p urp oses of th is If such a patient presents w ith a potentially reversible m ass
chapter, w e lim it ou r discussion to m issile w oun ds. lesion and is deem ed otherw ise m edically viable, consid-
Historically, th e m an agem en t of civilian m issile inju ries h as eration m ay be given to em ergent operative intervention.
been in form ed by an d evolved in con cer t w ith m ilit ar y prac- If n o ext ra-axial m ass lesion is presen t , con siderat ion m ay
t ice. Sin ce World War II, m ilitar y n eurosurgeon s h ave un iform ly be given to a t rial of hyperosm olar th erapy (20% m an n i-
advocated th orough debridem en t an d w ater t igh t du ral closu re tol bolus 1 g/kg); if a sign i can t im provem en t in m otor
to preven t cerebrosp in al u id (CSF) leak an d p ossible in fect ion . exam an d/or pu pillar y respon se is n oted , th e p at ien t m ay
During th e Viet n am War era, cran iectom y or cran iotom y w as be con sidered a poten t ial can didate for surger y.
accom pan ied by aggressive d ebridem en t of th e in -driven bon e, Hem odyn am ic in st abilit y an d/or p rofou n d coagu lopathy
project ile fragm en t s, an d associated debris. Th e pursuit of m ay in u en ce th e d ecision to forego op erat ive in ter ven t ion .
debris in to areas of poten t ially viable brain t issue w as believed Certain om inous radiographic ndings portend a poor prog-
to be respon sible for addit ion al n eu rologic de cit s an d im pair- nosis: anteroposterior or bilateral hem ispheric through-
m en t .2,3 Part ially in respon se to th is n ding an d as th e result and-through trajector y; or trajectory through the brainstem ,
of experien ce glean ed from m ult iple m ilitar y con icts over th e hypothalam us, posterior fossa, and/or venous sinuses. These
past 40 years, a n ew m an agem en t paradigm h as em erged. In i- factors should be taken into account w hen determ ining can-
t ial t reatm en t of project ile w oun ds of th e brain is n ow design ed didacy for operative inter vention.
to p reser ve th e m axim u m cerebral t issu e an d fu n ct ion eith er by On th e oth er h an d, a p at ien t p resen t ing w ith a GCS score of
lim it ing th e w ou n d debridem en t p erform ed th rough a cran iec- 14 or 15 an d m in im al radiograph ic injur y m ay require on ly
tom y or by care of scalp w ou n ds on ly.46 Branvold et al fou n d n o local w oun d care an d close obser vat ion .
relat ion sh ip bet w een th e presen ce of ret ain ed fragm en ts an d Clin ical exam an d radiograph ic feat u res gu ide th e extent of
th e developm en t of eith er a seizure disorder or an in fect ion of operat ive intervent ion.5,8
th e cen t ral n er vous system .7 Fin dings such as th is on e support Lim ited su rger y m ay be app ropriate for a pat ien t presen t-
th e grow ing con sen su s th at rout in e reoperat ion for rem oval of ing w ith a sm all en t ran ce w oun d, coupled w ith m in im ally
retain ed fragm en ts is u n n ecessar y. Th e n et result of th is st rat- depressed bon e fragm en t s an d lit tle or n o m ass e ect an d/
egy h as been im p roved ou tcom es w ith sign i can tly d ecreased or h em atom a on h ead com puted tom ography (CT). Su ch a
m orbidit y an d m ort alit y. 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 of an atom ic in form at ion . CT w ill reveal th e presen ce of
e ect, som e in-driven bone fragm ents, som e projectile frag- h em atom a an d foreign bodiesboth bony an d m et allicas
m ents, and m ild to m oderate cerebral edem a. Only the easily w ell as in form at ion regard ing th e likely m issile t rajector y.
accessible bone and projectile fragm ents should be retrieved. Th e CT sh ould be st udied for poten t ial violat ion of vascular
Aggressive adjacent brain debridem ent should be avoided. st ru ct u res.
These patients do very well w ith a com bination of copious If direct vascu lar inju r y is su spected , em ergen cy vascu lar
intraoperative antibiotic irrigation, form al dural closure, good im aging m ay be approp riate.
scalp closure, and periprocedural broad-spectrum antibiotics. Im aging n dings arou sing su spicion m ay in clu de: orbitofa-
Craniotom y/craniectom y w ith m ore extensive debridem ent cial or pterion al locat ion ; t rajector y th rough a ven ous sin us
is appropriate in the presence of signi cant m ass e ect. or th e Sylvian ssure; th e presen ce of fragm en t s crossing
Space-occupying lesions should be evacuated. Debridem ent dural com par t m en t s; or th e presen ce of a large h em atom a
of necrotic brain tissue, along w ith safely accessible bone and proxim ate to a n am ed vessel.
m issile fragm ents, is recom m ended.5,10,11 Deep-seated bone Form al cerebral angiograp hy n ot on ly perm it s d iagn ost ic
and m issile fragm entsespecially in eloquent areasshould assessm en t bu t also o ers th e poten t ial for in ter ven t ion .
not be retrieved because this has been show n to correlate In recogn it ion of expedien cy, CT angiograp hy m ay be
w ith worse outcom es. When the projectiles trajectory tra- an oth er opt ion in th is set t ing.9
verses an air sinus, operative intervention is recom m ended to A single n egat ive st u dy does n ot d e n it ively ru le ou t inju r y.
achieve water-tight closure of the dam aged dura.1,9 This m ay Th e developm en t of un explain ed subarach n oid h em or-
decrease the risk of CSF stula and abscess form ation.1,12 rh age or h em atom a in th e days follow ing th e in it ial inju r y
No eviden ce-based recom m en dat ion s address th e t im ing of m ay p rovide an in dicat ion for delayed or rep eat im aging.
in ter ven t ion . Here, pragm at ism ap plies. Magn et ic reson an ce im agin g (MRI) is ge n e rally con t rain -
If a sign i can t space-occu pying lesion is p resen t , em ergen t 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 al-
su rgical in ter ven t ion is w arran ted for relief of m ass e ect lic fore ign b od y. How eve r, it sh ou ld b e n ot e d t h at m ost
as a life-saving m easu rew ith th e recogn it ion th at it m ay civilian am m u n it ion p ar t icu larly p istol am m u n it ion is
n ot ch ange ou tcom e. act u ally n on fe r rom agn et ic an d , h yp ot h et ically, sh ou ld n ot
If n dings suggest ing m ass e ect are less com p elling, it p re clu d e MRI evalu at ion . Cau t ion m u st b e exe rcise d w it h
w ou ld be reason able to m on itor in t racran ial pressu re (ICP) 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
an d m an age expect an tly. sh ot (d u e to Environ m e n t al Prote ct ion Age n cy legislat ion
If th e goal is sim ple w ou n d care, it w ou ld follow th at exp e- regard in g lead p ollu t ion ). MRI m ay p lay a role in t h e d iag-
dien t in ter ven t ion m ay dim in ish th e risk of in fect ion an d n ost ic evalu at ion of p e n et rat in g in ju r ies from w ood e n or
CSF com p licat ion s.9,10 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 i-
cal 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 r-
for 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
Preprocedure Considerations 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).
General
At ten d to th e ABCs of resu scitat ion (air w ay, breath ing,
circulat ion ).
Medication
Con t rol brisk bleeding from th e scalp an d associated w oun ds An t im icrobial prophylaxis is adm in istered. Broad-spect rum
w ith h em ost at s or tem porar y st aple closure, as w ell as a pres- coverage, perh aps skew ed tow ard skin ora, is appropriate in
su re dressing. Large, isolated scalp w ou n d s m ay lead to fat al th e set t ing of gross con t am in at ion of th e w ou n d.
blood loss. An t iepilept ic drug prophyla xis is in it iated.
Docu m en t en t ran ce an d exit (if p resen t) w ou n ds, as w ell as A loading dose of m an n itol 20% (1 g/kg) m ay be given .
th e presen ce of pow der burn s, CSF leak, an d brain h ern iat ion . A t ype an d cross-m atch sh ou ld be perform ed. Coagulopa-
Early invasive ICP m on itoring is an opt ion w h en un able to thy often develops in th e set t ing of pen et rat ing injur y due
follow a serial n eurologic exam , w h en th e n eed to evacu ate to in creased t issue th rom boplast in act ivit y. En sure avail-
an obser ved m ass lesion is u n cert ain , an d/or w h en im aging abilit y of a range of blood p rodu cts (red blood cells, fresh
suggest s in creased in t racran ial p ressu re.9 Brain t issu e oxygen frozen plasm a, an d p latelets), as w ell as adju n ct ive agen ts
m on itoring m ay be con sidered as w ell. (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.
Radiographic Imaging
Anteroposterior and lateral skull X-rays m ay provide general in-
form ation regarding the presence of radiopaque foreign bodies
Operative Field Preparation
as well as entrance and exit sites. The ease w ith w hich m ultipla- If vascu lar inju r y is su sp ected, en su re th at app rop riate
nar CT can be obtained in m ost settings has largely obviated the su p p lies (m icroscop e, an eu r ysm clip s, m icrosu rgical in st ru -
need for this diagnostic m odalit y. m en t s, blood produ cts) are available prior to skin in cision .
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8 Surgical Debridem ent of Penetrating Injuries
a b
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
c 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 ovidon e-iodin e or ch lorh exidin e solu t ion in th e usu al sterile
p reparat ion of th e eld. fash ion . Avoid th e lat ter if exp osed brain is presen t . A dilu ted
Foreign bod ies prot ruding from th e h ead are left in place d ur- p ovidon e-iodin e solut ion m ay be u sed for th e preparat ion of
ing prep arat ion of th e su rgical site. large con t am in ated w ou n ds.
A w ide area of scalp is sh aved to ensure iden t i cat ion of Th e in cision is m arked an d in lt rated w it h 1% lid ocain e
en t ran ce an d exit sites, to clear su p er cial scalp d ebris, an d w it h 1:100,000 ep in ep h r in e. Avoid areas of exp osed brain
to allow for a large cran ial open ing. t issu e.
121
I Cerebral Traum a and Stroke
Operative Procedure
Positioning (Fig. 8.2)
Fig. 8.2 The patient position w ill be dictated by the localization of the If the cervical spine has not been cleared,
pathology. A donut or horseshoe head holder is used to expedite the the cervical collar should be m aintained
procedure. and the patient rotated in-line to expose
the side of the approach.
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.
122
8 Surgical Debridem ent of Penetrating Injuries
Fig. 8.3 A reverse question marktype incision is traced on the scalp for a Avoid incorporating the entrance/exit
unilateral approach. A bicoronal incisionpositioned posterior to wound into the incision, given the high
the hairlineis marked for a bilateral procedure. likelihood of devitalized local soft tissue. By
the sam e token, be sensitive to the position
A no. 10 blade is used to incise the skin along the previously of the wound(s) with respect to the planned
marked line. The incision is carried dow n to the level of pericranium incision and scalp blood supply.
superiorly and temporalis fascia inferiorly. Scalp clips are applied to
the skin edges to facilitate hemostasis.
123
I Cerebral Traum a and Stroke
Fig. 8.4 The pericranium is opened w ith monopolar electrocautery, Dissection of soft tissue away from areas of
in-line w ith the scalp incision. The temporalis fascia and muscle known bony defect (i.e., entrance and exit
are also opened w ith monopolar electrocautery. The resultant sites) should be accomplished with a periosteal
myocutaneous ap is re ected forw ard until the keyhole and elevator rather than electrocautery.
root of zygoma are visible. The ap is secured w ith the surgeons In the set ting of a bicoronal approach, the
retraction system of choice. pericranium may be elevated in a separate
layer to provide vascularized grafting material
later in the procedure.
124
8 Surgical Debridem ent of Penetrating Injuries
Fig. 8.5 For a unilateral approach, bur holes are placed at the key hole, If substantial bony injury is present, it
just above the root of zygoma, over the parietal eminence, m ay be feasible to rem ove portions of
and at a point that is just anterior to coronal suture and 1 cm the involved calvarium without the use of
lateral to midline. power tools. In such cases, bur holes should
be positioned to facilitate creation of a
For a bilateral approach, bur holes are placed bilaterally at bone ap that allows access to adequate
the keyhole ; just above the root of zygoma; at the junction of surface area to perm it control of vascular
superior temporal line and coronal suture ; and at one or tw o structures, judicious debridem ent, and
points straddling the midline, anterior to coronal suture. dural closure.
Take particular care when adequate access
Bone w ax is applied to the bony edges. A no. 3 Pen eld is used requires crossing the m idline. If the path
to strip the dural attachments from the undersurface of the is not readily cleared, rem em ber that bur
calvarium betw een each set of holes. holes are cheap relative to a sinus injury.
125
I Cerebral Traum a and Stroke
Fig. 8.6 The craniotome is used to create a path that circumnavigates the Direct visualization of the dural
previously placed bur holes.The resulting bone ap is carefully elevated surface during elevation of the bone
aw ay from the underlying dura and set aside in antibiotic solution. ap is key, as the craniotomy site likely
includes an area of known bony and
For a bilateral approach, it may be easier to create tw o separate unilateral dural defect.
aps, temporarily leaving a strip of bone along the midline. Craniotome If direct injury to the sinus is
cuts then can be made across the midline and the bony isthmus removed. suspected, it may be necessary to
proceed with repair and/or ligation
Venous sinus bleeding is controlled w ith a combination of gentle pressure (anterior one-third only). Preoperative
and hemostatic agents. imaging should prompt appropriate
forethought and preparation.
Epidural hematoma, if present, may be evacuated at this time.
126
8 Surgical Debridem ent of Penetrating Injuries
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
128
8 Surgical Debridem ent of Penetrating Injuries
Fig. 8.8 Subdural hematoma, if present, should be evacuated w ith Principles of debridem ent for penetrating injuries
a combination of gentle suction and saline irrigation. encom pass techniques previously discussed for
(a) Inspect the cortical surface. Address obvious points evacuation of subdural hem atom a (Chapter 1)
of arterial or venous bleeding. There is likely obvious and cerebral contusions (Chapter 3). Managem ent
cortical disruption. This should be the portal of entry of venous sinus injury is discussed in Chapter 10.
for debridement. Associated large intraparenchymal Techniques for frontal sinus reconstruction are
hematoma should be approached w ith a combination of discussed in Chapter 27. Please refer to these sections
gentle suction and bipolar electrocautery. Upon entry to for m ore detailed nuances of m anagem ent.
the hematoma cavity, suction out any liquid clot. Remove A hand-held m alleable retractor, introduced over a
solid clot in a piecemeal fashion. (b) If no signi cant saline-m oistened 1 3 3 cm cot ton pat tie m ay assist
hematoma is present, super cial, necrotic brain tissue visualization.
should be debrided w ith gentle suction and irrigation. No at tempt should be made to follow m issile trajectory
Readily accessible missile and bone fragments should be to deep subcortical structures.
retrieved. Continue until gliotic brain is visible on all sides. Always maintain awareness of position relative to the
Hemostasis should be achieved w ith a combination of lateral ventricles. Avoid entry to the ventricle, if feasible.
bipolar electrocautery and hemostatic agents.
129
I Cerebral Traum a and Stroke
Fig. 8.9 Once debridement of devitalized brain tissue is complete, assess It is important to determ ine the relationship
the extent of the dural defect. of the defect to adjacent air sinuses.
If no viable pericranium is available,
For a unilateral approach, a piece of pericranium may be harvested temporalis fascia, fascia lata, or synthetic dural
to bridge the defect. The graft is incorporated circumferentially substitute may be prepared for this purpose.
w ith 4-0 braided nylon sutures.
130
8 Surgical Debridem ent of Penetrating Injuries
a b c
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
132
9 Management of Traumatic
Neurovascular Injuries
Boyd F. Richards and Mark R. Harrigan
133
I Cerebral Traum a and Stroke
Physical Findings
Physical ndings of penetrating, extracranial cerebrovascular
Fig 9.1 Type I traumatic cerebrovascular injury. A mid-cervical internal injury
carotid artery intramural hematoma (arrow) causing , 25% reduction in
Act ive bleeding
luminal diameter.
Hem atom a
Th rill or bruit
Absen ce of carot id pulse
Occlu sion is m u ch less com m on th an ar terial dissect ion . Neu rologic de cit
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) Intracranial Blunt Injury
Presen t w ith t inn it us, cer vical radiculopathy, h eart failure,
Dat a regarding th e overall in ciden ce of blun t in t racran ial
h em orrh age, steal, in t racran ial ven ou s hyp erten sion , or
TCVIs is lacking. Su ch inju ries are su bst an t ially less com m on
em bolic st roke.
th an blun t ext racran ial injuries.
Type I traum atic ce rebrovascular injury (Fig. 9.1).
GCS score , 8 an d th e p resen ce of facial fract u res are in de-
Type II traum atic ce rebrovascular injury (Fig. 9.2).
pen 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
Extracranial Penetrating Injury closed h ead t raum a, as w ell as pen et rat ing injur y.
Pen et rat ing n eck t rau m a is accom pan ied by vascu lar inju r y Th e m ost com m on a ected sites are th e su praclin oid ICA
in 20% of pat ien t s.7 an d th e in t radu ral p or t ion of th e ver tebral arter y.
Seven t y- ve p ercen t of th ese vascu lar inju ries are at- In t racran ial dissect ion m ay be associated w ith u n derly-
t ribu t able to st abbing. Gu n sh ot w ou n ds accou n t for th e ing vascu lar abn orm alit y of th e cerebral ar teries, in clu d -
rem ain d er.8 ing broelast ic th icken ing an d congen it al de cien cy
Th e ven ous system is m ore com m on ly a ected bu t less likely w ith disrupt ion of th e in tern al elast ic lam in a. Associated
to requ ire t reat m en t . con dit ion s th at m ay predispose on e to dissect ion in th e
134
9 Managem ent of Traum atic Neurovascular Injuries
a b
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 la- Ar t er ioven ou s f st u la
sia, cyst ic m edial degen erat ion , Marfan syn drom e, h o- Ar terioven ous st ulasarising from eith er th e carot id
m ocyst in u ria, an d syph ilis. or ver tebral circulat ion are presen t in 4% of all pat ien t s
Pat ien t s m ay p resen t w ith u n ilateral h eadach e, w ith blu n t TCVI.14
cran ial n er ve palsy (from m ech an ical com pression or Th e m ost com m on in t racran ial t raum at ic st ula is a di-
n eurap raxia from th e expan ded ar ter y or t ran sien t im - rect carot id-cavern ous st ula (CCF).
p airm en t of blood su pply), Horn ers syn drom e, an d/or Seven t y- ve p ercen t of direct CCFs occu r secon dar y to
focal cerebral isch em ia. t raum a.
An eu r ysm Most are associated w ith facial or sku ll base fract u res.
Trau m at ic an eu r ysm s accou n t for , 1%of all in t racran ial Iat rogen ic injur ydue to tran ssph en oidal surger y, skull
an eu r ysm s in adu lt s, bu t com prise abou t on e-th ird of base surger y, or percutaneous lesioning of the trigem i-
p ediat ric an eu r ysm s.13 n al ganglion also accoun ts for a signi can t n u m ber of
An eur ysm s in th is set t ing result from rapid decelerat ion , t raum at ic st ulas.
w h ich cau ses sudden brain m ovem en t an d arterial w all Pat ien t s t yp ically p resen t w ith cavern ou s sin u s syn -
injur y from stat ion ar y st ru ct ures su ch as th e skull base drom e (see box on n ext page).
or falx cerebri. In d icat ion s for u rgen t t reat m en t in clu de:
Pe r icallosal bran ch (an t e r ior com m u n icat in g ar te r y In creased in t racran ial p ressu re or th e p resen ce of cere-
[ACA]) an e u r ysm s, resu lt in g from collision b et w e e n bral cort ical ven ous hyperten sion
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 . Progressive visual de cit
Basilar arter y an d pet rocavern ou s segm en t an eu r ysm s In creased in t raocu lar p ressu re
often are associated w ith skull base fract ures. Worsen ing proptosis
135
I Cerebral Traum a and Stroke
a b c d
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 Managem ent of Traum atic Neurovascular Injuries
Occlu sion MRI an d MRA are u sefu l in cases of a w ooden foreign body
Dissect ing an eu r ysm injur y, as it is di cult to visualize w ooden m aterial on a CT.
Mu ral th icken ing Repeat , delayed angiography sh ould be perform ed 3 to
Cerebral angiography is in dicated w h en n ecessar y for clari- 6 m on th s later for pat ien t s in w h om an arterioven ous st u la
cat ion of th e diagn osis or w h en en dovascu lar t reat m en t is is suspected.
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 Management
an d p earl sign )
Flam e-sh ap ed occlu sion Extracranial Blunt Injury (Fig. 9.4)
Dissect ing an eu r ysm Th e corn erston es of m an agem en t for ext racran ial blun t
In t ralu m in al th rom bu s 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.
Extracranial Penetrating Injury
Medica l m a n a gem en t
CTA or MRA is th e rst-lin e im aging m odalit y at our in stit ution . Anticoagulation w ith intravenous heparin, followed by war-
Angiograp hy is reser ved for cases in w h ich t h e CTA re- farin, has been com m on practice. However, hem orrhagic
su lt s are equ ivocal or w h en en d ovascu lar t reat m en t is com plication rates range from 8 to 16%19 and a signi cant pro-
an t icip ated . portion (3036%) of patients w ith this type of injury are not
Angiography is also in dicated if th ere is a retain ed m et allic candidates for system ic anticoagulation due to concom itant
foreign object th at m igh t obscu re in terp retat ion of CTA or injuries.
MRA du e to art ifact . 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
Intracranial Blunt Injury agen t an t iplatelet th erapy in th e form of aspirin 325 m g
Dissect ion per day.
All pat ien t s suspected of h aving an in t racran ial dissect ion Repeat n on invasive im aging, preferably CTA, sh ou ld be
sh ou ld u n d ergo a CTA or MRA as a rst-lin e im aging m o- u n der t aken in 6 m on th s.
dalit y. How ever, if a dissect ion is st rongly suspected, con - En dova scu la r m a n a gem en t
ven t ion al angiography rem ain s th e gold st an dard. Dissect ion
An eu r ysm Dissect ion s requ ire t reat m en t (u su ally sten t ing) if th ere
CTA is th e recom m en ded screen ing m odalit y. How ever, are n ew n eu rologic de cits or oth er sym ptom s desp ite
t raum at ic an eur ysm s are often located dist ally an d can be an t iplatelet th erapy.
dangerous even w h en , 3 m m . Th ese t w o feat ures ren der Sten t ing requires dual an t iplatelet th erapy for a period of
CTA less reliable. app roxim ately 1 m on th ; th is m ay p rove p roblem at ic for
Angiography is recom m en ded for all pat ien t s in w h om a p olyt rau m a pat ien ts.
t raum at ic an eur ysm is suspected. Trau m at ic an eur ysm
Ar t er ioven ou s f st u la En dovascular t reat m en t is in dicated if th e pat ien t is
Angiography is th e gold st an dard to im age ar terioven ous sym ptom at ic despite an t ip latelet th erapy or if th e
st u las. an eu r ysm is fou n d to en large sign i can tly on follow -u p
An early- lling vein m ay be a path ogn om on ic sign . im aging. Follow -u p im aging sh ould be perform ed after
Assess for access to th e lesion by looking at th e direct ion 6 m on th s (see Fig. 9.5).
of ow w ith in each of th e ven ou s st ruct ures. A covered sten t m ay be appropriate if th e t raum at ic
For CCFs, assess th e presen ce of th e superior op h th alm ic an eu r ysm occu rs in a port ion of th e vessel devoid of
vein as a possible access p oin t for t reat m en t . im port an t bran ch es.
CTA an d MRA are st at ic st u dies. Early ven ou s lling often Coil em bolizat ion of t raum at ic an eur ysm s sh ould be
is n ot visu alized as th e t im ing of th e con t rast bolu s m ay avoided w h en ever possible as th e w all of th e an eu r ysm
a ect t im ing of th e lling of th e vein s. 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
Intracranial Penetrating Injury an eu r ysm .
A screen ing CTA or MRA (un less con t rain dicated) sh ould be Occlu sion
p erform ed for any pat ien t presen t ing w ith p en et rat ing h ead Vessel occlu sion sh ou ld b e ap p roach e d in a sim ilar
inju r y. 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
Met allic foreign bodies m ay com p rom ise CT im ages secon d- occlu sion s sh ou ld u n d e rgo re can alizat ion w h e n fea-
ar y to scat ter art ifact . Th ey m ay also ren der an MRA im p os- sible an d ap p rop r iate. Pat ie n t s w it h asym p tom at ic oc-
sible. In th is case, an angiogram m ay be n ecessar y p rior to clu sion s m ay d o w ell w it h con se r vat ive m an age m e n t
rem oval of th e foreign object . (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 No evid en ce of
vascular inju r y vascu lar inju r y
Traum at ic Un explain ed
Dissect ion Occlu sion
An eu r ysm n eu rologic
deficit or
An t ip latelet An t ip latelet h igh susp icion
Agen t Agen t Asym ptom at ic Sym ptom at ic
DSA
Neu rologic Neu rologic
obser vat ion an d obser vat ion an d An t ip latelet
repeat CTA in 6 repeat CTA in 6 <8 h ou rs >8 h ou rs
Agen t
m on th s m on th s
Neurologic At tem pt
CT
If stable If en larging If resolved, obser vat ion an d en d ovascu lar
New Perfusion
con t in u e or n ew d/c repeat CTA in 6 recan alizat ion
n eu rologic m on th s
an t iplatelet n eu rologic an t iplatelet
deficit
agen t deficit agen t At tem pt
recan alizat ion if CT
Con sider Perfusion sh ow s
DSA
en dovascu lar reversible isch em ia
t reat m en t
Su p p ort ive care
If un ch anged, n o reversible
If resolved, d/c New Trau m at ic isch em ia
con t in u e
ant ip latelet agen t An eu r ysm
an t iplatelet agen t
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 - A few elem ents of m anagem ent are com m on to all such injuries:
bectom y an d at tem pted recan alizat ion , sh ould be Asser t ive m an u al com pression sh ould be used to con t rol
con sidered if th e t im e from sym ptom on set is less th an bleeding in it ially.
8 h ou rs an d n on invasive im aging m odalit ies (such as CT Th e air w ay m ust be secured, preferably by en dot rach eal
perfusion or MR perfusion ) suggest a reversible isch em ic in t ubat ion . If en dot rach eal in t u bat ion is n ot feasible,
pen um bra. Reperfusion tech n iques in such cases m ay in - cricothyrotom y is th e n ext best opt ion for air w ay con t rol.
clude em ergen t sten t placem en t or th rom bectom y. Nasot rach eal in t u bat ion sh ou ld be avoided w h en p ossible
Sten t ing in th e acute set t ing requires loading w ith t w o because of th e possibilit y of cran ial or n asoph ar yngeal
an t iplatelet agen t s (e.g., aspirin an d clopidogrel) at least inju r y due to th e p en et rat ing injur y.
3 h ours prior to th e procedure. An altern at ive w ould En dova scu la r Tr ea t m en t
be to t reat th e pat ien t w ith an in t raven ous GPIIB/IIIA En dovascular t reat m en t m ay be preferable for pat ien t s
in h ibitorto perm it sten t ing im m ediatelyan d p roceed w ith Zon e I an d III injuries due to th e di cult y of surgi-
w ith an t iplatelet agen t loading later. Th e use of th ese cal access to th ese areas (see Fig. 9.9).
agen ts in any pat ien t w ith polyt rau m a sh ou ld be con sid - Covered sten t placem en t m ay be e ect ive for carot id lac-
ered carefu lly becau se of bleeding risks an d th e p oten t ial erat ion s, p rovided th e lesion can be crossed .
n eed for oth er invasive in ter ven t ion s. En dovascular ar terial occlu sion m ay be in dicated. Se-
lect 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 -
Extracranial Penetrating Injury 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
(Fig. 9.7) circulat ion to th e a ected brain territor y can h elp de-
Th e ch oice of an open surgical or en dovascular approach for term in e th e risk of resultan t cerebral isch em ia. Sacri ce
th e m an agem en t of pen et rat ing n eck inju ries is based on th e of an ar ter y sh ou ld in clu de occlusion of th e vessel both
locat ion of th e inju r y (see Fig. 9.8). Th e surgical approach for proxim al an d dist al to th e inju r y, if possible, to m in im ize
pen et rat ing vascular injuries w ill be described in m ore det ail th e ch an ce of ret rograde bleeding th rough th e distal seg-
(see Operat ive Procedure, p. 145). m en t of th e a ected arter y.
138
9 Managem ent of Traum atic Neurovascular Injuries
a b
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.
139
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I Cerebral Traum a and Stroke
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9 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.
a b
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
Su spected Blu n t
In t racran ial TCVI
CTA eviden ce of
vascu lar inju r y?
Yes No
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
9 Managem ent of Traum atic Neurovascular Injuries
a 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.
CTA eviden ce of
vascu lar inju r y?
Yes No
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. ing tam pon ade for a poten t ial vascular inju r y, th e foreign
In pat ien t s w ith n o eviden ce of in t racran ial h em orrh age or body sh ould be rem oved in th e operat ing room un der
cerebrovascular injur y, th e pen et rat ing object can be re- direct vision .
m oved u n der gen eral an esth esia. Pen et rat ing in t racran ial inju r y (Fig. 9.13).
a 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
9 Managem ent of Traum atic Neurovascular Injuries
Operative Procedure
Surgical Management of Extracranial Penetrating Arterial
Injuries Zone II
Positioning (Fig. 9.14a, b)
a b
145
I Cerebral Traum a and Stroke
146
9 Managem ent of Traum atic Neurovascular Injuries
147
I Cerebral Traum a and Stroke
148
9 Managem ent of Traum atic Neurovascular Injuries
149
I Cerebral Traum a and Stroke
a b
Remove the arterial clamps in the follow ing order: ECA, CCA, and ICA.
150
9 Managem ent of Traum atic Neurovascular Injuries
Closing 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 plica-
t ion s, part icularly in pat ien t s w ith in t racran ial h em orrh age
Leave a drain in place. Close the wound w ith absorbable braided or polyt raum a. Alth ough level III clin ical eviden ce an d gu ide-
stitches in the platysm a m uscle and staples or stitches in the skin.
lin 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 -
Postoperative Management 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 racere-
bral h em orrh age), an d/or for w h om cran ial surger y is an t ici-
Monitoring p ated or h as been don e, avoiding an t ith rom bot ic m edicat ion s
seem s p ru den t .
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 References
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. 1. Hugh es KM, Collier B, Green e KA, Ku rek S. Trau m at ic carot id
Main ten an ce of systolic blood pressu re bet w een 90 an d arter y dissect ion : a signi cant in ciden t al n ding. Am Surg
180 m m Hg is adequ ate for m ost pat ien t s. 2000;66(11):10231027
2. Bi W L, Moore EE, Ryu RK, et al. Th e u n recogn ized ep idem ic of
Th e n eed for invasive in t racran ial m on itoring is dictated
blun t carot id arterial injuries: early diagn osis im proves n euro-
by st an dard n eurosurgical criteria (e.g., for pat ien t s w ith
logic ou tcom e. An n Su rg 1998;228(4):462470
elevated in t racran ial p ressu re du e to h ead injur y).
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
Medication 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
An t ithrom bot ic th erapy w ith aspirin (325 m g daily) is in di-
from blu n t cerebrovascu lar inju ries: im p or t an ce of rou t in e follow -
cated for m ost pat ient s w ith t raum at ic cerebrovascular injur y.
up ar teriography. An n Surg 2002;235(5):699706; discussion
More aggressive an t ith rom bot ic th erapy, w ith system ic an - 706707
t icoagulat ion , m ay be n ecessar y for pat ien ts w ith sign i can t 6. Stein DM, Bosw ell S, Sliker CW, Lu i FY, Scalea TM. Blu n t cere-
in t ralu m in al arterial or ven ou s th rom bosis. brovascular injuries: does t reat m en t alw ays m at ter? J Traum a
Du al an t ip latelet th erapy (e.g., asp irin an d clop idogrel) is n ec- 2009;66(1):132143; discussion 143144
essar y for all p at ien t s receiving a vascu lar sten t . 7. Nason RW, Assu ras GN, Gray PR, Lipsch it z J, Bu rn s CM. Pen et rat -
In m ost cases, an t ith rom bot ic th erapy for 3 m on th s is ing n eck inju ries: an alysis of experience from a Can adian t raum a
app ropriate. 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):
Special Considerations ch ildh ood and adolescen ce. Case repor t s and review of th e lit-
erat 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
Antithrombotic Therapy con tem porar y review. J Traum a 1993;35(6):855860
15. Dusick JR, Esposito F, Malkasian D, Kelly DF. Avoidan ce of
Th e u se of an t ith rom bot ic m edicat ion is a reason able op - carot id ar ter y injuries in t ran ssph enoidal surger y w ith th e
t ion in pat ien t s w ith cerebrovascular injuries as a m easure Dop p ler p robe an d m icro-h ook blad es. Neu rosu rger y 2007;
to preven t th rom boem bolic isch em ic st roke. How ever, all 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 is- pen et rat ing h ead inju ries occu rring d u ring w ar: p rin ciples an d
sile h ead w ou nds. Neurosurger y 1988;22(6 Pt 1):10561063 pitfalls in diagn osis an d m an agem en t . A su r vey of 31 cases an d
17. du Trevou MD, van Dellen JR. Pen et rat ing st ab w ou n d s to th e review of th e literat ure. J Neurosurg 1996;(5):769780
brain : th e t im ing of angiography in p at ien t s presen t ing w ith th e 19. Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt
w eapon already rem oved. Neurosurger y 1992;31(5):905911; cerebrovascular injuries: analysis of diagnostic m odalities and out-
discu ssion 911912 com es. Ann Surg 2002;236(3):386393; discussion 393395
18. Am irjam sh idi A, Rah m at H, Abbassiou n K. Trau m at ic an eu r ysm s 20. Beletsky V, Nadareishvili Z, Lynch J, et al. Cervical arterial dissection:
an d ar terioven ou s st u las of in t racran ial vessels associated w ith tim e for a therapeutic trial? Stroke 2003;34(12):28562860
152
10 Management of Venous Sinus Injuries
Laurence Davidson and Rocco A. Arm onda
Cerebral angiography
Introduction Alth ough angiography rem ain s th e gold stan dard for im ag-
ing th e du ral ven ous sin uses, it is invasive an d t im e con -
Major du ral ven ou s sin u ses form at th e d u ral re ect ion s w h ere
su m ing, w h ich ren ders it im pract ical in th e set t ing of acu te
th e super cial an d deep layers of th e dura split an d th e deep
t raum a.
layer fu ses to form th e falx cerebri an d th e ten torium cerebelli.
Pre o pe rative im aging (Fig. 10.1).
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 - Medication
erally by th e adjacen t du ra m ater an d deep ly by th e falx cerebri An t im icrobial prophylaxis is in it iated.
or ten torium cerebelli. Hem orrh age can arise from th e sin us An t iseizure prophylaxis is in it iated.
roof, lateral w alls, ven ou s lakes, arach n oid gran u lat ion s, em is-
sar 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
Operative Field Preparation
exten t of inju r y w ill largely dict ate th e opt im al repair tech n iqu e, Gen eral pat ien t p osit ion ing
w h ich ranges from direct repair to segm en t al replacem en t . Secu re th e p at ien t to th e table, as u p to 60 degrees of re-
verse Tren delen bu rg m ay be n eeded to m in im ize in t racra-
n 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
Indications h igh est poin t of th e op erat ive eld.
Avoid excessive n eck rotat ion or exion .
Trau m at ic injur y resu lt ing in sign i can t h em orrh age or A bilateral craniotom y exposure is indicated to address injury
th rom bosis to the superior sagittal sinus. A supra- and infratentorial ap -
Resect ion of an in lt rat ing n eoplasm proach is necessary to address injury to the transverse sinus.
Th ree areas require repair to m ain tain paten cy 1,4 Measu res to m axim ize cran ial ven ou s ou t ow
Posterior t w o-th irds of th e su p erior sagit t al sin u s Avoid com pressive air w ay t ap e.
Torcu lar h eroph ili Min im ize jugu lar com p ression from a rigid cer vical collar.
Dom in an t t ran sverse sin u s Avoid excessive n eck rotat ion or exion .
All oth er areas m ay be ligated w ith m in im al risk 1,4 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 pair-
m en t of cran ial ven ou s ou t ow.
Blood loss
Preprocedure Considerations Large volu m e h em orrh age m ay occu r from th e inju red ve-
n ou s sin u s. Sign i can t losses m ay also occu rboth preop -
Radiographic Imaging 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
Com puted tom ography (CT) m u st be available in th e op erat ing room .
Du ral ven ou s sin u s inju r y sh ou ld be su sp ected if im aging Ven ou s air em bolism
sh ow s an ep id u ral h em atom a in th e region of a m ajor ve- Ven ou s air em bolism m ay occu r w h en th e h ead is elevated
n ou s sin us.5 In on e st u dy, 89% of ep id u ral h em atom as aris- above th e h eart , resu lt ing in n egat ive p ressu re in th e du ral
ing from a du ral ven ou s sin us h ad an associated fract ure ven ou s sin u sallow ing air to en ter an d becom e t rap ped in
th at crossed th e sin us.1 Posterior fossa ep id u ral h em ato- th e righ t at rium .
m as involve th e du ral ven ou s sin u ses in 42.5% of cases.6 A fall in th e en d t idal p CO2 an d hypoten sion m ay en sue.
CT ven ography (CTV), w hich requires the adm inistration of St rong con siderat ion sh ould be given to th e use of cap n og-
intravenous contrast and is taken during the venous phase, raphy, a precordial Dop pler probe, an d an ar terial lin e. Air
can be diagnostic of sinus throm bosis. The em pt y delta sign em bolism p rodu ces w ash ing m ach in e sou n ds by Dop pler.
m ay be seen in the area of sinus th rom bosis.7 CTV is indicated Rem oval of air from th e righ t at riu m is p ossible if a righ t
w hen there is a depressed skull fracture over a dural venous at rial cath eterplaced via th e brach ial or subclavian
sinus, w hich can cause sinus stenosis and throm bosis.8,9 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 sten osis is likely to resu lt from p rim ar y su t u re repair, a
If substantial sinus disruption is anticipated, vascular patch sh ould be placed.
reconstruction equipm ent should be available, including a Rep lacem en t of segm en ts of th e su p erior sagit t al sin u s is
properly sized temporary vascular shunt, Fogarty balloon cath- th e m ost ext rem e of in ter ven t ion s, reser ved on ly for th ose
eters, nonabsorbable vascular suture, and a vein allograft. 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 si-
Operative Management n u s recon st ru ct ion .3,4 Th is w as m ade of a p ed iat ric en do-
Treat m en t is discu ssed sep arately for th e follow ing p ar ts of th e t rach eal t ube w ith a pediat ric t rach eostom y cu placed at
ven ou s sin u s system : an terior on e-th ird of th e su p erior sagit t al each en d. Sin dou an d Alvern ia avoided th e balloon sh u n t
sin u s, p osterior t w o-th irds of th e su p erior sagit t al sin u s, torcu- an d Fogar t y balloon cath eter du e to risk of inju r y to th e
lar h eroph ili, an d d om in an t t ran sverse sin us. 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 dis-
General Considerations by Anatomic tal en ds of th e sin u s repair to en sure patency.
Torcular h eroph ili
Location Inju ries th at su bst an t ially disru pt th e torcu lar h erop h ili are
Su p erior sagit t al sin u san terior on e-th ird rarely sur vivable an d, in m ost cases, th e clin ical grade of
Th e m ajorit y of inju ries in th is area can be m an aged w ith th e pat ien t is su ch th at expect an t m an agem en tw ith out
tam pon ade tech n iques or direct sut ure repair if th e lacera- su rgical in ter ven t ion m ay be app ropriate.
t ion is sm all. Th e tech n iqu es for t am p on ade, prim ar y rep air, an d p atch -
Lacerat ion s th at are too large to su t u re directly often can be ing described for inju ries to th e sup erior sagit tal sin u s also
t reated w ith a sut ured, bolstered patch . ap p ly to th e torcu lar h erop h ili.1
Lesion s th at can n ot be repaired can be t reated relat ively Dom in an t t ran sverse sin u s
safely w ith sin u s ligat ion via an en circling su t u re or Th e tech n iqu es for t am p on ade, prim ar y rep air, an d p atch -
vascu lar clips. ing described for inju ries to th e sup erior sagit tal sin u s also
Su p erior sagit t al sin u sp osterior t w o-th irds ap p ly to th e su p erior sagit t al sin u s.
Th is p or t ion of th e sin u s sh ou ld be rep aired or rep laced in Sin d ou et al d escr ibed a byp ass of t h e t ran sverse sin u s
vir t u ally all cases, bu t especially w h en m ajor cor t ical ve- to t h e exter n al jugu lar vein u sin g a sap h en ou s vein graft
n ou s drain age is involved. in a p at ien t w it h bilateral t ran sverse sin u s t h rom bosis.10
Avoid p rim ar y su t u re closu re th at com p rom ises greater Met icu lou s w ou n d closu re is n ecessar y to p reven t com -
th an 50% of th e sin us lu m en , as th is m ay be m ore likely to p ression an d su bsequ en t t h rom bosis of t h e su bcu t an eou s
resu lt in com prom ised ow an d even t ual sin us occlusion . vein graft .
154
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)
155
I Cerebral Traum a and Stroke
156
10 Managem ent of Venous Sinus Injuries
(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
a b
Fig. 10.5 (a) Apply digital pressure, supplemented w ith sinus Sinus pat ties should be prepared prior to exposure.
patties (a combination of 1 3 3 in cotton patties, This com bination m ay be supplem ented with
hemostatic absorbable gelatin compressed sponge, and strips of hemostatic oxidized cellulose polym er and
strips of hemostatic oxidized cellulose polymer). absorbable hemostatic m atrix paste or comparable
(b) Place epidural tack-up stitches w ith 4-0 braided nylon hem ostatic agents. Also, cot ton balls and m uscle m ay
suture w hen usable bone is adjacent to the injury. be employed to bolster the tamponade.
(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.
158
10 Managem ent of Venous Sinus Injuries
Fig. 10.6 Injuries involving the anterior third of the superior sagittal sinus Tamponade sinus bleeding during dissection
(in front of the coronal suture) may be amenable to ligation. through the use of hemostatic agents and
cot ton pat ties, augm ented with head of bed
The sinusanchored by the falx and convexity dura rst must elevation (while m onitoring for VAEs).
be released. Alternatively, ligation m ay be perform ed with
a surgical hem ostatic double clip at the inferior
Follow ing release of the sinus, ligation may be performed insertion of the sinus into the falx, near the
by a double ligature technique, using 2-0 nonabsorbable crista galli. At tention m ust be paid to ensure
polypropylene suture or nylon. Make a double circular course that the clips cross the sinus completely.
beneath the sinus, into the falx and then more super cially, to be
ligated and divided.
159
I Cerebral Traum a and Stroke
Fig. 10.7 Lacerations that are too large to suture directly may be treated This technique does not work well on the
w ith a sutured, bolstered patch. lateral sinus walls.
Options for patch material include adjacent dura (curled over Avoid direct suturing of the patch to the
the sinus), temporalis fascia, fascia lata, and synthetic dura or double layers of the sinus.
vascular substitutes.
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
Fig. 10.8 Interposition grafting may be appropriate in cases of complete Typical synthetic vascular graft m aterial is prone
sinus disruption (posterior to the coronal suture), in patients to throm bosis in this location and should be
deemed to be salvageable. avoided, if possible. Likewise, arterial grafts m ay
progressively occlude from extensive arterial wall
The greater saphenous vein must be harvested in advance throm bosis. Cadaveric vein may be an option in
from the upper portion of the thigh. The graft should be rare cases.
reversed to prevent the valves from obstructing ow. Historically, the vascular shunt featured a double
balloon conf guration that allowed venous
(a) A temporary shunt should be placed, w ith heparin uid ow without bleeding around the shunt. More
irrigation of the shunt tubing as w ell as the proximal and recently, other authors have described the use of
distal ends of the sinus. (b) The vein graft is placed around the a Rum ell vessel loop around the shunt proximally
shunt and incorporated w ith multiple, interrupted, end-to -end and distally to avoid endothelial sinus injury and
6-0 nonabsorbable polypropylene stitches, leaving a small delayed throm bosis.
dorsal region to remove the shunt and tie the nal stitches.
161
I Cerebral Traum a and Stroke
Fig. 10.9 The approach to these sinus segments is best accomplished w ith Refer to Fig. 10.2 for details regarding
the patient in prone position. anesthetic adjuncts in this set ting.
162
10 Managem ent of Venous Sinus Injuries
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
Fig. 10.11 The position of bur holes depends on the anatomy of The bony opening should perm it access to both sides of
the speci c fracture. the sinus in question.
164
10 Managem ent of Venous Sinus Injuries
Fig. 10.12 The use of adjuncts discussed in Fig. 10.5 Tamponade is particularly poorly tolerated in the region of the central
for tamponade may be e ective, but sulcus when the vein of Trolard is involved.
must be tempered by the risk of sinus
and/or cortical vein occlusion.
Primary suture repair of lacerations may Injury involving a single lateral wall at the junction of a venous lake,
be attempted w ith 6-0 nonabsorbable which does not respond to tamponade, m ay be isolated and treated with
polypropylene suture. 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
Fig. 10.13 Lacerations that are too large to suture directly may be treated w ith a Refer to Fig. 10.7 for details regarding
sutured, bolstered patch. patching of the venous sinus.
Replacement of a superior sagit tal sinus
Interposition grafting is a daunting proposition in this area. segm ent is reserved only for cases that
involve both lateral walls or the m ajorit y
The vein graft must be oriented such that the valves allow ow of the dorsal wall, where a sutured patch
from the anterior to posterior portions of the sinus in a nonlimiting cannot reconstruct a lum en at least 50% of
fashion. the original size.
Refer to Fig. 10.8 for details regarding
interposition grafting.
166
10 Managem ent of Venous Sinus Injuries
Closing Medication
An t im icrobial prophylaxis is con t in u ed for 24 h ours.
Du ral closu re is perform ed w ith 4-0 braid ed nylon su t u re. An t iepilept ic prophylaxis is con t in ued for 7 days.
Th e bon e ap is reapproxim atedif feasiblew ith an in t ra-
cran ial plat ing system .
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 cra- 4. Kap p JP, Sch m idek HH. Su rger y of th e cerebral ven ou s system . In :
n iectom y in clu de: Kapp JP, Sch m idek HH, eds. Th e Cerebral Venous System an d It s
Elevated in t racran ial p ressu re n ot resp on sive to m axim al Disorders. Orlan do: Gr u n e & St rat ton , In c.; 1984:597623
m edical th erapy 5. Ch ee CP, Habib ZA. Hyp oden se bu bbles in acu te ext radu ral h ae-
Severe cerebral edem a or th e p resen ce of an in t racran ial m atom as follow ing ven ous sin us tear. A CT scan appearan ce.
Neuroradiology 1991;33(2):152154
h em atom a w ith im pen ding brain h ern iat ion
6. Bor-Seng-Sh u E, Agu iar PH, de Alm eida Lem e RJ, Man del M,
Elevat ion of a dep ressed sku ll fract u re or rem oval of a for-
An drade AF, Marin o R, Jr. Epidural h em atom as of th e posterior
eign body w h en d u ral sin u s paten cy is com prom ised
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 d-
ings in cerebral sin us an d ven ous throm bosis. Radiology 1981;
140(2):391398
References 8. Forbes JA, Reig AS, Tom ycz LD, Tulipan N. Intracran ial hypertension
caused by a depressed skull fracture resulting in superior sagit tal
1. Pricola KL, Zou H, Chang SD. Successful repair of a gunshot wound sin us throm bosis in a pediatric patient: treatm ent w ith ven tricu-
to the head w ith retained bullet in the torcular herophili. World loperitoneal shunt insertion. J Neurosurg Pediatr 2010;6(1):2328
Neurosurg 2011;76(34):e361364 9. Yokot a H, Egu ch i T, Nobayash i M, Nish ioka T, Nish im u ra F, Nikaido
2. Sin dou MP, Alvern ia JE. Resu lt s of at tem pted radical t u m or Y. Persisten t in t racran ial hyperten sion caused by superior sagit-
rem oval an d ven ous repair in 100 con secut ive m en ingiom as t al sin us sten osis follow ing depressed skull fract u re. Case repor t
involving th e m ajor dural sin uses. J Neurosurg 2006;105(4): an d review of th e literat u re. J Neu rosu rg 2006;104(5):849852
514525 10. Sin dou M, Mercier P, Bokor J, Bru n on J. Bilateral th rom bosis of
3. Kap p JP, Gielch in sky I. Man agem en t of com bat w ou n ds of th e th e t ran sverse sin u ses: m icrosu rgical revascu larizat ion w ith
du ral ven ou s sin u ses. Su rger y 1972;71(6):913917 ven ou s byp ass. Su rg Neu rol 1980;13(3):215220
168
II Spinal Emergency Procedures
11 Application of Closed Spinal Traction
Nirit W eiss
170
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
11 Application of Closed Spinal Traction
173
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174
11 Application of Closed Spinal Traction
175
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176
11 Application of Closed Spinal Traction
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
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Postoperative Management 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
Monitoring n eu rologic inju r y.
For t ract ion in pat ien ts w ith locked facet s, apply gen tle
Mon itor n eu rologic st at u s an d vital sign s ever y 2 h ou rs. exion force for bilateral locked facet s, or exion plu s gen tle
Mon itor for skin breakdow n /decu bit is u lcers. 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
Medication to 5 to 10 lb w h ile gen tly exten ding (by sliding in a sh oulder
Pain m an agem en t an d m u scle relaxat ion can be adm in istered. 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. References
1. Lu K, Lee T, Ch en H. Closed redu ct ion of bilateral locked facet s
Pin Site Management of th e cer vical spin e un der gen eral an esth esia. Act a Neuroch ir
(Wein ) 1998;40:10551061
Gardner-Wells pins are checked at 24 and 48 hours to ensure 2. Sect ion on Disord ers of th e Sp in e an d Perip h eral Ner ves of
that the spring-loaded force indicator is protruding. Halo pins th e Am erican Associat ion of Neu rological Su rgeon s an d Th e
are re-torqued to 8 in-lb once at 24 hours, and again at 48 hours. Congress of Neu rological Su rgeon s: In it ial closed redu ct ion
Additional tightening beyond this point can lead to skull of cer vical spin e fract u re-dislocat ion injuries. Neurosurger y
penetration, skull fracture, pin loosening, and/or infection. 2002;50(suppl 3):s4450
Maintain t w ice-daily pin site cleaning w ith hydrogen peroxide 3. Goldstein R, Deen HG, Zim m erm an RS, Lyon s MK. Preplacem en t
or povidon e iodine oin tm ent. 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
Further Management 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.
After su ccessfu l realign m en t , decide to brace, p lace in h alo Spin e 1999;24:17771780
vest (see Fig. 11.6), or operate. 5. Arkader A, Hosalkar HS, Dru m m on d DS, Dorm an s JP. An alysis of
After failed realign m en t , a decision to op erate is u su ally 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
m ade.
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
Special Considerations 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
Pediat ric pat ien t s h ave special con cern s regarding n u m ber of 2008;24(1):E1117
pin s an d pin torque pressures (see above). In pat ien t s w ith an - 8. Th u m bikat P, Harih aran RP, Ravich an d ran G, McClellan d MR,
kylosing spon dylit is,7,8 ligh t cer vical t ract ion (, 5 or 10 lb) is ad - Math ew KM. Sp in al cord inju r y in pat ien t s w ith an kylosis
vised. Prolonged t ract ion w ith ligh t w eigh ts m ay lead to desired spon dylit is: a 10-year review. Spin e 2007;32(26):29892995
178
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 Disru pt ion of th e t ran sverse ligam en t cau sing atlan toa xial
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 ) in st abilit y.
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 Type II odon toid fract ures w ith eviden ce of in st abilit y
od on toid p rocess con st it u t e ap p roxim at ely 15 % of all ce r - (i.e., greater th an 6 m m of displacem en t).
vical fra ct u res. Th ey a re p r im a r ily cau se d by h igh -velocit y Movem en t at th e fract u re site in h alo vest dem on st rated on
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 su p in e an d u prigh t X-rays.
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 i-
n 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 Preprocedure Considerations
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 -
Radiographic Imaging
logic in ju r y b u t com m on ly com p lain of a xial n e ck p ain Radiological st u diesin it ial lm s sh ou ld in clu de an terop os-
su bse qu e n t to t rau m a . terior, lateral, an d open -m outh odon toid view s.
Alt h ough evid en ce-based m an agem en t recom m en dat ion s Com pu ted tom ography (CT) scan s w ith reform at ted im ages
for od on toid fract u res are lackin g, p at ien t ou tcom es for t h e m ay be u sed to d eterm in e th e t ype of odon toid fract u re an d
m ost com m on con ser vat ive an d su rgical t reat m en t s h ave m ay p rovide m ore det ail of bony an atom y th an plain lm s.
been rep or ted .1 Th is ch apter d iscu sses t h e em ergen cy m an - Carefu l preoperat ive review of CT im ages w ith iden t i cat ion
agem en t of od on toid fract u res w it h a sp eci c focu s on t h e of fract ure sites, bony an atom y, an d vertebral ar ter y course
m ost com m on ly p er for m ed t reat m en t s, in clu d in g: (1) an te- is n ecessar y to determ in e w h eth er in st rum en tat ion can be
r ior fu sion tech n iqu es (od on toid screw ) an d (2) p oster ior fu - placed safely.
sion tech n iqu es (C1- C2 t ran sar t icu lar screw s; C1 lateral m ass/ Th e An derson an d DAlon zo classi cat ion system , w h ich
C2 p ars/C2 p ed icle screw s). Con t rain d icat ion s for od on toid classi es fract ure t ypes I, II, an d III, is com m on ly applied
screw p lacem en t in clu d e od on toid fract u res w it h an an ter ior- (Figs. 12.1 an d 12.2; Table 12.1).2
ly an gled t ip fragm en t , osteop orosis, t ran sverse ligam en t d is-
r 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
Medication
tech n iqu e. In t h ese cases, p oster ior at lan toa xial fu sion m ay Periop erat ive an t ibiot ics are in it iated an d m ain t ain ed for
be w ar ran ted . 24 h ours after in cision .
179
II Spinal Em ergency Procedures
a 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)
181
II Spinal Em ergency Procedures
182
12 Em ergency Managem ent of Odontoid Fractures
c d
183
II Spinal Em ergency Procedures
a b
184
12 Em ergency Managem ent of Odontoid Fractures
a b
185
II Spinal Em ergency Procedures
a b
186
12 Em ergency Managem ent of Odontoid Fractures
187
II Spinal Em ergency Procedures
a b
188
12 Em ergency Managem ent of Odontoid Fractures
a b
189
II Spinal Em ergency Procedures
a b
190
12 Em ergency Managem ent of Odontoid Fractures
191
II Spinal Em ergency Procedures
192
12 Em ergency Managem ent of Odontoid Fractures
193
II Spinal Em ergency Procedures
194
12 Em ergency Managem ent of Odontoid Fractures
a b
195
II Spinal Em ergency Procedures
Periop erat ive an t ibiot ics are m ain t ain ed for 24 h ou rs after
in cision .
References
Further Management 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
Drain s are rem oved on p ostoperat ive day 1 or 2. 2010;15(3):6572
Skin su t u res are rem oved after 2 w eeks. 2. An derson LD, DAlon zo RT. Fract u res of th e odon toid process of
For posterior procedures, pat ien ts are t ypically kept in a rigid th e axis. J Bon e Join t Su rg Am 1974;56(8):16631674
cer vical collar for 6 to 12 w eeks after th e procedure, at w h ich 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
poin t X-rays are taken to assess fusion .
single-screw an terior xat ion . Neurosurger y 1999;45(4):
For an terior procedures, a form al sw allow evaluat ion m ay be
812819; discu ssion 819820
requ ired prior to st art ing a diet becau se of th e h igh in ciden ce
4. Apfelbau m RI, Lon ser RR, Veres R, Casey A. Direct an terior screw
of postoperat ive dysph agia, par t icu larly in elderly pat ien ts. 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
Special Considerations JB, Jr. C1- C2 t ran sar t icu lar screw xat ion for atlan toaxial in st a-
bilit y: a 6-year experien ce. Neurosu rger y 2001;49(1):6568;
discu ssion 6970
The senior author (JSH) prefers not to use additional bone w ir- 6. Harm s J, Melch er RP. Posterior C1- C2 fu sion w ith polyaxial screw
ing techniques though several have been described. A posterior an d rod xat ion . Sp in e (Ph ila Pa 1976) 2001;26(22):24672471
bone w iring technique is often perform ed to provide three-point 7. Sm ith HE, Vaccaro AR, Malten for t M, et al. Tren ds in su rgical m an -
xation. The C1-C2 transarticular screw, as initially described by agem en t for t ype II odon toid fract u re: 20 years of exp erien ce at a
Magerl in 1987, was the rst m ajor advance from bone w iring region al spin al cord injur y cen ter. Or th opedics 2008;31(7):650
techniques.8 Using this technique, im m ediate three-dim ensional 8. Grob D, Magerl F. [Su rgical st abilizat ion of C1 an d C2 fract u res].
unisegm ental fusion can be achieved and, w hen perform ed in Or th op ad e 1987;16(1):4654
com bination w ith bone w iring techniques, the use of external 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
im m obilization (e.g., halo vest) is not necessary. One advantage
(Ph ila Pa 1976) 1997;22(22):26092613
of this technique is that it elim inates rotational m otion at C1-C2,
10. Bagn all AM, Jon es L, Du y S, Riem sm a RP. Sp in al xat ion su rger y
w hich increases the chance of bony fusion. However, its popularit y
for acute t raum at ic spin al cord injur y. Coch ran e Dat abase Syst
has been lim ited by its relative technical com plexit y and associ-
Rev 2008(1):CD004725
ated risks such as hypoglossal nerve and vertebral artery injuries.5 11. Feh lings MG, Ar vin B. Th e t im ing of su rger y in pat ien t s w ith cen -
Th e basic prin ciples of m ult isystem t rau m a m an agem en t t ral spin al cord injur y. J Neurosurg Spin e 2009;10(1):12
sh ou ld n ot be foregon e in th e set t ing of sp in al cord inju r y (SCI). 12. Feh lings MG, Vaccaro A, Wilson JR, et al. Early versu s delayed de-
The ABCs (air w ay, breath ing, circulat ion ) sh ould be m on itored com pression for t raum at ic cer vical spin al cord injur y: result s of
an d t reated app ropriately. SCI p at ien t s m ay p resen t w ith oth er th e su rgical t im ing in acu te sp in al cord inju r y st u dy (STASCIS).
life th reaten ing inju ries th at m ake op erat ive in ter ven t ion for PLoS On e 2012;7:e32037
196
13 Cervical Burst Fractures
Teresa S. Purzner, Jam es G. Purzner, and Michael G. Fehlings
197
198
II Spinal Em ergency Procedures
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199
II Spinal Em ergency Procedures
(MRI) n dings associated w ith can al com prom ise an d foun d Secon dar y ou tcom es w ere rates of com plicat ion an d m or talit y.
th at m axim um spin al cord com pression as w ell as spin al cord Tw en t y percen t of pat ien t s un dergoing early su rger y sh ow ed a
h em orrh age an d cord sw elling w ere m ost associated w ith a 2 grade im provem en t com pared to 8.8% in th e late decom -
poor progn osis for n eurologic recover y.8 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.
Initial Evaluation and Medical 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%,
Management 30% recurren t displacem en t or m alalign m en t , 2 to 4% chan ce
Th e in it ial m an agem en t of cer vical bu rst fract ures occurs out- of t ran sien t de cit , an d 1% ch an ce of perm an en t de cit . Over-
side of th e h osp ital at th e scen e of inju r y. Th ese fract u res often all rates of failu re in com pression fract u res of th e su ba xial
occur in th e set t ing of polyt rau m a w h ere oth er life-th reaten ing C-spin e w ere fou n d to be aroun d 5%. Sim ilarly, Koivikko et al
inju ries can dist ract from possible n eu rologic deteriorat ion . Full fou n d a rate of reop erat ion in p at ien t s t reated w ith orth osis to
cer vical spine precaut ion s w ith im m obilizat ion an d t ran sfer to be 4%(com pared to 3%in surgically m an aged pat ien ts).11 W h ile
an ap prop riate t rau m a cen ter sh ou ld be p erform ed e cien tly n on surgical m an agem en t is cert ain ly th e appropriate decision
an d safely. On ce at th e t rau m a cen ter, th e Advan ced Trau m a Life in a large percen tage of pat ien ts, th ere is som e eviden ce th at
Su p p or t p rotocol is in st it u ted. In th e set t ing of ret rop u lsed seg- n eu rologic im p rovem en t , kyp h ot ic deform it y, an d can al sten o-
m en t s an d com pressive sp in e inju r y, part icu lar at ten t ion is paid sis w ere all im p roved in pat ien t s t reated su rgically.11 Most st u d-
to oxygen at ion an d m ain ten an ce of adequ ate p erfu sion . St rict ies, h ow ever, w ere ret rospect ive review s an d outcom es w ere
blood pressu re con t rol is im port an t w ith a t arget m ean arterial gen eralized to a sp ect ru m of fract u re p at tern s. Furth erm ore,
pressure (MAP) above 80. Hypoten sion can in it ially be m an aged th e di eren ces in recover y bet w een surgical an d non surgical
w ith uid boluses; h ow ever, in it iat ion of vasopressors sh ould m an agem en t is far ou t w eigh ed by th e stat u s at presen t at ion
be con sidered if adequate perfusion is n ot ach ieved w ith uid th an ch oice of t reat m en t . Pat ien ts w h o are t reated w ith a h alo
boluses alon e. Th e role of steroids rem ain s am biguous an d is vest or h ard cer vicoth oracic orth osis for 2 to 3 m on th s sh ou ld
w ell review ed elsew h ere. On ce th e p at ien t is st abilized , a th or- be follow ed up w ith exion -exten sion X-rays to h elp determ in e
ough h istor y can reveal th e m ech an ism of injur y an d t im ing of su ccess of fu sion .
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 obvi- Preprocedure Considerations
ous 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
Radiographic Imaging
of injur y. Next , a dedicated n eu rologic exam sh ould focus on Th e ch oice of im aging in su spected cer vical burst fract ures
lim b st rength , sen sat ion an d re exes, t run cal sen sat ion , an d h as ch anged over th e past few decades. Tradit ion ally, an -
perspirat ion as w ell as bow el an d bladder sph in cter fun ct ion . teroposterior (AP), lateral, an d odon toid plain lm s of th e
Th e Am erican Spin al Injur y Associat ion classi cat ion system C-spin e w ere th e rst-lin e im aging of choice. Th ere are sev-
(ASIA) is a com m on clin ical classi cat ion system th at allow s for eral radiograp h ic feat u res suggest ive of bu rst fract u resm ost
an organ ized ap proach to th e n eu rologic exam an d categorizes im port an tly, loss of ver tebral body h eigh t , cort ical fract ure
degree of injur y in to four groups.9 ASIA A inju ries are com p lete of th e posterior VB w all, ret ropu lsion of fragm en t s in to th e
SCIs w h ere n o sen sor y or m otor fu n ct ion is p reser ved. ASIA E can al result ing in loss of th e dorsal ver tebral body lin e, an d
inju ries h ave n o m otor or sen sor y de cit . ASIA B to D injuries an in crease in in t rapedicu lar distan ces or sp laying of th e facet
are in com plete SCIs w h ere sen sory fu n ct ion is p reser ved bu t join t s. Th is is occasion ally accom pan ied by VB kyph ot ic or
w ith var ying degrees of loss in m otor fun ct ion . Im port an tly, t ran slat ion al deform it y.
ongoing progression of n eurologic de cit s can suggest ongoing In m any cen ters, com p u ted tom ography (CT) scan is n ow th e
or progressive com pression w h ether by un st able or ret ropulsed rst-lin e im aging m odalit y of ch oice in cases su sp iciou s of
fract u re fragm en t s or an expan ding h em atom a. Th ese are im - n eck t rau m a. Typ ically, bu rst fract u res w ill h ave d isru pt ion of
port an t to iden t ify early as t im ely decom pression can h ave sig- th e posterior VB w all w ith or w ith ou t ret ropulsed fragm en t s.
n i can t im p act on overall ou tcom e. As in plain lm s, th ey w ill dem on st rate an in creased IPD w ith
Early opt im izat ion of m edical m an agem en t h as been sh ow n splaying of th e vertebral arch . CT angiograp hy (CTA) sh ou ld
to ben e t long-term p rogn osis; h ow ever, th e t im ing of su rgical also be con sidered w h en th ere is con cern of com p rom ise of
in ter ven t ion rem ain s som ew h at m ore con t roversial. Th ere ex- th e ver tebral can al an d, in m any in st it ut ion s, it h as becom e
ist s a large body of literat u re invest igat ing th e role of early sur- part of th e st an dard im aging protocol for con rm ed C-spin e
gical in ter ven t ion . Th e best eviden ce to date w as pu t for w ard by inju ries.
Feh lings et al in th e Su rgical Tim ing in Acu te Spin al Cord Injur y MRI can often be h elp fu l in bet ter visu alizing soft t issu e
St u dy (STASCIS t rial).10 Th is in tern at ion al m ult icen ter prospec- st ru ct u res, disk, can al sten osis as w ell as cerebrospin al u id
t ive coh ort st udy looked at 313 pat ien t s w ith acute cer vical SCI. (CSF) e acem en t , cord im pingem en t , or sign al ch anges23%
Of th ese, 182 u n der w en t early su rger y (w ith in 24 h ou rs) an d of all blu n t t raum a pat ien t s presen t ing w ith a cer vical in -
131 un der w en t late surger y (after 24 h ours). Prim ar y ou tcom e jur y h ave eviden ce of disk injur y on MRI. Th is in creases to
w as ch ange in ASIA Im p airm en t Scale (AIS) grade at 6 m on th s. as h igh as 36% of th ose p at ien ts w ith com p lete SCI, 54% of
200
13 Cervical Burst Fractures
in com p lete SCI, an d 47% of p at ien t s w ith u n st able SCI.12 MRI st udies looking at th e stabilit y of th e cer vical spin e after an terior
sh ou ld be p erform ed in a t im ely m an n er, part icu larly w h en fu sion , posterior fusion , an d com bin ed fusion s in pat ien ts w ith
th e clin ical exam is n ot explain ed by radiograph ic n dings. In VB fract ures. It w as found th at alth ough posterior fusions w ere
th ose pat ien t s w ith equivocal exam or radiograph ic n dings, stronger th an an terior fusion s both w ere stronger th an th e in-
15.5% h ave been fou n d to h ave both disk an d ligam entous tact spine. This w as true in both isolated anterior injur y or com -
disrupt ion , w h ile 20% h ave isolated ligam en tous abn orm al- bined anterior/posterior injuries. Therefore, particularly in the
it y.13 T1-w eigh ted im ages are useful for th eir en h an cem en t set t ing of in tact posterior elem en ts, th e role of corpectom y w ith
of subacute h em orrh age w h ile T2 w eigh ted im ages w ill sh ow an terior recon struct ion provides adequate stabilizat ion for long-
hyperin ten sit y at areas of edem a. Sh or t inversion recover y term bony fusion. Nonunion rate is approxim ately 3%.15
(STIR) im aging is a fat suppression sequ en ce th at is par- More exten sive recon st ru ct ion s, involving com bin ed an terior
t icularly h elpful in h igh ligh t ing areas of ligam en tous injur y. an d p osterior app roach es, are n ecessar y in cases w ith su bopt i-
Gradien t ech o im aging an d su scept ibilit y-w eigh ted im aging m al bon e qu alit y, involvem en t of th e posterior elem en t s, or ex-
w ill fur th er evaluate th e presen ce of h em orrh age. Di u sion - isting long fused segm en ts. Bon e m in eral den sit y h as a sign i -
w eigh ted im aging (DW I) u ses rap id ech o p lan ar sequ en ces to cant im pact on overall fu sion rates 16 an d th e degree of fu sion
h igh ligh t acu te isch em ic even t s. It h as been u sed ver y su c- m u st be t ailored to both th e den sit y of h ealthy bon e an d degree
cessfully in evaluat ing t rau m at ic brain injur y an d cerebral of bony disrupt ion . Gen erally, at least th e caudal th ird of th e
isch em ia bu t is st ill lim ited in th e spin al cord given th e car- caudal vertebral body an d caudal endplate of th e rost ral ver-
diorespirator y m ot ion ar t ifact , CSF pulsat ion , an d th e sm aller tebral body sh ou ld be in tact for appropriate fusion . Com bined
region of in terest . Non eth eless, it is an area of act ive research an terior an d posterior fu sion is u sed in p at ien t s w ith ver y st i
th at h as been sh ow ing prom ising prelim in ar y results. MRI or spon dylot ic spin es (di use idiopath ic skeletal hyperostosis
sh ould be st rongly con sid ered in th e set t ing of bu rst fract u res [DISH], an kylosing spon dylit is) or in th e set t ing of injur y to th e
p ar t icularly w h en th ere is con cern of a t rau m at ic disk prot ru - posterior elem en ts. Com bin ed operation s h ave been sh ow n to
sion or to assess th e degree of can al sten osis resu lt an t from provide im m ediate rigid st abilizat ion , increased fusion , an d de-
ret rop ulsion of th e posterior elem en ts. Eith er of th ese w ou ld creased rates of ven t ral plate failu re. Par t icularly w h en both can
be im port an t in surgical plan n ing. be perform ed un der a single an esthet ic, a com bin ed approach
Preoperat ive im aging (Fig. 13.2). 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 ypi-
cally con sidered in th e set t ing of facet fract u res or dislocat ion s
Approach 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 use-
On ce th e decision to operate h as been m ade, th e role of an terior, fu l w h en pat ien t s h ave failed closed red u ct ion an d th ere is su s-
posterior, or com bined approaches m ust be con sidered. There picion th at in t raoperat ive reduct ion w ill be di cult .
are risks an d ben e ts to both an d approach is ult im ately deter-
m 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. Operative Field Preparation
Neurologic com pression is a result of retropu lsed an terior ele-
m en ts w h ich can be rem oved un der direct vision w ith an an teri- Fiberopt ic in t ubat ion w h ile th e pat ien t is asleep is recom -
or approach and therefore on e can provide opt im al decom pres- m en ded in all u n stable cer vical bu rst fract u res w h en p ossible.
sion . Fu rth erm ore, corpectom y w ith an terior recon st ruction Povidin e iodin e or ch lorh exidin e is applied to th e surgical site
provides excellent biom echanical stabilit y and correction of ky- an d allow ed to dr y for 3 m in u tes. Th e u se of p reop erat ive local
photic deform it ies. The resected vertebral body provides large an esth et ic is u p to th e d iscret ion of th e su rgeon ; t yp ically th e
am oun ts of excellen t m aterial for autologous bon e graft ing. m arked in cision is in lt rated w ith 1% lidocain e w ith ep in ep h -
An terior approach es also h ave less blood loss an d postopera- rin e 1:100,000.
t ive pain. Indeed, w hen directly com pared, Toh et al found an - Prophylact ic an t ibiot ics sh ou ld be given an d dexam eth ason e
terior fusion preferred to posterior fusion in cer vical burst and sh ou ld be con sidered p art icu larly in th e set t ing of cord com -
teardrop fract ures.14 This w as echoed by several biom echanical p ression or n eurologic com prom ise.
201
II Spinal Em ergency Procedures
a b
c d
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)
203
II Spinal Em ergency Procedures
Subplatysmal aps are elevated and the omohyoid muscle is isolated and divided w ith diathermy cautery.
204
13 Cervical Burst Fractures
205
II Spinal Em ergency Procedures
206
13 Cervical Burst Fractures
207
II Spinal Em ergency Procedures
208
13 Cervical Burst Fractures
209
II Spinal Em ergency Procedures
210
13 Cervical Burst Fractures
211
II Spinal Em ergency Procedures
Postoperative Management 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
Monitoring 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
Pat ien t s sh ou ld be m on itored for blood pressu re an d n eu- an d requ ire in dividu al con sid erat ion .
rologic 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 .
References
Medication
1. Allen BL, Jr., Fergu son RL, Leh m an n TR, OBrien RP. A m ech an ist ic
Th e u se of postoperat ive an t ibiot ics is con t roversial. Th ere is classi cat ion of closed, in direct fract ures an d dislocat ions of th e
n o good evid en ce th at rou t ing postoperat ive an t ibiot ics pro- low er cer vical spin e. Spin e (Ph ila Pa 1976 ) 1982;7(1):127
vides any advan t age to p ostop w ou n d in fect ion s. 2. Vaccaro AR, Hu lber t RJ, Patel AA, et al. Th e su baxial cer vical
The use of steroids in acute SCI is also controversial and its po- spin e injur y classi cat ion system : a n ovel approach to recogn ize
ten tial ben e t m ust be w eigh ed again st th e risk of pn eu m on ia, th e im por t an ce of m orph ology, n eurology, an d integrit y of th e
poor w ound healing, and recover y from associated injuries. 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 a-
Radiographic Imaging (Fig. 13.12) bilit 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 iolog-
ic 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 assess-
ing 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 analy-
sis 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 -
Fig. 13.12 The patient was treated with a C4 corpectomy and C3-5 dards for n eurological classi cat ion of spin al cord injur y. J Spin al
anterior reconstruction with a bular allograft (packed with local Cord Med 2003;26 Su p pl 1:S50S56
corticocancellous autograft), and anterior screw-plate xation. Under 10. Feh lings MG, Vaccaro A, Wilson JR, et al. Early versu s delayed de-
the same anesthetic, the patient was turned (using May eld cranial com pression for t rau m at ic cer vical spin al cord injur y: result s of
xation and a Jackson table) in the supine position and a C3-5 posterior th e Su rgical Tim ing in Acu te Spin al Cord Inju r y St u dy (STASCIS).
lateral mass reconstruction was undertaken. PLoS On e 2012;7(2):e32037
212
13 Cervical Burst Fractures
11. Koivikko MP, Myllyn en P, Karjalain en M, Vorn an en M, San t avir t a th e e ect s of p late d esign , en dp late p rep arat ion , an d bon e
S. Con ser vat ive an d operat ive t reat m en t in cer vical burst frac- m in eral den sit y. Spin e (Ph ila Pa 1976 ) 2005;30(3):294301
t ures. Arch Or th op Traum a Surg 2000;120(7-8):448451 17. Leh m an n W, Briem D, Blauth M, Sch m idt U. Biom ech an ical com -
12. Rizzolo SJ, Vaccaro AR, Cotler JM. Cer vical sp in e t rau m a. Sp in e parison of anterior cer vical spin e locked an d u n locked plate-
(Ph ila Pa 1976 ) 1994;19(20):22882298 xat ion system s. Eur Spin e J 2005;14(3):243249
13. Benzel EC, Hart BL, Ball PA, Baldw in NG, Orrison W W, Espinosa 18. Spivak JM, Ch en D, Ku m m er FJ. Th e e ect of locking xat ion
MC. Magnetic resonance im aging for the evaluation of patients screw s on th e st abilit y of an terior cer vical plat ing. Spin e (Ph ila
w ith occult cervical spine injur y. J Neurosurg 1996;85(5):824829 Pa 1976 ) 1999;24(4):334338
14. Toh E, Nom u ra T, Wat an abe M, Moch ida J. Su rgical t reat m en t 19. DuBois CM, Bolt PM, Todd AG, Gupt a P, Wet zel FT, Ph illips FM.
for inju ries of th e m iddle and low er cer vical spin e. Int Or th op St at ic versus dyn am ic plat ing for m ult ilevel an terior cer vical dis-
2006;30(1):5458 cectom y an d fusion . Spine J 2007;7(2):188193
15. Zigler J, Eism on t F, Gar n S, Vaccaro A. Sp in e Trau m a. Rosem on t , 20. Leh m an n W, Blauth M, Briem D, Sch m idt U. Biom echan ical
IL: Am erican Academ y of Or th opaedic Su rgeon s; 2011 an alysis of anterior cer vical spine plate xat ion system s w ith
16. Dvorak MF, Pit zen T, Zh u Q, Gordon JD, Fish er CG, Oxlan d TR. An - un icort ical an d bicor t ical screw purch ase. Eur Spin e J 2004;
terior cer vical plate xat ion : a biom echan ical st u dy to evaluate 13(1):6975
213
14 Cervical Facet Dislocation
Daniel Resnick and Casey Madura
Introduction 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.
Dislocat ion of th e facets join t s of th e spin e can occu r at all levels,
If the articular surface fails, fracture of the inferior articulating
but it is m ost com m on ly an injur y fou n d in th e cer vical spin e.
process can occur, weakening the facet joint as a w hole. The inev-
First , th e coron al orien t at ion of th e join t s th em selves leaves
itable hyper exion that follow s then causes the dislocation, un-
th em suscept ible to dislocat ion w ith hyper exion . Secon d, un -
hindered by the norm al ligam entous and joint capsule restraints.
like th e su bstan t ial size of th e lum bar ar t icu lat ing processes,
The ultim ate result of any facet dislocation in the cervical spine
th ose in th e cer vical spin e are m uch less robust .1 Th erefore,
is an unstable spine that requires im m ediate treatm ent. Treatm ent
th e ar t iculat ing processes in th e cer vical spin e are m uch m ore
options include nonoperative m anagem ent w ith closed reduction
p ron e to fract u re an d dislocat ion . Th ird , th e cer vical spin e is
followed by im m obilization in an external xation device such as
n at u rally h igh ly m obile in com p arison to th e th oracic an d lu m -
a halo vest or Minerva brace versus operative xation follow ing
bar spin e w ith th e h eads w eigh t ser ving as a con t ribut ing fac-
either closed or open reduction. The details of the di erent op -
tor. Th is ch aracterist ic leaves th e cer vical spin e vuln erable to
tions are discussed below, but there is a general agreem ent that
su dden ch anges in m ovem en t su ch as th at w h ich occu rs in a
the universal presence of ligam entous injury in facet dislocations
h ead-on collision .
m akes operative xation a preferred technique for treatm ent of
Dislocat ion of th e cer vical facet join ts can be both u n ilateral
both unilateral and bilateral facet dislocations of the cervical spine.
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 ex-
ion . 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
Indications
exp erien ced at th e sam e t im e cau ses on ly on e of th e t w o el-
Hyp er exion inju r y resu lt ing in u n ilateral or bilateral facet
evated in ferior art icu lat ing p rocesses to t ran slate for w ard, lock-
dislocat ion such as a h ead-on m otor veh icle collision .
ing an terior to th e su perior art icu lat ing p rocess of th e ver tebra
Com bin ed hyperexten sion /hyper exion injur y result ing rst
below it .2 A pu rely hyp er exion m om en t w ith ou t rot at ion is
in facet fract ure due to hyperexten sion w ith su bsequen t facet
m u ch m ore likely to cau se bilateral facet dislocat ion as th e force
dislocat ion due to hyper exion as is experien ced during a se-
vectors exp erien ced by each facet are th eoret ically sim ilar. In
vere rear-en d collision .
eith er scen ario, th e dislocat ion is visu alized as eith er a p erch ed
If th e exam in at ion reveals n o n eu rologic de cit or a com p lete
facet (on e in w h ich th e in ferior p roject ion of th e in ferior ar t icu -
sp in al cord inju r y, su rgical st abilizat ion sh ou ld occu r as soon
lat ing p rocess of th e p roxim al ver tebral body ar t iculates w ith
as th e p at ien t is m edically st able an d an ap p rop riate team is
th e superior project ion of th e superior ar t icu lat ing process of
available.
th e dist al ver tebral body) or a locked facet (in w h ich th e in ferior
If th e exam in at ion reveals n dings con sisten t w ith a p art ial
art icu lat ing process of th e p roxim al ver tebral body is an terior
sp in al cord inju r y, u rgen t redu ct ion an d st abilizat ion is rec-
to th e su perior art iculat ing process of th e dist al ver tebral body).
om m en ded as soon as th e pat ien t is h em odyn am ically st able.
All region s of th e cer vical spin e are n ot created equ al. Un like
Hyp oten sion sh ou ld be avoid ed in all p at ien ts, esp ecially
th e su baxial cer vical spin e, th e C1-C2 facet join t s are orien ted
th ose w ith n eurologic de cits.
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 else-
w h ere. It is th e su baxial cer vical spin e, speci cally C4- C7, th at is
Examination
m ost p ron e to hyper exion inju ries.3 In large p art , th is is du e to Any pat ien t th at su ers a cer vical facet dislocat ion h as su s-
th e dyn am ic forces th e cer vical spin e experien ces as a collision t ain ed forces su cien t to cause a m yriad of oth er life-th reat -
evolves. At th e on set of a h ead -on collision , th e low er cer vico- en ing inju ries; th erefore, a fu ll t rau m a w orku p sh ou ld be
th oracic jun ct ion of th e spin e com presses an d extends w h ile com pleted w ith priorit y given to th e ABCs (air w ay, breath ing,
th e subaxial cer vical spin e exes w ith great force. As th e forces circulat ion ). Im m obilizat ion of th e cer vical spin e du ring th is
evolve, th e cer vical sp in e is even t u ally th row n in to exten sion . evalu at ion m u st be a priorit y.
Th is evolut ion of forces, com m on ly referred to as w h iplash , A full n eurologic exam in at ion sh ould be perform ed as th is
causes th e spin e to assum e an S-shape, a ph en om en on referred h as im plicat ion s regarding th e t im ing of in ter ven t ion .
to as sn aking. Th e hyper exion , if severe en ough , can lead to Ad dit ion ally, evalu at ion of n eu rologic st at u s m ay allow local-
facet dislocat ion by it self. izat ion of th e injur y prior to im aging.
214
14 Cervical Facet Dislocation
4
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 -
Class III eviden ce suggest s early redu ct ion of cer vical facet ister steroids.
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 se- Operative Management 11
dat ion .5 If th e pat ien t is un respon sive or u nable to cooper-
ate, m agn et ic reson an ce im aging (MRI) is in dicated prior to Approach
redu ct ion as th e n eu rologic exam in at ion can n ot be follow ed
If closed redu ct ion h as been ach ieved, an terior xat ion an d
an d th e p resen ce of a large ven t ral lesion m ay be a relat ive
fu sion , p osterior xat ion an d fu sion , or h alo im m obilizat ion
in dicat ion for an open redu ct ion via an an terior approach .
are t reat m en t opt ion s. In gen eral, h alo im m obilizat ion is as-
Closed redu ct ion tech n ique in cludes h alo or tongs t ract ion ,
sociated w ith a relat ively h igh failu re rate an d th e vast m ajor-
w h ich is discu ssed in Ch apter 11. Closed reduct ion an d exter-
it y of su rgeon s w ill o er a direct xat ion p rocedu re.
n al bracing is associated w ith in creased m orbidit y an d m or-
If th e dislocat ion requ ires op en redu ct ion , th e su rgeon m ay
t alit y related to prolonged bedrest .
ch oose bet w een an terior or posterior approach es depen d-
Su ccess of closed redu ct ion is 80%.
ing on th e an atom y of th e injur y an d th e experien ce of th e
Risk of su ering ad dit ion al p erm an en t n eu rologic inju r y du r-
su rgeon . Th e p resen ce of a large ven t ral disk h ern iat ion m ay
ing closed reduct ion is , 1%.
be a relat ive in dicat ion for an an terior approach as a kn ow n
Risk of su ering addit ion al t ran sien t n eu rologic inju r y du ring
u n ilateral ver tebral arter y inju r y. In th ese cases, th e use of
closed reduct ion is 2 to 4%.
MRI is app ropriate. If th e dislocat ion is com p lete en ough th at
If reduction fails, the likelihood of other injuries such as facet
th e surgeon does n ot believe an an terior approach feasible for
fracture or herniated disks is increased. This necessitates further
reduct ion , th en a posterior approach is in dicated.
im aging studies such as MRI prior to open reduction to deter-
m ine the initial direction of approach (anterior versus posterior).
Techniques
Opt ion s in clu de: an terior fu sion w ith or w ith ou t p late xa-
Preprocedure Considerations 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
Radiographic Imaging xat ion p rovides in st an t stabilit y (allow ing early m obiliza-
Com puted tom ography (CT) scan: CT is the workhorse of cervi- t ion of th e pat ien t). Ch oice of tech n iqu e is based on th e in teg-
cal spine traum a evaluation. Identi cation of osseus abnorm al- rit y of th e bony st ru ct u res an d th e exp erien ce of th e su rgeon .
it y is straightforward w hile ligam entous injury is not always Posterior fu sion w ith w iring m ay also be associated w ith an
detectable. Ligam entous injury m ay be detected due to enlarged in creased risk of late kyph ot ic angulat ion com p ared to m ore
spaces bet ween otherw ise norm al appearing osseus structures. rigid tech n iqu es. In on e st u dy, 22 of 165 pat ien t s w ith cer vi-
MRI: Th is test h as, in th e past , been advocated as a n ecessar y cal facet dislocat ion t reated via posterior fusion an d w iring
p ar t of any pre-reduct ion w orkup, w h eth er th at reduct ion be developed kyph osis com pared to just 1 of 40 pat ien t s t reated
in th e in ten sive care un it (ICU) or operat ing room set t ing. Th e via p osterior fu sion an d lateral m ass xat ion .11
rat ion ale for th is w as to iden t ify any ven t ral in ter vertebral Anterior fusion w ithout plating is associated w ith a h igh er
disk h ern iat ion s th at m ay cause n eurologic injur y du ring re- in ciden ce of graft displacem ent and late developm en t of ky-
duct ion . According to an eviden ce-based review, th ere w as ph osis th an posterior fusion w ith xat ion. Six of 101 pat ient s
n o relat ion sh ip bet w een th e p resen ce of h ern iated disks an d t reated in th is fash ion developed late instabilit y com pared to 6
risk of n eu rologic inju r y du ring closed redu ct ion of facet dis- of 237 pat ients t reated via a posterior fusion w ith lateral m ass
locat ion s in th e presen ce of a ven t rally h ern iated disk.4 W h ile xat ion .11 Th e use of an terior fu sion w ith plate xation is w ell
p re-redu ct ion or preop erat ive MRI m ay be useful in term s of described an d is associated w ith excellen t outcom es.1216
de n ing associated injuries an d in som e cases dict at ing surgi-
cal 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 Operative Field Preparation
n ot be delayed in a p at ien t w ith a severe n eu rologic inju r y.
Cer vical im m obilizat ion m ust be m ain t ain ed at all t im es.
Cervical X-ray: The role of plain radiographs in the initial assess-
With regards to anesthesia, the inherent instability of this
m ent of severe traum a has been lim ited by the advent of aggres-
t ype of spinal colum n injury encourages beroptic intubation.
sive use of CT im aging. Plain lm s are quite helpful for diagnosing
Regardless of th e n al posit ion (pron e or su pin e), th e n eck
cervical facet dislocations and are em ployed serially (or w ith u-
sh ou ld be kept in a n eu t ral p osit ion at all t im es.
oroscopy) during the process of either open or closed reduction.
Th e operat ive area is cleared of h air u sing clippers on ly an d
clean sed w ith alcoh ol.
Medication Povidin e iodin e or ch lorh exidin e prep is used to sterilize
th e operat ive eld w idely.
Steroids: Methylprednisolone for spinal cord injur y is a topic of Th e in cision s are m arked. In lt rat ion w ith 1% lidocain e
great con troversy. Draw ing from the 2002 an d 2013 AANS/CNS w ith 1:100,000 epin eph rin e is opt ion al.
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II Spinal Em ergency Procedures
Operative Procedure
Posterior Approach (Fig. 14.1a, b)
a b
Fig. 14.1a, bCaseexample:posterior xation.Thisyoungmanwasinvolvedinamotorvehicleaccidentandpresentedwithacompletespinal
cordinjuryatC6-C7.(a, b)CTim agesdemonstratethebilateralfacetsubluxationinjuryalongwithsomeadditionalposteriorelem entinjuriesand
distractionindicatingcircumferentialligamentousdisruption.Becauseofthedegreeofdistractionandposteriorelementinjuries,alongsegment
posterior xationwasplanned.
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14 Cervical Facet Dislocation
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II Spinal Em ergency Procedures
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14 Cervical Facet Dislocation
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II Spinal Em ergency Procedures
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14 Cervical Facet Dislocation
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II Spinal Em ergency Procedures
a b
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14 Cervical Facet Dislocation
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II Spinal Em ergency Procedures
224
14 Cervical Facet Dislocation
a b c
Fig. 14.10acCaseexample:reductionandanterior xation.Thismiddle-agedwomanpresentedfollowingafallwithasevereC6(ASIAB)spinal
cordinjury.(a)Sagit taland(b)parasagit talCTimagesdemonstratethefacetsubluxationinjuryandfracture.(c)Shewasbroughtdirectlytothe
operatingroomwheretractionwasapplied,almostcompletelyreducingthesubluxation.
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II Spinal Em ergency Procedures
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14 Cervical Facet Dislocation
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14 Cervical Facet Dislocation
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14 Cervical Facet Dislocation
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II Spinal Em ergency Procedures
a b
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14 Cervical Facet Dislocation
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II Spinal Em ergency Procedures
Closing Radiographic
Anterior A postoperat ive CT scan m ay be obtain ed to evaluate th e
placem en t of th e screw s an d th e exten t of reduct ion .
Ret ract ion is rem oved slow ly w ith all poin t s of bleeding Pat ien ts are follow ed on an ou t pat ien t basis w ith an teropos-
coagu lated u sing bipolar elect rocauter y. terior an d lateral plain lm s of th e cer vical spin e at 1 m on th ,
Th e plat ysm a is closed using 2-0 absorbable braided sut ures. 3 m on th s, an d 6 m on th s for evaluat ion of th e exten t of fu-
Th e pu rpose is reapproxim at ion an d does n ot h ave to be sion . Fig. 14.19 sh ow s n al con st ruct of posterior approach
w ater-t igh t . an d Fig. 14.20 sh ow s n al con st ru ct of an terior ap p roach .
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 Further Management
braided sut ures.
Th e skin m ay be closed using a subcut icu lar st itch , t ypically It is ou r pract ice to rem ove drain s w h en th e ou t pu t drops be-
4-0 braided or m on o lam en t absorbable sut ure, a layer of low 100 m L in a sh ift .
brin glue, or a com bin at ion of th e t w o. Skin su t u res/st ap les th at are n ot absorbable are rem oved
2 w eeks postoperat ively.
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14 Cervical Facet Dislocation
References
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 Neuro-
a logical Su rger y an d th e Nat ion al In st it u te of Health . Spring eld,
Fig. 14.19a, bPostoperativeimagesofpatientdepictedinFig. 14.1. IL: Th om as; 1970
(a)Oncestabilized,hewasbroughttotheoperatingroomforanopen 4. Gelb DE, Hadley MN, Aarabi B, et al. In it ial closed redu ct ion
posteriorreductionand(b)stabilizationusinglateralmassscrewsinthe of cer vical spin e fract ure-dislocat ion injuries. Neurosurger y
midcervicalspineandpediclescrewsinC7andT1. 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. 15. De Iu re F, Scim eca GB, Palm isan i M, et al. Fract u res an d disloca-
Closed reduct ion of t raum at ic cer vical spin e dislocat ion us- t ion s of th e low er cer vical spin e: surgical t reat m ent . A review of
ing t ract ion w eigh t s up to 140 poun ds. Spin e 1993;18(3): 83 cases. Ch ir Organ i Mov 2003;88:397410
386390 16. Ordon ez BJ, Ben zel EC, Naderi S, et al. Cer vical facet d islocat ion :
6. Hadley MN, Beverly CW, Grabb PA, et al. Ph arm acological th er- tech n iques for ven t ral reduct ion an d st abilizat ion . J Neurosurg
apy after acute cer vical spin al cord injur y. In : Neu rosurger y 2006;92:1823
Sect ion on Disorders of th e Spin e an d Periph eral Ner ves of the 17. Leh m an n W, Blauth M, Briem D, Sch m idt U. Biom ech an ical analy-
Am erican Associat ion of Neu rological Surgeon s an d th e Con - sis of anterior cer vical spin e plate xat ion system s w ith un icort i-
gress of Neurological Surgeon s Gu idelin es for th e m an agem en t cal and bicor t ical screw purchase. Eur Spine J 2004;13(1):6975
of acute cer vical spin e an d spin al cord injuries. Neu rosurger y 18. Seybold EA, Baker JA, Criscit iello AA, Ordw ay NR, Park CK, Con -
2002;50(S3):S6372 n olly PJ. Ch aracterist ics of un icor t ical an d bicor t ical lateral m ass
7. Hu rlber t RJ, Hadley MN, Walters BC, et al. Ph arm acological screw s in th e cer vical spin e. Spin e 1999;24(22):23972403
th erapy for acute spinal cord injur y in Guidelin es for th e m an - 19. Ryken TC, Hu rlber t RJ, Had ley MN, et al. Th e acu te cardiop u lm o-
agem en t of acu te cer vical sp in e an d spin al cord inju ries. Neu ro- n ar y m an agem en t of pat ien t s w ith cer vical spin al cord injuries.
su rger y 2013;72 [suppl 2]:93105 Neurosu rger y 2013;72[suppl 2]:8492
8. Bracken MB, Sh epard MJ, Hellen bran d KG, et al. Methylpredn iso- 20. Bucholz RD, Chang KC. Halo vest versus spinal fusion for cervical in-
lon e an d n eurological fun ct ion 1 year after spin al cord injur y. Re- jury: Evidence from an outcom e study. J Neurosurg 1989;71(6):955
su lt s of th e Nat ion al Acu te Spin al Cord Injur y St udy. J Neu rosurg 21. Son t ag VK, Hadley MN. Non operat ive m an agem en t of cer vical
1985;63:704713 spin e injuries. Clin Neurosurg 1988;34:630649
9. Bracken MB, Sh ep ard MJ, Collin s W F, et al. A ran d om ized, con - 22. Hadley MN, Fit zp at rick BC, Son n t ag VK. Facet fract u re- dislocat ion
t rolled t rial of m ethylpredn isolon e or n aloxon e in th e t reat m en t injuries of the cer vical sp in e. Neu rosurger y 1992;30:661666
of acute spin al-cord injur y. Result s of th e Secon d Nat ional Acute 23. Mon roe MA, Ball PA. Spin al t ract ion . In : Ben zel EC, ed. Sp in e
Spin al Cord Inju r y St udy. N Engl J Med 1990;322:14051411 Surger y: Tech n ique, Com plicat ion , Avoidan ce, an d Man agem en t .
10. Bracken MB, Sh ep ard MJ, Collin s W F Jr, et al. Methylp redn iso- Ph iladelph ia: Saun ders; 1999:13531362
lon e or n aloxon e t reat m en t after acu te spin al cord inju r y: 1-year 24. In am asa J. Gu iot BH. Ver tebral ar ter y inju r y after blu n t cer vical
follow -up dat a. Result s of th e secon d Nat ion al Acute Spin al Cord t raum a: an update. Surg Neurol 2006;65:238246
Injur y St udy. J Neurosu rg 1992;76(1):2331 25. Hadley MN, Beverly CW, Grabb PA, et al. Man agem en t of ver-
11. Gelb DE, Aarabi B, Dh all SS, et al. Treat m en t of su baxial cer vical tebral arter y injuries after n onpen et rat ing cer vical t raum a. In :
spin e injuries. Neurosurger y 2013;72[suppl 2]:187194 Neurosu rger y Sect ion on Disorders of th e Spin e an d Periph eral
12. Rein dl R, Ou ellet J, Har vey EJ, et al. An terior redu ct ion for cer vical Ner ves of th e Am erican Associat ion of Neurological Surgeons
spin e dislocat ion . Spin e 2006;31:648652 an d th e Congress of Neu rological Su rgeon s Gu idelin es for th e
13. Joh n son MG, Fish er CG, Boyd M, et al. Th e rad iograp h ic failu re of m an agem en t of acute cer vical spin e an d spin al cord injuries.
single segm en t an terior cer vical plate xat ion in t raum at ic cer- Neurosu rger y 2002;50(3):S173S178
vical exion dist ract ion inju ries. Spin e 2004;29:28152820 26. Harrigan MR, Hadley MN, Dh all SS, et al. Man agem en t of ver te-
14. Maim an DJ, Barolat G, Larson SJ. Man agem en t of bilateral locked bral arter y injuries follow ing n on -pen et rat ing cer vical t raum a.
facet s of th e cer vical spin e. Neu rosu rger y 1986;18:542547 Neurosu rger y 2013;72[suppl 2]:234243
236
15 Classi cation and Treatment of
Thoracic Fractures
Joseph Hsieh, Doniel Drazin, Michael Turner, Ali Shirzadi, Kee Kim , and J. Pat rick Johnson
Introduction Facets
Th e art icular processes arise from th e su perior an d in ferior
Th oracic fract ures in h ealthy in dividuals are un com m on due lam in ar surfaces.
to th e st abilizing e ect of th e rib cage. How ever, h igh en ergy From T1 to T10, the thoracic facets are oriented coronally. This
t raum a an d predisposing con dit ion s can in crease th e likeli- m inim izes an terior translation during exion. From T11 to T12,
h ood of fract u re.1 Alth ough th ere is n o id eal st an dard for clas- the facets have an oblique sagittal orientation to lim it rotation.
si cat ion of th oracolu m bar (TL) inju ries, th e evolu t ion of th e Th e coron al facet orien t at ion of th e upper th oracic spin e al-
th ree- colu m n m odel of Den n is, th e AO/Magerl com p reh en sive low s for rotat ion aroun d th e cran iocaudal axis (75 degrees of
classi cat ion , an d th oracolu m bar injur y severit y scale an d rot at ion to each side) w ith th e greatest rot at ion at T8-T9.8 In
score (TLISS)/th oracolu m bar inju r y classi cat ion an d severit y con t rast , lu m bar spin e rot at ion is lim ited by th e orien tat ion
score (TLICS) poin t system h ave provided sign i can t in sigh t of th e facet s an d an terior an n ulus to on ly 10 degrees.
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 Ribs
of injur y an d an atom y.
Th e m ost dist inguish ing feat ures of th e th oracic spin e are th e
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
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II Spinal Em ergency Procedures
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15 Classi cation and Treatm ent of Thoracic Fractures
of surgical plan n ing. Care sh ou ld be taken to evaluate for t ypically an terior approach is preferred w ith con siderat ion of
p ossible an atom ic varian t s (e.g., cer vical ribs or lu m barized an atom ic lim it at ion s.
sacral ver tebrae). How ever, th e u p per th oracic colu m n is McAfee et al p rovided on e of th e earliest gen eral t reat m en t
p oorly visu alized on plain radiography. 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 re-
fabricated brace im m obilizat ion for 12 w eeks
Computed Tomography St able bu rst: cu stom t t ing orth osis or cast im m obilizat ion
Modern com puted tom ography (CT) allow s rapid characteriza- for 12 w eeks. L4 an d above: TLSO; L5: HTLSO; if kyp h osis
tion of spinal fracture m orphology and provides critical detail . 15 degrees, hyperexten sion cast .
in the acute and therapeutic setting.1 In a study by Sm ith et al, Un stable bu rst: su rgical decom p ression an d st abilizat ion
nonreconstructed CT detected TL fractures m ore accurately than (approach con t roversial). Con sider em ergen t posterior
plain radiographs and is recom m ended for diagnosis of TL frac- sh or t-segm en t d ecom p ression an d fu sion (w ith extern al
tures in acute traum a for patients w ith altered m ental status.18 im m obilizat ion in a custom TLSO for 12 w eeks), an d de-
In form at ion in clu des can al n arrow ing d u e to ret rop u lsed layed an terior decom pression an d fusion if th e p at ien t h as
fragm en t s, bet ter evalu at ion of u n st able rot at ion al inju ries, n eu rologic d e cit an d residu al cord/root com pression .
an d in d irect assessm en t of ligam en tou s an d d isk inju ries. Flexion -dist ract ion (an d Ch an ce inju r y): con sider hyper-
Facet dislocat ion an d posterior in terspin ous w iden ing due to exten sion cast for a p u rely osseou s inju r y w ith n o associ-
dist ract ion m ay dem on st rate a n aked facet sign . ated n eurologic de cit . Con sider posterior sh or t-segm en t
CT m yelogram m ay dem on st rate areas of com p ression of th e st abilizat ion an d fu sion for associated n eu rologic inju r y
th ecal sac. 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 a-
Magnetic Resonance Imaging bilizat ion w ith pedicle screw xat ion t w o to th ree levels
Magn et ic reson an ce im aging (MRI) dem on st rates associated above an d below th e inju r y w ith local bon e graft fu sion .
soft t issu e inju r y th at w ill n ot be visible on th e CT. 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
Occasion ally decom pression of th e sp in al cord from th ese St u dy Grou p of t h e Ger m an Associat ion of Trau m a Su rger y
soft t issu e elem en ts w ill be in dicated even for fract u res th at sh ow ed lim it at ion s for isolated p oster ior in st r u m en t an d
app ear to be st able on CT. fu sion tech n iqu es in cases w it h a com p rom ised an ter ior
If th e fract u re ap pears to be associated w ith som e p ath ology, colu m n .
th en it m ay be h elpful to in clude en h an ced im ages in th e MRI Sin ce then , operat ive approach es an d adju n cts h ave advan ced
to determ in e if th e bon e appears to h ave an associated in fec- con siderably to in clude en doscopic an d m in im ally invasive
t ion or t um or. 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
Medication Group of th e Germ an Associat ion of Trau m a Su rger y re-
view ed t rau m at ic TL (T1-L5) inju ries as an u p date to MCSI. Of
Steroids h ave had w axing an d w an ing p opularit y in th e set- 733 pat ien ts w ith acu te TL injuries t reated surgically 23 :
t ing of acute spin al cord injur y. If th ere is a neurologic injur y, 380 (51.8%) p at ien t s w ere op erated on by posterior st abili-
som e report s h ave in d icated th at h igh dose m ethylp redn iso- zat ion an d in st rum en tat ion alon e
lon e h as given som e ben e t .19 How ever, th ese in it ial repor t s 34 (4.6%) h ad an an terior p rocedu re alon e
h as n ot been replicated, an d th e risk to th e p at ien t con com i- 319 (43.5%) h ad com bin ed p osteroan terior p rocedu res.
t an t w ith steroid use in clu ding life-th reaten ing in fect ion s is Overall th ey fou n d:
n ot in con siderable.20 Recen t gu idelin es h ave recom m en ded Sh or t angular stable im plan t system s h ave replaced con -
again st th eir u se.21 ven t ion al n on angu lar stabilizat ion system s.
An t ibiot ics: If th e pat ien t h as an associated in fect ion , it m ay Post t rau m at ic deform it y w as restored best w ith com -
be ben e cial to obtain a specim en for cult ure prior to st ar t ing bin ed posteroan terior surger y.
an t ibiot ics. Oth er w ise st an dard preoperat ive an t ibiot ics are Di eren t surgical approach es did n ot h ave a sign i can t
u sed, t ypically cefazolin . 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.
Operative Management Th e m ost com m on surgical in ter ven t ion s for th oracic inju ries
are described below.
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 Operative Field Preparation
(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 -
Positioning
out in st rum en t at ion m ay dest abilize a spin e th at already h as Th e pat ien t is in t u bated supin e an d th en posit ion ed carefully
dam age to an oth er colu m n an d th erefore is in appropriate as n eeded.
w h en ever stabilit y is in quest ion . For an terior com pression , Pressu re poin t s are padded.
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II Spinal Em ergency Procedures
In t raoperat ive m on itoring in clu ding som atosen sor y evoked Posterolateral Approaches to the
poten t ials (SSEP) an d m otor evoked poten t ials sh ould be
con sidered. Anterior Thoracic Spine
Posterolateral approaches to the anterior thoracic spine include
the transpedicular, costotransversectomy, and posterolateral ex-
Localization tracavitary. These provide progressively greater visualization of the
Im aging an d p hysical exam review is crit ical to d eterm in e anterior spine as exposure extends farther laterally from m idline
th e su rgical levels. Preoperat ive im aging m ay in clu de local- w ith greater dissection of the ribs. The transpedicular corpectom y
izat ion u sing cross t able lateral p lain lm s w ith a radiopaqu e is the easiest progression from the direct m idline approach and is
m arker. 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
Prior to Incision costotransversectomy utilizes a m idline or param edian incision
Th e skin is prepped in sterile fash ion an d th e in cision is in l- and involves com plete rem oval of the rib head and transverse pro-
t rated w ith lidocain e 1% w ith epin eph rin e 1:100,000 cess and provides greater visualization for partial vertebrectom y.
The lateral extracavitary approach utilizes a hockey stick postero-
lateral incision w ithout violating the chest cavit y and provides
Approaches good visualization and decom pression of the anterior thecal sac.
These approaches are discussed in Special Considerations
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, Anterior Approach: Thoracotomy
th e approach w ill depen d on th e path ology, locat ion , spin al Anterior exposure to the thoracic spine is often critical in traum a.
cord com pression , in st abilit y, an d m edical con dit ion . Anterior exposure m akes it far easier to perform m ultilevel de-
com pression and stabilization through a single approach w ith
possibilit y of anterior stabilization. For fractures involving the an-
Posterior Approach terior elem ents of T1 or T2, an anterior approach can be used that
Poster ior ap p roach es to t h e t h oracic sp in e are t h e m ain - is sim ilar to an anterior cervical corpectom y and fusion. However,
st ay of sp in e p roced u res. Th e id eal p at h ology for t h ese ap - T3-T5 cannot be reached e ectively from the front unless the chest
p roach es is gen erally p oster ior to t h e sp in al cord . Th e m ost is opened by perform ing a m anubrial resection or sternotom y and
com m on p oster ior ap p roach (lam in ectom y w it h or w it h ou t are often best accessed through a transthoracic approach.
in st r u m en t at ion ) is u sed com m on ly for rad icu lom yelop at hy Tran sth oracic app roach es (e.g., th oracotom y an d th oracos-
from t h oracic d isk h er n iat ion , sp on dylosis, an d t rau m a w it h copy) provide several ben e ts in com parison to posterior or
st able sp in e alon g w it h som e t u m ors an d in fect ion . How ever, posterolateral approach es. A t ran sth oracic approach provides
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 opt im al exposure of th e an terior dura an d posterior longit udi-
cord inju r y. n al ligam en t . How ever, th e t radeo in clu des redu ced exp osu re
Th ese approach es can be tailored for access to a region of in - to th e posterior sp in e. Th ere are also associated com p licat ion s
terest from directly m idlin e to th e spin al can al (e.g., lam in ec- in clu ding pn eu m oth orax, pu lm on ar y con t u sion , pn eu m on ia,
tom y) to fu rth er p osterolateral in at tem pt s to reach an terior pleural e usion , em pyem a, an d possible n eed for an access
to th e can al (e.g., t ran sp ed icu lar, costot ran sversectom y, lateral su rgeon . W h ile th oracotom y is th e m ain stay, th oracoscopy h as
ext racavit ar y ap proach es). becom e in creasingly an opt ion .
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15 Classi cation and Treatm ent of Thoracic Fractures
Operative Procedure
Posterior Approach (Fig. 15.1ac and Fig. 15.2)
a b
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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.
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15 Classi cation and Treatm ent of Thoracic Fractures
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II Spinal Em ergency Procedures
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15 Classi cation and Treatm ent of Thoracic Fractures
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15 Classi cation and Treatm ent of Thoracic Fractures
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15 Classi cation and Treatm ent of Thoracic Fractures
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15 Classi cation and Treatm ent of Thoracic Fractures
a 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.
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15 Classi cation and Treatm ent of Thoracic Fractures
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15 Classi cation and Treatm ent of Thoracic Fractures
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15 Classi cation and Treatm ent of Thoracic Fractures
a 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.
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Transthoracic Vertebrectomy
Positioning and Approach Planning (Fig. 15.18)
T1 to T4 can be approached anteriorly Often the lesion will determ ine the lateralit y but in cases of m idline
utilizing resection of the third rib. The lesions or lesions that span the entire vertebral body, the vascular
incision w ill follow the medial border of the anatomy m ay dictate the approach. The position of the aorta needs to
scapula and extend caudally. The incision w ill be reviewed on CT to determ ine if it will be in the way. The vena cava
end at the sternocostal junction of the third is t ypically m idline and rarely a ects the choice of left versus right.
rib. For levels T5 to T9, the rib above the level The aorta has a m ore variable position, but often surgery above T9
to be operated on is removed. For levels T10 is best approached from the right. Below T9 the left side is an easier
to T12, the rib tw o levels above the level in approach as the liver pushes up on the diaphragm on the right.
question is removed.
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15 Classi cation and Treatm ent of Thoracic Fractures
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15 Classi cation and Treatm ent of Thoracic Fractures
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II Spinal Em ergency Procedures
Closing Medication
Postop erat ive an t ibiot ics sh ou ld be adm in istered for 24 h ou rs
Su rgical w ou n ds are closed in layers. or as long as th e drain is in place.
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
Radiographic Imaging
t ube to allow drain age from th e pleu ral space. A ch est t ube Postop erat ive lm s sh ou ld be obtain ed to visu alize th e
is p laced un der d irect visualizat ion . It can be placed directly con st ru ct an d th e degree of realign m en t of th e spin e. Th is
on w ater seal if n o leak is suspected. Th e w oun ds are closed. allow s com parison of th e fusion con st ruct during follow -u p
A p ostoperat ive ch est X-ray is obt ain ed to ch eck for p n eu m o- (Figs. 15.22, 15.23, an d 15.24).
th orax or h em oth orax. Th e ch est t ube can be rem oved w h en If th e p at ien t h as any n ew sym ptom s or fails to im prove, th en
out pu t is less th an 100 m L/day. m ore detailed im aging is in dicated su ch as MRI.
a 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.
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15 Classi cation and Treatm ent of Thoracic Fractures
a 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 b
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.
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15 Classi cation and Treatm ent of Thoracic Fractures
of acute cer vical spin e an d spin al cord injuries. Neurosurger y 23. Rein h old M, Kn op C, Beisse R, et al. Operat ive t reat m en t
2013;72[suppl 2]:93105 of 733 pat ien t s w ith acute th oracolum bar spin al injuries:
22. McAfee PC, Yu an HA, Fredrickson BE, Lu bicky JP. Th e valu e of com preh en sive result s from th e secon d, prospect ive, In tern et-
com pu ted tom ography in th oracolum bar fract ures. An an alysis based m ult icen ter st udy of the Spin e St udy Group of th e Ger-
of on e h un dred con secut ive cases an d a n ew classi cat ion . m an Associat ion of Traum a Surger y. Eur Spin e J 2010;19(10):
J Bon e Join t Su rg Am 1983;65(4):461473 16571676
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16 Thoracolumbar Fractures
Michael Y. W ang and Brian Hood
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 - Flexion-Distraction
bar spin e. Th is zon e of t ran sit ion is related to th e loss of th e (Ch an ce): Prim ar y an terior force vector act ing along an axis of
rib cage as w ell as th e ch anging orien tat ion of th e facet join ts. rotat ion located an terior to m iddle colum n . Th e p osterior an d
Becau se of th ese factors th is area is p ron e to t rau m at ic inju r y m iddle colu m n s fail in ten sion an d th e an terior colu m n fails in
an d accou n t s for ap proxim ately u p to 50% of all vertebral body ten sion or com pression depen ding on th e axis of rot at ion .
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 - Fracture -Dislocation
p ression an d st abilizat ion is gen erally accepted for pat ien t s Results from violen t com plex sh earing force an d by de n it ion
w ith clear in st abilit y an d an in com plete n eu rologic inju r y. Ad- involves all th ree spin al colum n s. High est rate of com plete n eu -
van t ages of su rger y in clu de a bet ter correct ion of deform it y rologic inju r 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, de-
creased 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 AO Thoracolumbar System
t reat m en t is m ore con t roversial for pat ien t s w ith m ild to m od- (of Magerl)
erate d eform it y, w ith ou t n eu rologic de cit , an d residu al sp i-
n al can al com p rom ise, an d th e ideal solu t ion rem ain s largely De n es th e m ajor m ech an ism of sp in al inju r y com p ression (A),
u n kn ow n .1,39 dist ract ion (B), an d torsion (C) to in dicate in creasing inju r y se-
verit 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
Classi cation m orp h ological criteria. Th e categories are est ablish ed accord-
Th e m ost com m on fract ure pat tern s at th e th oracolum bar jun c- ing to th e m ain m ech an ism of injur y, an d take in to con sider-
t ion in clude com pression fract ures, burst fract ures, exion -dis- at ion th e progn ost ic aspect s of poten t ial h ealing. Th e t ypes are
t ract ion injuries, an d fract ure-dislocat ion s. 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 rac-
Denis Classi cation
t ion s; an d t ype C lesion s refer to an terior an d posterior elem en t
Compression Fractures 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 -
Failu re of th e an terior colum n in exion /com pression
ing fract ure pat tern s, but it is a vict im of it s com p reh en sive-
A: Failure of th e superior an d in ferior en dplates
n ess; it does n ot con sider n eu rologic st at u s, an d does n ot aid in
B: Su p erior ver tebral en d plate failu re (m ost com m on t yp e of
decision m aking.10
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 Thoracolumbar Injury Classi cation
and Severity Score (TCLIS)
Burst Fractures Th is system w as developed due to th e n eed for a classi cat ion
Com pression failure of th e an terior an d m iddle spin al colum n s system th at cou ld be u sed to p rogn ost icate th e n eed for su rgical
A: Failure of both superior an d in ferior en dplates in ter ven t ion . Th e system w as based on a review of th e exist-
B: Su p erior en dp late failu re on ly (m ost com m on t ype of bu rst ing literat u re as w ell as con sen sus opin ion from a m u lt in at ion al
fract u re) grou p of leading sp in al t rau m a su rgeon s. Th ree m ajor inju r y
C: In ferior en dplate failu re on ly ch aracterist ics w ere de n ed: injur y m orph ology, n eurologic
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16 Thoracolum bar Fractures
Injury morphology
Compression 1
Burst 11
Rotation/translation 3
Distraction 4
Neurologic status
Intact 0
Nerve Root 2
Spinal cord, conus m edullaris Incomplete 3
Complete 2
Cauda equine 3
Posterior ligam entous complex integrit y
Intact 0
Suspected/Indeterm inate 2
Disrupted 3
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
Fig. 16.1 Sagit tal reconstruction of trauma CT scan showing fractures
To correct deform it y
of T12 and L1 in a 55-year-old man who had fallen from a height.
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 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
Preprocedure Considerations 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
Radiographic Imaging 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.
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 fol-
low ing spin al t rau m a. In som e cen ters th is h as been largely Medication (Neuroprotection and
rep laced for su r vey purposes by w h ole body com puted to-
m ograp hy (CT) scan n ing.
Nonoperative Management)
Becau se th ere is a h igh p ercen t age of n on con t igu ou s associ- According to th e secon d NASCIS t rial, in p at ien t s w ith con -
ated sp in al fract u res, en t ire n euraxis im aging m ay be w ar- rm ed spin al cord inju r y, p at ien ts st ar ted on m ethylp red-
ran ted if clin ical su spicion is h igh . n isolon e w ith in 3 h ou rs of inju r y h ad a su bstan t ial ben e t in
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term s of ult im ate n eurologic recover y. We do n ot use steroids Post e r ior ap p roach es allow for realign m e n t of t h e sp in e,
at ou r in st it u t ion . Recen t pu blish ed gu idelin es do n ot recom - 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,
m en d steroid u sage.14 an d p rot e ct ion again st lat e d efor m it y an d in st ab ilit y. Sp i-
In t raven ous uid, colloid, an d vasopressors are u sed as n eeded n al can al d e com p ression via ligam e n t ot a xis is op t ion ally
to m ain tain a m ean arterial pressu re of 85 m m Hg or greater.15 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 os-
Surgical Management t 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
Th e goals of surgical t reat m en t in clude: (1) decom pression of 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
th e spin al can al an d n er ve root s to facilit ate n eurologic recov- ap p roa ch .
er y, (2) restorat ion an d m ain ten an ce of ver tebral body h eigh t Th is ch apter addresses th e posterior approach , both open an d
an d align m en t to m in im ize post t rau m at ic deform it y, (3) ob - percut an eous.
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
Operative Field Preparation
can gen erally be classi ed in to on e of ve grou ps: (1) posterior Th e skin is clean sed w ith alcoh ol th en a betadin e scrub is
decom pression an d st abilizat ion , (2) costot ran sverse/lateral ex- used.
t racavitar y/t ran spedicular decom pression an d recon st ruct ion / Altern at ively, alcoh ol an d ch lorh exidin e can be u sed.
stabilizat ion , (3) an terior corp ectom y/st abilizat ion , (4) com - Th e au th ors u se van com ycin an d ceft riaxon e for an t ibiot ic
bin ed an terior/posterior decom pression /st abilizat ion (360), prophylaxis provided th e pat ien t does n ot h ave ren al failure
an d (5) p ercu t an eou s fract u re xat ion . or oth er con t rain dicat ion s.
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16 Thoracolum bar Fractures
Operative Procedure
Open Approach
Positioning (Fig. 16.2)
Fig. 16.2 The patient is positioned carefully on a radiolucent A four-posted spinal table is used. Preincision
frame to obtain optimal preoperative reduction of uoroscopy veri es abilit y to visualize pedicles
deformity. 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.
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Fig. 16.3 (a) A midline posterior approach is most common for Instrum entation requires a wider exposure for optim al
thoracolumbar instrumentation. (b) Subperiosteal placem ent of instrum entation. Inadequate exposure
exposure of the posterior elements is carried out risks screw malposition.
laterally over the tips of the transverse processes.
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Fig. 16.4 The lamina is removed w ith a drill and rongeurs. At this point Lam inectomy alone as a decompressive
a costotransversectomy, or a transpedicular vertebrectomy, procedure has been shown to be ine ective in
can be performed if indicated (see Chapter 15). achieving anterior spinal cord decompression.
The only indication for a standalone
Ligamentotaxis may be used to mobilize anterior fracture lam inectomy is to evaluate for dural tears or
fragments aw ay from the spinal cord. Alternatively, a posterior compression.
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.
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16 Thoracolum bar Fractures
b c
Fig. 16.5 (a) The facet joint is stripped of its capsule. The inferior portion of Rem oving the inferior portion of
the inferior facet is removed w ith a rongeur or osteotome. Partial the inferior facet allows m ore soft
facetectomy should reveal a pedicle blush. tissue rem oval and helps to nd the
entrance to the pedicle.
(b) At T12 the starting point is the junction of the bisected transverse Anatom ic starting points can be
process and border of the lateral pars. The starting point trends medially veri ed with AP uoroscopy and
and cephalad as one moves cranially tow ard the midthoracic region. pedicle m arkers can be placed.
Lateral uoroscopy can then be used
A thoracic (blunt, curved) probe is placed in the blush or starting point for pedicle cannulation.
as determined by AP uoroscopy. The curve is directed laterally and Any abrupt step o when
advanced 15 to 20 mm letting the probe fall into the pedicle. cannulating the pedicle should
raise suspicion of a pedicle breach
(c) After advancing 15 to 20 mm, the probe is removed and replaced and should be investigated with a
facing medially and advanced to a depth of 30 to 40 mm in the sounding probe and radiographic
midthoracic spine. A feeler/sounder probe is then introduced. Only blood evaluation. Pay at tention to the
should return from the tract and not cerebrospinal uid. A oor and then medial portion of the tract where
four w alls should be palpated. violations of the pedicle are critical.
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Fig. 16.6 The pedicle is then under-tapped 0.5 mm. Charting pedicle size and depth preoperatively
Preoperative assessment of pedicular size guides the facilitates appropriate screw selection.
appropriate tapping and screw placement (1). After All screws placed should be veri ed by intraoperative
tapping, the tract is once again sounded w ith a feeler imaging. In addition, electrodiagnostic testing can be
probe searching for violations. Slow screw placement perform ed with abdom inal leads.
allow s utilization of viscoelastic properties of the
pedicle and avoids pedicle fracture (2).
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16 Thoracolum bar Fractures
a b c
Fig. 16.7 A rod is selected and contoured appropriately. The rod should be passed approxim ately 5 m m beyond
Distraction and reduction maneuvers can be applied the m ost cranial and caudal screw. Compression
to aid in reduction of compression via ligamentotaxis. maneuvers gain lit tle in achieving additional rod length.
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Fig. 16.8 Spinous processes and lamina local autograft removed Intraoperative relaxation of retractors periodically
are morselized. The remaining lamina, transverse facilitates blood ow and preservation of extensor
process, and facets are decorticated w ith a high speed m usculature. Careful preservation of regional blood
drill (1). The bone graft is then laid on bleeding bone (2). supply supports rapid graft incorporation and focuses
Iliac crest bone autograft remains the gold standard. on fusion versus construct failure.
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16 Thoracolum bar Fractures
Percutaneous Approach
Positioning and Pedicle Targeting (Fig. 16.9ac)
Fig. 16.9 (a) The patient is carefully positioned prone on a A good AP im age is imperative. The endplates must be
radiolucent table, as in Fig. 16.2, in order to obtain absolutely parallel, and the spinous process equidistant
the best preoperative reduction of deformity. bet ween the pedicles. At each level, it is helpful to m ark
(b) Prior to prepping and draping, the pedicles are the degree of rotation of the C-arm needed to obtain
targeted using AP uoroscopy. (c) K w ires are placed the view. This help to decrease uoroscopy tim e, as well
at the 9 oclock position on the left sided pedicles and as operative tim e.
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.
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16 Thoracolum bar Fractures
Fig. 16.10 (a) The bone trephine needle is started in the skin We use AP im ages to place the bone trephine needles.
just lateral to the marked pedicle and advanced to Alternatively, the needles can be advanced to 20 m m
the starting point (3 oclock on the right, 9 oclock under AP im aging, and then switched into a lateral
on the left). Once bone is encountered, an image is view to advance the rem ainder of the distance into the
obtained. The needle is lightly malleted to engage vertebral body (c).
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.
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II Spinal Em ergency Procedures
Fig. 16.11 (a, b) The stylet is removed from the bone trephine The K wire can be used as a exible feeler probe to
needle and a K w ire is placed (1). The K w ire is ensure that bone is encountered when advancing.
advanced several mm beyond the bone trephine
needle and then the needle is removed (2).
280
16 Thoracolum bar Fractures
Fig. 16.12 If a long-term fusion is required, dilators are then placed over the K w ire The necessit y for fusion is
and docked on the pedicle screw starting point. A tubular retractor is then decided on an individual basis.
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.
281
II Spinal Em ergency Procedures
Fig. 16.13 If a facet fusion is not performed, next make a 15 mm skin incision It is imperative to m aintain control of
about the K w ires. (a) A dilator is passed to open the fascia, and the K wire at all tim es. If the K wire is
docked at the starting point. The inner cannula of the dilator is inadvertently rem oved, it is best to switch
removed (1). An aw l is placed over the K w ire to enhance the starting back to AP im aging to try to replace the
point for the tap (2). Next, the C-arm is brought into lateral position. wire. If unable, it is possible to try to
replace the bone trephine needle without
(b) We tap the pedicle under lateral imaging (1). At this point, the the st ylet.
tap can be stimulated to assess for a medial pedicle breach. The tap We t ypically under tap for traum a cases.
is removed w ith care to not dislodge the K w ire. A cannulated screw Try to keep the position of the screw
w ith a screw extension is then advanced (2). Several images are heads the sam e for all screws to facilitate
taken as the screw is advanced. It is important to not advance the K passage of the rod.
w ire w ith the screw. The K w ire is then removed.
282
16 Thoracolum bar Fractures
a b
Fig. 16.14 (a) A rod is measured and cut. It is extremely important that the It is important to leave the rods on
rod is passed subfascially w hen inserted into the rst screw head. the rod holders until all the caps have
(b) Through a cantilever approach, deformity correction occurs been applied. Minim al distraction and
as the rod is locked into place (1). A derotation device is used compression can be perform ed with the
and the screw caps are nal tightened (2). The extended tabs are m inim ally invasive system ; therefore,
then removed (3). If the tabs are inadvertently removed prior positioning is imperative.
to passing the rod, a rod can still be placed, but it makes rod
placement very di cult.
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 bleed-
ing is en cou n tered due to a t am p on ade e ect from th e dila-
tors 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 oros-
copy before th e w oun d is closed.
Postoperative Management
Fig. 16.15 Lateral X-ray of patient depicted in Fig. 16.1 showing posterior
Monitoring 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 patients w ith thoracolum bar fractures, the surgeon m ust rst
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,
decide if the injury requires an operation. If an operation is re-
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 .
quired, 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
Medication an anterior, posterior, or com bined approach.
It is ou r pract ice to place p at ien t s on a p at ien t-con t rolled We gauge the length of our construct based on the degree of
an algesia device w ith eith er m orp h in e or hydrom orp h on e in instabilit y. In m ost instances we xate two levels above and t wo
th e in it ial postoperat ive period. below. For burst fractures it is possible to perform a cem ent aug-
Pat ien t s are gradu ally t ran sit ion ed to oral m edicat ion on th e m entation of the fractured level (vertebroplast y or kyphoplast y;
secon d or th ird p ostop erat ive day. see Fig. 16.15). Short pedicle screw s can also be placed into the
We continue antibiotic prophylaxis for approxim ately 24 hours fractured level, thus allow ing som e cases to be instrum ented
after surgery. only one level above and below the fracture. The thoracic seg-
We rout in ely start pat ien t s on deep vein th rom bosis prophy- m ents are relatively im m obile so sacri cing m otion segm ents is
laxis w ith low m olecular w eigh t h ep arin on th e rst postop - biom echanically irrelevant. Lengthening the construct distally
erat ive day if th ere are n o oth er bleeding con t rain dicat ion s. into the lum bar spine has di erent biom echanical consider-
ations 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
Radiographic Imaging 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
We t ypically obtain uprigh t AP an d lateral im ages prior to
on literat ure from th e AO Fixateu r In tern e, rem oval is per-
disch arge (Fig. 16.15).
form ed t ypically 12 m on th s p ostop erat ive an d after radio-
Im aging is th en p erform ed at 3, 6, an d 9 m on th s
grap h ic eviden ce of fu sion .1621
postoperat ively.
284
16 Thoracolum bar Fractures
2. Dai LY, Jiang SD, Wang XY, Jiang LS. A review of th e m an age- 12. Joaquim AF, Fernandes YB, Cavalcante RA, Fragoso RM, Honorato
m en t of th oracolum bar bu rst fract ures. Surg Neurol 2007;67(3): DC, Patel AA. Evaluation of the Thoracolum bar Injury Classi cation
221231, discussion 231 System in Thoracic and Lum bar Spinal Traum a. Spine 2011;36:
3. Th om as KC, Bailey CS, Dvorak MF, Kw on B, Fish er C. Com pari- 3336
son of operat ive an d n on operat ive t reat m en t for th oracolum bar 13. Alan ay A, Acaroglu E, Yazici M, Surat A. Th oracolum bar spin e
burst fract ures in pat ien t s w ith ou t neurological de cit: a sys- fract u res. Sp in e 2001;26(7):840841
tem at ic review. J Neurosurg Spin e 2006;4(5):351358 14. Hurlbert RJ, Hadley MN, Walters BC, et al. Ph arm acological
4. Verlaan JJ, On er FC. Operat ive com pared w ith n on op erat ive th erapy for acute spin al cord injur y. Neurosu rger y 2013;72
t reat m en t of a th oracolum bar burst fract ure w ith out n eurologi- (Su p pl 2):93105
cal de cit . J Bon e Join t Surg Am 2004;86-A(3):649650, auth or 15. Vale FL, Burn s J, Jackson AB, Hadley MN. Com bin ed m edical an d
reply 650651 surgical t reat m en t after acute spin al cord injur y: result s of a
5. Vaccaro AR, Lim MR, Hu rlber t RJ, et al; Sp in e Trau m a St u dy prospect ive pilot st udy to assess th e m erit s of aggressive m edi-
Grou p . Su rgical d ecision m akin g for u n st able t h oracolu m - cal resuscit at ion an d blood pressu re m an agem en t . J Neurosurg
bar sp in e inju r ies: resu lt s of a con sen su s p an el review by t h e 1997;87(2):239246
Sp in e Trau m a St u dy Grou p . J Sp in al Disord Tech 2006;19(1): 16. Faun dez AA, Taylor S, Kaelin AJ. In st r um en ted fusion of th oraco-
110 lum bar fract ure w ith t ype I m in eralized collagen m at rix com -
6. Siebenga J, Leferin k VJ, Segers MJ, et al. Treat m en t of t rau m at ic bin ed w ith autogen ous bon e m arrow as a bon e graft su bst it ute:
th oracolu m bar sp in e fract u res: a m u lt icen ter p rospect ive ran - a four-case report . Eu r Spin e J 2006;15(Suppl 5):630635
dom ized st u dy of op erat ive versu s n on su rgical t reat m en t . Sp in e 17. Dick W, Kluger P, Magerl F, Woersdrfer O, Zch G. A n ew device
2006;31(25):28812890 for in tern al xat ion of th oracolu m bar an d lu m bar sp in e frac-
7. Hear y RF, Salas S, Bon o CM, Ku m ar S. Com p licat ion avoidan ce: t u res: th e xateu r in tern e. Parap legia 1985;23(4):225232
th oracolu m bar an d lu m bar bu rst fract u res. Neu rosu rg Clin N Am 18. Ben ce T, Sch reiber U, Grupp T, Stein h auser E, Mit telm eier W. Tw o
2006;17(3):377388, viii colum n lesions in the th oracolum bar jun ct ion : an terior, posteri-
8. Harris MB, Sh i LL, Vacarro AR, Zd eblick TA, Sasso RC. Non su rgical or or com bin ed approach ? A com parat ive biom ech an ical in vit ro
t reat m en t of th oracolum bar spin al fract ures. In st r Course Lect invest igat ion . Eur Spin e J 2007;16(6):813820
2009;58:629637 19. Dai LY, Jiang LS, Jiang SD. Posterior sh or t-segm en t xat ion w ith
9. Dai LY, Jiang LS, Jiang SD. Con ser vat ive t reat m en t of th oracolu m - or w ith out fusion for th oracolum bar burst fract ures. a ve to
bar bu rst fract ures: a long-term follow -up result s w ith special seven -year prospect ive ran dom ized st udy. J Bon e Join t Surg Am
referen ce to th e load sh aring classi cat ion . Spin e 2008;33(23): 2009;91(5):10331041
25362544 20. Haiyun Y, Rui G, Sh u cai D, et al. Th ree-colum n recon st r uct ion
10. Magerl F, Aebi M, Gert zbein SD, Harm s J, Nazarian S. A com pre- th rough single p osterior app roach for th e t reat m en t of u n st able
h en sive classi cat ion of th oracic an d lum bar injuries. Eu r Spin e J th oracolu m bar fract u re. Sp in e 2010;35(8):E295E302
1994;3(4):184201 21. Katonis P, Pasku D, Alpan taki K, et al. Com binat ion of the AO-
11. Patel AA, Vaccaro AR. Th oracolu m bar sp in e t rau m a classi cat ion . Magerl an d load-sh aring classi cat ion s for th e m an agem en t of
J Am Acad Or th op Su rg 2010;18(2):6371 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
286
17 Spinal Epidural Com pression
287
II Spinal Em ergency Procedures
Spinal Epidural Abscess 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%
Th e rst operat ive in ter ven t ion a lam in ectom yfor SEA w as m ortalit y.
perform ed in 1892; after in creasing report s of successes, sur- Prevailing convict ion h olds th at if com pression is of sh ort du -
ger y becam e th e m ain stay of t reat m en t by th e 1930s. An early rat ion , n eurologic de cit s m ay be reversible, as re-m yelin at ion
series 10 n oted th at SEA pat ien t s w ith out paralysis or w h ose an d recover y of fu n ct ion are p ossible. How ever, w ith prolonged
p aralysis h ad developed less th an 36 h ours before th e opera- com pression , secon dar y vascu lar injur y w ith in farct ion of th e
t ion h ad bet ter postoperat ive ou tcom es w ith respect to sur vival spin al cord m ay occu r w ith irreversible con sequ en ce.
an d fu n ct ion . In con t rast , in p at ien ts w h ose p aralysis develop ed Based on th ese an d sim ilar st u dies, gen erally accepted in d ica-
m ore than 48 h ou rs before su rger y, n on e recovered n eu rologic t ion s for surger y in clude: th e n eed for t issue for diagn osis; spi-
fu n ct ion ; all m ort alit ies in th e series w ere rep or ted in th is lat- nal in stabilit y; cord com pression w ith dysfun ct ion from bon e
ter group. Th is correlat ion of outcom e w ith t im e to in ter ven t ion or t um or n ot radiosen sit ive; an d deteriorat ion or recurren ce
h as been rep eatedly con rm ed.11,12 Con ser vat ive t reat m en t is during/despite RT. Surgical decom pression to preven t irrevers-
rarely in dicated: eith er for th ose w h o can n ot tolerate surger y, ible dam age sh ou ld be im m ediate. Conversely, RT is a reason -
or w h o h ave large abscesses exten ding a con siderable length of able altern at ive for p at ien ts w ith radiosen sit ive t u m ors, st able
th e spin al cord. 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 dis-
MESCC ease versus arising from osseous lesion w ith extension) as well
as considerations of spinal stabilit y should dictate choice of
Con sen su s an d exper t opin ion s regarding in dicat ion s for sur- operative procedure. A thorough description of all surgical ap -
ger y largely d erive from st u dies invest igat ing th e p rogn os- proaches is beyond the scope of this chapter. However, a sim ple
t ic value of surgical in ter ven t ion given variou s pat ien t group lam inectom y should be reserved for dorsally located disease, and
at t ribu tes. Th e eviden ce dictat ing th e app ropriate approach to a posterolateral or ventral approach should be utilized w henever
t um or decom pression h as evolved sign i can tly over th e past ventral disease is present, as tum ors m ay continue to grow or
50 years. Early t reat m en t un derscored in direct decom pres- swell and thus w ithout a direct rem oval of the o ending pathol-
sion of th e ep idu ral sp ace via st raigh t lam in ectom y, follow ed ogy, an indirect decom pression w ill result in further deform ation
by radiat ion th erapy (RT).13,14 How ever, later st u dies 15,16 dem - of the spinal cord. At the spinal cord level (occiput to bottom of
on st rated n o advan t age for lam in ectom y, ren dering radiat ion conus m edullaris), the cord should never be retracted to gain
alon e th e p referred th erap eu t ic st rategy for a p eriod of years. access to ventral tum or; the approach should be selected that
More recen t st u dies w ith m odern an esth et ic an d im aging tech - obtains the m ost advantageous angle to access the tum or instead.
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
Preprocedure Consideration
life expect an cy . 3 m on th s; on e n eurologic sym ptom (in clu d-
ing pain ); n ot tot ally p araplegic for . 48 h ou rs. Radiosen sit ive Radiographic Imaging
t um ors an d sole root com pression or cau da equin a syn drom es Com pu ted tom ography (CT) m yelography w as on ce th e diag-
w ere exclu ded; 84% of th e su rger y grou p versu s 52% of th e RT n ost ic tool of ch oice for evalu at ion of SEH. CT m yelogram also
group w ere able to w alk after t reat m en t , 62% versus 19% re- is m ore invasive an d carries th e risk of seeding in fect ion . It is
gain ed am bu lat ion w h en ce lost , an d 94% versu s 74% rem ain ed th erefore n o longer recom m en ded in th e con text of spin al
am bulator y. Ad dit ion ally, th e st u dy revealed sign i can t d if- ep idu ral abscess. Magn et ic reson an ce im aging (MRI) w ith or
feren ces bet w een t reat m en t grou p s w ith resp ect to m ain te- w ith out CT h as em erged as th e less invasive an d m ore available
n an ce of con t in en ce; m u scle st rength ; fu n ct ion al abilit y; an d m eth od of ch oice. MRI also o ers th e advan t age of di eren t iat-
in creased sur vival (126 versu s 100 days), w ith am bulat ion an d ing bet w een t um or, in fect ion , h ern iated disk, an d h em atom a 20
con t in en ce persist ing for th e lifet im e of th e surger y group. (Figs. 17.1 an d 17.2). CT is also n ecessar y to evaluate for bony
Spin al in stabilit y can in depen den tly con tribu te to sym ptom s, invasion an d st abilit y (Fig. 17.3).
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
Medication
in depen den tly am bulator y, assisted am bulator y, paraparet ic, For SEH, in pat ien t s w h o cann ot tolerate surger y, an t icoagu la-
an d paraplegic: w ith ou t bony com pression , post -RT am bula- t ion sh ould be stopped an d possibly reversed; h igh dose ste-
t ion rates w ere 100%, 94%, 60%, 11%, respectively. These rates roids sh ould be con sidered alth ough th eir u se is con t roversial.21
dropped to 92%, 65%, 43%, and 14%, respectively, w hen all pa- For SEA, broad-sp ect rum IV an t ibiot ics sh ould be in it iated
t ients (w ith bony an d non bony com pression ) w ere considered.18 im m ediately, in cluding coverage for Gram -posit ive cocci an d
A com preh en sive literat ure review 19 suggested that w ith RT Gram -n egat ive rods.
alon e, 36%subjects im proved w h ile 17%w orsen ed; w ith decom - For MESCC, steroids decrease edem a and m ay have an onco-
pressive lam inectom y 6 RT, 42%im proved w h ile 13%w orsen ed; lytic e ect on som e t um ors such as lym phom a and breast cancer.
288
17 Spinal Epidural Com pression
a b
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.
aw ake beropt ic, lar yngeal in t ubat ion w ith an illum in ated la-
Operative Management r 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
Anesthesia be used.
For all cases, gen eral en dot rach eal an esth esia is th e preferred W h en em ergen t air w ay com prom ise is presen t an d in t uba-
tech nique, assum ing favorable an atom y an d th e pat ien ts con - t ion is n ot likely to be able to be perform ed in a t im ely fash ion ,
dit ion . In t ubat ion -related m an ipulat ion of th e n eck con cern s th en em ergen t cricothyroid or t rach eostom y in t u bat ion w ill
in pat ien t s w ith cer vical spin al cord com pression n eed to be n eed to be p erform ed , an d it w ou ld be pru den t to h ave a t rach e-
w eigh ed again st th e u rgen cy of obt ain ing a reliable air w ay. ostom y kit at th e side of any pat ien t w ith em ergen t spin al cord
W h ere possible, a m in im ally m an ipulat ion tech n iquesu ch as com pression in case th ey deteriorate on th eir w ay to or from
a b
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 th e path ology directly, su ch as w h en a t rach eostom y, an terior
en dot rach eal in t u bat ion . scar, sp in al deform it y, or oth er con dit ion m akes th e app roach
For those cases w here the opportunit y presents and the sur- m ore ch allenging or h as h igh er risks of com p licat ion . W h ere
geon w ishes, if intraoperative m onitoring is to be used, then possible, th e m ost direct approach leads to th e best resu lt ing
the anesthetic should take into account any potential e ects on t reat m en t , but on e or m ore factors m ay ch ange th at decision
electrom yography or m otor evoked potential (MEP) m onitoring process, in cluding availabilit y of an access surgeon , result ing
by focusing on a total intravenous anesthetic (TIVA) technique to postoperat ive in stabilit y, an d pat ien t appropriaten ess for stabi-
prevent the detrim ental im pact of inhalational anesthetic. TIVA lizat ion tech n iques, am ong oth ers. W h en th e disease process or
also includes the absence or m inim al use of paralytics to prevent th e approach to th e disease causes spin al in st abilit y, fu sion of
their im pact upon the m uscle activit y being m onitored by elec- th e u n stable levels is addit ion ally recom m en ded. Several t reat-
trom yography (EMG) or MEP. Som atosensory evoke potentials m en t opt ion s exist (allograft bon e, p olym ethyl m eth acr ylate
(SSEPs) are used to avoid potential peripheral nerve com plica- [PMMA] cem en t w ith Stein m an pin s, t it an ium cages, carbon -
tions such as arm positioning apraxias, or even in ltration of an ber cages, an terior t it an ium plate/rod xat ion devices, etc.), th e
IV leading to com partm ent syndrom e, w hich if caught intraopera- discussion of w h ich is beyon d th e scope of th is ch apter.
tively instead of identi ed postoperatively m ay result in im m edi- A dedicated spin al t able can h elp to posit ion properly an d
ate treatm ent of the problem and prevent perm anent m orbidit y. possibly preven t di eren t posit ion ing com plicat ion s, as w ell
W here practical and feasible, m ean arterial pressures (MAP) as being radiolu cen t to opt im ize im aging. Kn ee-elbow p osit ion
sh ould be m ain tain ed as h igh as can be tolerated (u p to 100 m m on a stan dard n on spin al operat ing room t able can be used for
Hg), an d w h en a n eu rologic de cit is presen t , if th e pat ien t can dorsal th oracic or lum bar procedures. W h ile an on -call n euro-
tolerate, MAPs in th e 901 m m Hg range sh ould be th e goal, to m on itoring team m ay be desirable, on e sh ou ld n ot d elay th e
m ain tain spin al cord perfusion given th e presum ably edem atou s case to w ait for a team to be available.
state of th e spin al cord. Th is can be correlated w ith in t raopera- For dorsal/dorsolateral path ology, a un ilateral approach is
tive evoked potent ial m onitoring, and m any tim es a decrem ent often su cien t . For sh ort-segm en t path ologies, such as focal
in evoked poten tials can be corrected w ith elevat ion of the MAP. abscess or lateral an d d orsal ep idu ral sp in al m etast ases, a m i-
crosurgical 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 rolat-
erally or below th e con u s m edu llaris, can be app roach ed in a
Surgical Approach 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
General Principles at th e cord level, su ch as in th e cer vical or th oracic sp in e, can
Posit ion select ion d ep en ds on several factors, in clu ding th e lo- be approach ed via several approach es, depen ding on th e sur-
cat ion of th e prim ar y path ology (an terior, posterior, or lateral geons com fort level an d th e facilit ys resou rces (in clu ding th e
w ith in th e can al), n um ber of levels, an d di cult y approach ing exp erien ce of th e even ing or on -call st a ). On e app roach is via
290
17 Spinal Epidural Com pression
u n ilateral h em ilam in ectom y w ith part ial t ran spedicular de- (an d th erefore m ore ven t ral access) locat ion , in clude: lam in ec-
com pression to gain access to th e ven t ral locu s of purulen ce, tom y, t ran spedicular, costot ran sversectom y (in th oracic spin e
leaving th e posterior m idlin e an d con t ralateral st ru ct ures in t act on ly), an d lateral ext racavitar y. Th e parascapular approach is a
to m in im ize delayed in st abilit y, reduce th e size of th e w oun d varian t of th e costot ran sversectom y or lateral ext racavit ar y at
an d cavit y to be closed, an d redu ce in t raoperat ive bleeding. Th e th e levels of T27 w h ere th e m uscles of th e scapu la n eed to be
less p ed icle rem oved, th e m ore st able th e sp in e w ill be over carefully separated an d th e scapula m obilized for th e exposu re,
t im e. Should a m ore exten sive exposure n eed to be perform ed an d recon n ected carefu lly after w ard to p reven t m orbidit y.
(com plete pedicle rem oval, bilateral decom pression plus t ran s-
p 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 Anterior Approaches
app ropriate, in st ru m en tat ion sh ou ld be u sed. In st ru m en tat ion Cervical
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 Tran soral, w h ich gives good access from th e clivus to C3
invasive approach from a part ial t ran sp edicu lar or costot ran s- St an dard ven t rom edial an terior cer vical, w h ich gives good
verse ap proach on eith er side can be p erform ed as w ell, w ith access from C2 to T1 or T2
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 rela- Cervicothoracic and Thoracic
t ively lique ed h em atom a), an angled in ser t ion tech n ique can
Su p raclavicu lar, w h ich gives access at th e cer vicoth oracic
allow for placem en t of a sm all-caliber d rain (like a ven t ricu los-
ju n ct ion (dow n to T3) via an ap p roach th at is sim ilar to th e
tom y cath eter) th at can be used to rem ove ven t ral path ology
t radit ion al ven t rom edial an terior cer vical approach , but uses
an d facilit ate irrigat ion in th e abscess plan e.
a m ore acu te angle to ap p roach th e th oracic vertebrae.
In gen eral, w e do n ot recom m en d a st raigh t lam in ectom y for
Transsternal, w hich gives good access to the T3-T10 region, but
p redom in ately ven t rally located in fect ion s at cord-level cases,
there is an association w ith an increased risk of m ediastinit is.
u n less th ere is en ough room to reach th rough laterally located
Tran sm an u brial, w h ich can be com bin ed w ith ven t rom edial
p u ru len t collect ion s an d p ass a righ t-angled in st ru m en t ven -
to give access to C5-6 dow n to T2-3, alth ough th ere is a risk of
t ral to th e th eca in to th e ven t ral pus w ith out pressure on th e
injur y to m ajor vascular or chylou s st ruct ures.
already ten u ou s sp in al cord .
Tran sth oracic, w h ich gives excellen t ven t ral access to th e
In acu te cases, th ere is rarely m u ch ep idu ral bleed ing, bu t in
T4-T11 region s an d can be used to expose m ult iple levels, but
m ore ch ron ically in fected cases, th ere m ay be an in am m ator y
in creased pulm on ar y m orbidit y lim it s it s u se today.
rin d th at h as sign i can t vascu lar inp u t . Ep idu ral d rain s sh ou ld
Th oracoscopic approach es, w h ich give sim ilar access as th e
be left beh in d, an d drain age con t in ued longer th an st an dard
t ran sth oracic w ith less pu lm on ar y m orbidit y, in clude a sig-
durat ion to preven t any furth er collect ion or con t am in at ion of
n i can t learn ing cu r ve an d th e p or t size lim it s som e of th e
in fected m aterial in th e epid ural space.22
access an d procedu res th at can be perform ed.
For m et ast at ic epidural disease, th e locat ion of th e origin of
Th oracoabdom in al, w h ich gives a w ide exposure to th e ver-
th e t u m or (isolated epidural disease versus arising from os-
tebral bodies an d ven t ral cord at th e region of T10 to L2, bu t
seou s lesion w ith exten sion ) as w ell as con sid erat ion s of sp i-
requires split t ing of th e diap h ragm , an d h as a h eigh ten ed risk
n al st abilit y sh ou ld dict ate ch oice of op erat ive p rocedu re.23
of injur y to abdom in al an d th oracic viscera.
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 Lumbar
ven t ral ap proach sh ou ld be u t ilized w h en ever ven t ral d isease Ret rop eriton eal or direct lateral exposu res from L1-S1. Varia-
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 t ion s of th ese can be used at di eren t levels, w ith good expo-
w ith out a direct rem oval of th e o en ding path ology, an in di- su re of th e vertebral bodies w ith less risk to in t rap eriton eal
rect decom p ression w ill resu lt in fu rth er deform at ion of th e organ s, alth ough th e t ran spsoas tech n iques do h ave greater
sp in al cord. At th e spin al cord level (occip u t to bot tom of con u s risks to th e n er ves, an d th e m ore ven t ral ap p roach es h ave a
m edu llaris), th e cord sh ou ld n ever be ret racted to gain access to greater risk of inju r y to u reters an d great vessels.
ven t ral t u m or; th e ap proach sh ou ld be selected th at obtain s th e Tran speriton eal, w h ich gives good exposu re from L1/2 to th e
m ost advan t ageou s angle to access th e t u m or in stead. 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;
Posterior Approaches an d in m ales a risk of sexu al dysfu n ct ion d u e to ret rograde
Lam in ectom y alon e is to be u sed at th e spin al cord level on ly ejacu lat ion , believed by som e to be related to injur y to th e
w h en th e disease is w h olly dorsal or ju st posterior to th e n er ve sym path et ic p lexu s.
root if lateral. Any m ass ven t ral to th e n er ve root , u n less pri-
m arily liqu id an d able to be drain ed w ith a cath eter p assed in The follow ing illustrations dem onstrate som e of the m ore
an exist ing m ass ch an n el (e.g., an abscess th at w raps arou n d com m on em ergency procedures for epidural com pression. W hile
th e lateral aspect of th e dura), sh ould be resected or drain ed open approaches are dem onstrated here, m inim ally invasive ap -
via a posterolateral ap p roach , an d th e m ore ven t ral an d m ed ial proaches can be chosen depending on the surgeons judgm ent
th e locat ion , th e m ore lateral th e approach sh ould be. Th e pos- and experience as n oted in th e case exam ples. Som e of the oth er
terolateral approach es, in order of successively m ore lateral 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)
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.
292
17 Spinal Epidural Com pression
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
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.
294
17 Spinal Epidural Com pression
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
Fig. 17.8 For ventral and ventrolateral disease related to a diskitis or It is important to send m ultiple
mycobacterium infection, the nerve root is retracted gently w ith a cultures for bacterial (anaerobic and
Pen eld no. 4. aerobic), fungal, and acid fast bacilli in
addition to pathology.
(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.
296
17 Spinal Epidural Com pression
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
Fig. 17.10 If not already disrupted by tumor a bur is used Many tum ors arising from the vertebrae have eroded the
to perform a partial facetectomy at the location pedicles. If there is lateral and ventral tum or without pedicle
of the pedicle and neural foramen. The pedicle erosion, it will be necessary to drill the pedicle down to the
is drilled dow n to the level of the posterior posterior aspect of the vertebral body to rem ove tum or
vertebral body. A Kerrison rongeur can be used without retracting the thecal sac and spinal cord. Unilateral
to remove more of the facet to expose the pediculectomy in the thoracic spine does not necessarily
neural foramen if tumor is occupying this area. 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).
298
17 Spinal Epidural Com pression
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
MESCC
Adjuvant Treatments Em erging technologies becom ing increasingly relevant, especially
MESCC: Radiat ion th erapy is u su ally an app rop riate adju n ct to for those w ho cannot tolerate surgery, include stereotactic radio-
t reat m en t postoperat ively after rem oval of epidural t um ors. surgery, proton beam , radiofrequency ablation, and cryotherapy.
300
17 Spinal Epidural Com pression
Minim ally invasive surgical treatm ents m ay lower the bar for 12. Rigam on t i D, Liem L, Sam path P, et al. Spin al epidural abscess:
surgical intervention, especially if it facilitates reoperation or con tem porar y t ren ds in et iology, evaluat ion , an d m an agem en t .
reim aging w ith less artifact If postoperative radiation is antici- Surg Neurol 1999;52(2):189196, discussion 197
pated, incision placem ent m ay be m odi ed in a m anner that w ill 13. Byrn e TN, Borges LF, Loe er JS. Met ast at ic epidural spin al cord
m inim ize exposure to the eld of radiation and m axim ize poten- com pression : update on m an agem en t . Sem in On col 2006;
33(3):307311 Review
tial for wound healing.
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
References 1978;3(1):4051
16. Rodriguez M, Din apoli RP. Spinal cord com pression : w ith spe-
1. Reih sau s E, Wald bau r H, Seeling W. Spin al ep idu ral abscess: cial referen ce to m et ast at ic epidural t um ors. Mayo Clin Proc
a m et a-an alysis of 915 pat ien t s. Neurosurg Rev 2000;23(4): 1980;55(7):442448
175204, discussion 205 17. Fessler RG, Steck JC, Giovan in i MA. Anterior cer vical cor-
2. Al-Mu t air A, Bedn ar DA. Spin al epid u ral h em atom a. J Am Acad pectom y for cer vical spondylot ic m yelopathy. Neurosurger y
Or th op Su rg 2010;18(8):494502 1998;43(2):257265, discussion 265267
3. Glot zbecker MP, Bon o CM, Wood KB, Harris MB. Postoperat ive 18. Loblaw DA, Perr y J, Ch am bers A, Laperriere NJ. System at ic re-
spin al ep idu ral h em atom a: a system at ic review. Sp in e 2010; view of th e diagn osis an d m an agem en t of m align an t ext radu -
35(10):E413E420 ral spin al cord com pression : th e Can cer Care On t ario Pract ice
4. Tom p kin s M, Pan u n cialm an I, Lu cas P, Palu m bo M. Sp in al Ep i- Guidelines In it iat ives Neuro- On cology Disease Site Group. J Clin
du ral Abscess. Jou r Em er Med . 2010;39(3):384390 On col 2005;23(9):20282037 Review
5. Felden zer JA, McKeever PE, Sch aberg DR, Cam p bell JA, Ho JT. 19. With am TF, Kh avkin YA, Gallia GL, Wolin sky JP, Gokaslan ZL. Sur-
The p ath ogen esis of spin al epidural abscess: m icroangiograph ic ger y in sigh t: cu rren t m an agem en t of ep idu ral sp in al cord com -
st udies in an experim en t al m odel. J Neurosurg 1988;69(1): pression from m et ast at ic spin e disease. Nat Clin Pract Neurol
110114 2006;2(2):8794, quiz 116
6. Patch ell RA, Tibbs PA, Regin e W F, et al. Direct decom pressive 20. Braun P, Kazm i K, Nogus-Meln dez P, Mas-Estells F, Aparici-
surgical resect ion in th e t reat m ent of spin al cord com pres- Robles F. MRI n dings in spin al subdural an d epidural h em ato-
sion caused by m et ast at ic can cer: a ran dom ised t rial. Lan cet m as. Eur J Radiol 2007;64(1):119125
2005;366(9486):643648 21. Sh ort DJ. El Masr y WS, Jon es PW. High dose m ethylpredn isolon e
7. Rad es D, Heiden reich F, Karsten s JH. Fin al resu lt s of a p rospec- in th e m an agem en t of acute spin al cord injur ya system at ic
t ive st udy of th e progn ost ic value of th e t im e to develop m otor review from a clin ical perspect ive. Midlan ds Cen t re for Spin al
de cit s before irrad iat ion in m et ast at ic sp in al cord com p ression . Inju ries, Rober t Jon es & Agn es Hu n t Or th op aedic & Dist rict Hos-
In t J Radiat On col Biol Phys 2002;53(4):975979 pit al NHS Tr ust , Osw est r y, Sh ropsh ire, SY109DP, UK.
8. Krep p el D, An ton iadis G, Seeling W. Sp in al h em atom a: a litera- 22. Recinas P, Pradilla G, Crom pton P, Th ai Q, Rigam ont i D. Spin al
t ure sur vey w ith m et a-an alysis of 613 pat ien t s. Neurosu rg Rev Epidural Abscess: Diagn osis an d Treat m en t . Operat ive Tech -
2003;26(1):149 n iques in Neurosu rger y 2004;7:188192
9. Joh n son KG. Sp in al ep idu ral abscess. Crit Care Nu rs Clin Nor th 23. Quraish i NA, Gokaslan ZL, Borian i S. Th e surgical m an agem en t of
Am 2013;25(3):389397 m et ast at ic epidural com pression of th e spin al cord. J Bon e Join t
10. Heusn er AP. Non t uberculous spinal epidural infect ion s. N Engl J Surg Br 2010;92(8):10541060
Med 1948;239(23):845854 24. Benn et t DL, George MJ, Oh ash i K, El-Khour y GY, Lucas JJ, Peterson
11. Yang SY. Spin al ep idu ral abscess. N Z Med J 1982;95(707): MC. Acu te t rau m at ic sp in al ep idu ral h em atom a: im aging an d
302304 n eurologic outcom e. Em erg Radiol 2005;11(3):136144
301
18 Treatment of Acute Cauda
Equina Syndrome
Harel Deut sch
Introduction 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
Acu te cau da equ in a syn drom e is th e su dden com p ression of th e
cauda equina syndrom e. Patients m ay have severe constipation
n er ves in th e lu m bar cistern resu lt ing in p ain an d n eu rologic
and im pacted stool. Diarrhea or loss of bowel issues are not
im p airm en t . Th e spin al cord en d s at approxim ately th e L1 to
com m on ndings in acute cauda equina syndrom e.
L2 levels an d, th erefore, cau da equin a com pression involves th e
For pat ien ts w ith a t raum at ic lu m bar fract u re as th e cau se of
n er ve roots rath er th e spin al cord. Clin ically it m ay n ot be p os-
an acu te cau da equ in a syn drom e, su rger y m ay be requ ired to
sible to di eren t iate bet w een a con u s m edu llaris inju r y versu s
address n eu rologic issu es as w ell as sp in al colu m n stabilit y.
a cau da equ in a syn drom e. Neu rologic m an ifestat ion s in clu de
Th is ch apter depicts decom pression for an acu tely h erniated
bilateral leg w eakn ess, loss of sen sat ion , an d bladder an d bow el
lum bar disk causing sign i can t sp in al can al com p rom ise.
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/disloca-
Preprocedure Considerations
t 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 Radiographic Imaging
lam in ectom y an d rem oval of th e com p ression . In cases w h ere MRI is th e p referred im aging st u dy to evalu ate for severe
th ere is a fract u re or dislocat ion , spin al redu ct ion an d in st ru - lum bar com pression . T2-w eigh ted MRI is excellen t in sh ow -
m en tat ion m ay be n ecessar y. Oth er cau ses of cau da equ in a ing th e absen ce h igh in ten sit y cerebrospin al uid sign al at
syn drom e in clu de h em atom as, t u m ors, an d in fect ion s su ch as th e level of th e com pression (Fig. 18.1).
ep idu ral abscesses. 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
Indications
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.
Pat ien t s w ith acu te cau da equ in a syn drom e h ave leg w eak-
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
Medication
bilateral leg pain. An t ibiot ics are adm in istered prior to in cision .
Som e lu m bar sten osis is a com m on n ding on m agn et ic Updated guidelines released in 2013 recom m end against the
reson an ce im aging (MRI) scan s. Cau da equin a syn drom e is use of steroids in spinal cord injur y. The guidelines conclude,
n ot p ossible u n less th e sten osis is ver y severe. Add it ion ally, In su m m ar y, th ere is n o con sisten t or com pelling m edi-
m ost pat ien t s w ith ver y severe lu m bar sten osis do n ot h ave cal evidence of any class to just ify the adm inistration of MP
cauda equin a syn drom e. For a cau da equin a syn drom e to oc- [m ethylprednisolone 1,2 ] for acu te SCI [spin al cord injur y]. Both
cur th ere usu ally is an acute w orsen ing of th e baselin e sten o- consistent and com pelling Class I, II, and III m edical evidence
sis. Som et im es a sm all acu te disk m ay be su p erim p osed on exists suggest ing th at high -dose MP adm in ist rat ion is associ-
ch ron ic severe sten osis. ated w ith a variet y of com plicat ions including infection , respi-
Pat ien t s w ith acu te cau da equ in a syn drom e h ave u rin ar y re- rator y com prom ise, GI hem orrhage, and death. MP sh ould not
ten t ion . Bladder cath eterizat ion after th e pat ien t t ries to void be routinely used in the t reatm ent of patients w ith acute SCI.3
302
18 Treatm ent of Acute Cauda Equina Sym drom e
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)
Fig. 18.2 Patient positioning. The There are several options for beds. Bolsters can be used for the chest. A Wilson fram e
patient is positioned allows for opening up of the lum bar spine. A spinal table with hip and chest pads avoids
prone. X-ray or uoroscopy abdom inal compression and m ay reduce bleeding due to venous congestion. In patients
is used to localize the level undergoing a fusion, a Wilson fram e should be used carefully to avoid an iatrogenic at
and plan the incision. back syndrom e.
304
18 Treatm ent of Acute Cauda Equina Sym drom e
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
306
18 Treatm ent of Acute Cauda Equina Sym drom e
307
II Spinal Em ergency Procedures
Fig. 18.6 (a) The dura is retracted and if there is a With a large ventral disk herniation, dural retraction m ay be very
signif cant disk herniation component, the di cult or impossible initially. More bone m ay need to be rem oved
disk fragment is removed. The disk space laterally. As the decompression progresses, dural retraction is easier.
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.
308
18 Treatm ent of Acute Cauda Equina Sym drom e
Closing 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
Lumbar Incision 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
Th e w oun d is h eavily irrigated. a ect pat ien t ou tcom e in cau da equ in a syn drom e.1012 Rath er,
A m edium suct ion drain age device is placed deep an d brough t outcom e w as depen den t on th e pat ien ts preoperat ive n euro-
out th rough a separate skin in cision . logic stat us. Cases of cau da equ in a syn drom e sh ould be t reated
Th e posterior lum bar fascia is reapproxim ated using 0 ab - expedit iou sly.13 W h ile absolu te t im ing m ay n ot m ake a d i er-
sorbable su t u re in an in terru pted fash ion . In terru pted loose en ce, earlier su rgical in ter ven t ion s seem s to p reven t fu r th er
m u scle su t u res to obliterate dead sp ace are opt ion al. deteriorat ion .
Th e subcut an eous t issue is closed using several in terrupted Cau da equ in a syn drom e inju ries sh ou ld be dist ingu ish able
2-0 Vicr yl sut ures. from inju ries to th e con u s m ed u llaris. Th e con u s m edu llaris is
The skin is closed w ith staples or a m ono lam ent nylon sut ure. 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 co-
n u s inju ries.
Postoperative Management
Medication References
Tw o to th ree doses of prophylact ic an t ibiot ics in th e im m edi-
1. Bracken MB, Sh ep ard MJ, Holford TR, et al. Adm in ist rat ion of
ate postoperat ive period are opt ion al. Longer term an t ibiot ics
m ethylpredn isolon e for 24 or 48 h ours or t irilazad m esylate for
or an t ibiot ics for drain m an agem en t are discouraged.
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
309
III Nontraumatic Emergencies
19 Removal of Spontaneous
Intracerebral Hemorrhages
Just in Mascitelli, Yakov Gologorsk y, and Joshua Bederson
Infratentorial ICH
2010 ASA/AHA in dicat ion s for surgical evacuat ion of cerebel-
lar ICH1
Pat ien t s w h o are deteriorat ing n eu rologically Fig. 19.1 CTA demonstrating right cerebellar arteriovenous malformation
Brain stem com p ression with associated intracranial hemorrhage and intraventricular hemorrhage
Hydrocep h alu s from ven t ricu lar obst ru ct ion (IVH).
312
19 Rem oval of Spontaneous Int racerebral Hem orrhages
313
III Nontraum atic Em ergencies
Operative Procedure
Frontal Craniotomy10
Positioning and Skin Incision (Fig. 19.3)
Fig. 19.3 The patient is placed supine on the operating table. A frontal craniotomy is described here. Of
course, the exact craniotomy should always
The May eld skull clamp is placed w ith the single pin at the equator be tailored to the location of the ICH.
in contralateral frontal bone above the orbit and the paired pins Su cient tim e should be devoted for ICH
placed at the equator in the ipsilateral occipital lobe. localization before the incision is m arked. The
patients head position should be correlated
Alternatively, the patients head may be placed on a horseshoe or a with the CT scan. It is often helpful to draw
donut w ithout a May eld clamp. the planned craniotomy on the scalp.
If tim e perm its, a volum etric CT scan m ay be
The head is rotated as far as possible to the contralateral side w ithout obtained and intraoperative navigation m ay
obstructing the airw ay or venous drainage. be used for precise localization of the ICH.
When applying the May eld clamp, the
The super cial temporal artery (STA) should be palpated at the level frontal sinus and m astoid air cells should be
of the zygoma and the vertical limb of the incision should be placed avoided.
betw een the artery and the tragus. Care should be taken to avoid the frontal
branch of facial nerve that originates just
The incision begins at the zygoma and then curves posteriorly to the below the root of the zygom a and travels in
parietal eminence and upw ard from the auricle to reach 2 cm from the super cial temporal facia to the orbital
the midline. rim .11
Care should also be taken when dissecting
The incision is then carried forw ard to the frontal region and curved adjacent to the auricle to not violate the
across the midline just behind the hairline. external auditory canal.
314
19 Rem oval of Spontaneous Int racerebral Hem orrhages
Fig. 19.4 The skull is then exposed by incising the temporalis muscle Use of electrocautery to elevate the temporalis
posteriorly and superiorly and elevating the muscle anteriorly m uscle m ay result in injury to the trigem inal
and inferiorly w ith a periosteal elevator. 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
Fig. 19.5 The craniotomy should be started w ith a single bur It is helpful to again re-correlate with the
hole, the location of w hich is tailored to the planned CT scan prior to m aking the craniotomy.
craniotomy (in this case, it is placed at the posterior While drilling the inner table of the
superior temporal line). frontal bone, care should be taken not
to enter the orbit or frontal sinus. If this
The craniotomy is then w idened using the craniotome. were to occur, the orbit can be packed
with oxidized cellulose and the sinus with
A high speed drill can be used to atten the orbital m uscle/fascia.
roof and remove the inner table of the frontal bone if If the temporal air cells are entered, they
needed. should be thoroughly waxed.
316
19 Rem oval of Spontaneous Int racerebral Hem orrhages
Fig. 19.6 Before opening the dura, tack up sutures should be placed Placem ent of dural tack ups m ay be
along the entire craniotomy to prevent postoperative delayed until after ICH evacuation if
epidural hematoma formation. 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
a b
Fig. 19.7 (a) A corticotomy is then performed w here the Eloquent tissue should be avoided when choosing the
hematoma comes closest to the surface (a). location for the corticotomy.
Intraoperative ultrasound m ay be used if the ICH does
Bipolar cautery should be used along the planned not com e to the cortical surface. (b) Intraoperative
cortical incision to prevent bleeding. ultrasound im age of a large frontal basal ganglia
hem atom a (arrow).
The cortical incision is then made using a no. 11
blade.
318
19 Rem oval of Spontaneous Int racerebral Hem orrhages
Fig. 19.8 A malleable can be used to gently retract the cortical opening. Self-retaining retractors are not advised as they
can dam age norm al parenchym a.
The hematoma is then evacuated from w ithin the cavity. The The operating m icroscope m ay be used for this
center of the hematoma is evacuated rst follow ed by the part of the case for increased illum ination and
peripheral blood. m agni cation, if needed.
Special at tention should be paid for sm all
Bipolar cautery is used to stop bleeding from the cavity w alls. tum ors, cryptic arteriovenous m alform ations
Gelatin sponge and oxidized cellulose available in various forms (AVMs), and cavernous angiom as.
may also be used for nal hemostasis.
319
III Nontraum atic Em ergencies
a 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
Fig. 19.10 The head is xed in a May eld skull clamp w ith the The m idline suboccipital craniectomy is described
single pin on the linea temporalis anterior to one here. The lateral suboccipital craniectomy can
external auditory meatus (EAM) and the paired also be used for m ore lateral cerebellar ICHs.
pins on the opposite linea temporalis (one pin over Care should be taken to not hyper ex the neck
the EAM and one pin anterior to the EAM). and com prom ise the airway as well as to inspect
and pad all pressure points.
The patient is placed in the prone position on the If not done already, an EVD should be placed rst.
operating table on bolsters. 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
Fig. 19.11 A linear midline skin incision is made from the The inferior extent of the incision should
inion to the upper cervical vertebrae. be determ ined by the size of the planned
craniectomy and need for C1 or C2 lam inectomy.
The subcutaneous musculature is divided along the The m idline raphe is avascular and blood loss can
midline raphe. The muscle is re ected laterally. be m inim ized by remaining along that plane.
322
19 Rem oval of Spontaneous Int racerebral Hem orrhages
Fig. 19.12 The craniectomy is made from just below the inion/torcula and The location and size of the lesion will
carried dow nw ard tow ard the foramen magnum. determ ine the extent of the craniectomy;
occasionally the posterior arch of C1 will
There are a number of w ays to perform the craniectomy; (a) the need to be rem oved.
authors prefer to thin the bone w ith a high speed drill and then
(b) complete the bone removal w ith rongeurs and punches.
323
III Nontraum atic Em ergencies
324
19 Rem oval of Spontaneous Int racerebral Hem orrhages
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
Fig. 19.14 A cerebellar hematoma should be If the cerebellum is noted to be signi cantly swollen or
evacuated using the same techniques as irritated, consideration should be given to resection of a
a supratentorial hematoma. portion of the cerebellar hem isphere.
326
19 Rem oval of Spontaneous Int racerebral Hem orrhages
Arteriovenous Malformation-
Associated ICH
Sp on t an eou s ICH can be secon dar y to AVM, an eu r ysm , or ve-
n 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 or-
rh 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 hypo-
Fig. 19.15 Postoperative CT following evacuation of right frontal tension . Cerebral perfusion pressure (CPP) sh ould alw ays be
hematoma shown in Fig. 19.2. 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
a 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 t urn , allow for a m uch safer ICH evacuat ion .25 If preoperat ive
th at can n ot be con t rolled w ith th e above m en t ion ed m an eu - em bolizat ion is n ot an opt ion du e to t im e con strain t s, th e su r-
vers. In th ese desp erate circu m stan ces, u rgen t resect ion of th e geon sh ou ld be fu lly p repared to clip th e an eu r ysm .
AVM m ay be th e on ly life-saving m easure available to th e sur- Prior to en tering or evacu at ing th e ICH, th e operat ing room
geon . If AVM resect ion is u n dert aken at th e t im e of h em orrh age, an d p erson n el sh ou ld be p rep ared for poten t ial an eu r ysm ru p -
th e basic ten et s of AVM surger y sh ould st ill be m ain tain ed: t ure. Ideally, a discussion of the follow ing steps sh ould occur
w ide exposure, occlusion of large feeding arteries rst , circum - before th e skin in cision is even m ade. Th e operat ing m icro-
feren t ial dissect ion of th e AVM n idu s, system at ic separat ion of scop e sh ou ld be d raped an d ready. A fu ll select ion of tem p orar y
th e AVM from w h ite m at ter, an d preser vat ion of drain ing vein s an d perm an en t clip s sh ou ld be open on th e surgical eld. Th e
u n t il th e en d of th e procedure.19 W h en ever blood loss is sig- an esth esiologist sh ou ld be p rep ared to adju st blood p ressu re
n i can t en ough to requ ire m ajor in fu sion of u ids an d t ran sfu - rapidly. At least t w o (possibly th ree) large suction s sh ou ld be
sion of p acked red blood cells, con siderat ion sh ou ld be given to prepared an d ready. On ce th e h em atom a is en tered, a con ser va-
rep len ish ing fresh frozen p lasm a, platelet s, an d oth er clot t ing t ive evacuat ion is w arran ted. Part icular care sh ou ld be t aken
factors to avoid a dilu t ion al coagulop athy. 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
Aneurysmal ICH 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
An eu r ysm ru pt u re t yp ically resu lt s in SAH bu t can also p rod u ce sh ou ld h ave im m ediate angiograp hy, ideally in th e operat ing
ICH an d u su ally involves an eu r ysm s distal to th e circle of Wil- room . Fin ally, a th ird reason able opt ion in clu des cran iectom y
lis su ch as th e m id dle cerebral ar ter y (MCA) or an eu r ysm s th at w ith out ICH evacuat ion to im m ediately address ICP follow ed by
h ave becom e adh eren t to th e brain . Pat ien t s w ith an eur ysm al im m ediate coil em bolizat ion .
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
External Ventricular Drainage
ICH.23 Th ere is a m u ch greater im p or tan ce in secu ring th e an - Placem en t of an EVD sh ou ld be con sidered in all pat ien ts w ith
eu r ysm given th e prop en sit y for an d devastat ing con sequ en ces IVH especially th ose w ith blood in th e th ird ven t ricle, th e cere-
of an eur ysm re-rupt ure. Alth ough cath eter angiography is th e bral aqueduct , or fourth vent ricle. Generally, th e EVD should be
gold stan dard for an eu r ysm diagn osis an d p reop erat ive evalu a- placed in th e lateral vent ricle cont ralateral to th e hem orrhage
t ion , som e advocate operat ing based on CTA alon e as th e delay to avoid clogging th e cath eter. Alth ough in traven tricular t issue
could lead to w orse outcom e.24 If t im e p erm it s, h ow ever, con - plasm in ogen act ivator (rt-PA) m ay h elp lyse clot and m aintain
siderat ion sh ou ld be given to p reop erat ive angiography an d coil cath eter patency,26 it is still con sidered invest igat ion al an d sh ould
em bolizat ion to p rotect th e an eu r ysm from re-ru pt u re an d , in not be used if th ere is a suspected vascular lesion . Im portan tly,
328
19 Rem oval of Spontaneous Int racerebral Hem orrhages
ven t ricu lar drain age alon e is n ot an acceptable treatm en t for 12. Spet zler RF, Lee KS. Recon st ru ct ion of th e tem poralis m us-
cerebellar h em orrhage w ith associated hydroceph alus. Th ese cle for th e pterion al cran iotom y: Tech n ical n ote. J Neu rosurg
patien ts should undergo surgical decom pression.1 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.
References Ph iladelp h ia: Sau n d ers; 2004
14. Auer LM, Dein sberger W, Niederkorn K, et al. En doscopic surger y
1. Morgen stern LB, Hem p h ill JC 3rd, An d erson C, et al. Gu id elin es versus m edical t reat m en t for spon t an eous in t racerebral h em a-
for th e m an agem ent of spon t an eous int racerebral h em orrh age: tom a: a ran dom ized st udy. J Neurosurg 1989;70(4):530535
a guidelin e for h ealth care profession als from th e Am erican 15. Teern st ra OP, Evers SM, Lodder J, Le ers P, Fran ke CL, Blaauw G.
Hear t Associat ion /Am erican St roke Associat ion . St roke 2010; Mu lt icen ter ran dom ized con t rolled t rial (SICHPA). Stereot act ic
41(9):21082129 t reat m ent of in t racerebral h em atom a by m ean s of a plasm in ogen
2. Broderick J, Connolly S, Feldm ann E, et al; Am erican Heart act ivator: a m ult icen ter random ized con t rolled t rial (SICHPA).
Association/Am erican Stroke Association Stroke Council; Am erican St roke 2003;34(4):968974
Heart Association/Am erican Stroke Association High Blood Pres- 16. Marin kovic I, St rbian D, Pedron o E, et al. Decom pressive cra-
sure Research Council; Qualit y of Care and Outcom es in Research n iectom y for in t racerebral hem orrh age. Neurosu rger y 2009
Interdisciplinary Working Group. Guidelines for the m anagem ent Oct;65(4):780786
of spontaneous intracerebral hem orrhage in adults: 2007 update: 17. Mart in NA, Wilson CB. Preoperat ive an d postop erat ive care:
a guideline from the Am erican Heart Association/Am erican Stroke Man agem en t of in t racran ial h em orrh age. In : Wilson CB, Stein
Association Stroke Council, High Blood Pressure Research Council, BM, eds. In t racran ial Ar terioven ous Malform at ion s. Balt im ore:
and the Qualit y of Care and Outcom es in Research Interdisciplin- William s & Wilkin s; 1984: 121129
ary Working Group. Circulation 2007;116(16):e391413 18. Solom on RA, Stein BM. Managem en t of deep supraten torial an d
3. Men delow AD, Gregson BA, Fern an d es HM, et al. Early su rger y brain stem arterioven ous m alform at ions. In : Barrow DL, ed. In -
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 a- t racran ial Vascular Malform at ion s. Park Ridge, IL: Am erican As-
n eous su praten torial in t racerebral h aem atom as in th e In ter- sociat ion of Neurological Surgeon s; 1990: 125141
n at ion al Surgical Trial in In t racerebral Haem orrh age (STICH): a 19. Yasargil MG. Micron eurosurger y. Vol 3B. AVM of th e Brain : Clini-
ran dom ised t rial. Lan cet 2005;365(9457):387397 cal Con siderat ion s, Gen eral an d Special Operat ive Tech n iques,
4. Teern st ra OP, Evers SM, Kessels AH. Met a an alyses in t reat m en t Surgical Result s, Non operat ive Cases, Cavern ous an d Ven ous An -
of spont an eous supraten torial in t racerebral h aem atom a. Act a giom as, Neuroan esth esia. New York: Th iem e; 1987
Neuroch ir (Wien ) 2006;148(5):521528 20. Jafar JJ, Rezai AR. Acute surgical m an agem ent of in t racran ial ar-
5. Green berg, Mark S. Han dbook of Neurosurger y. New York: terioven ou s m alform at ion s. Neurosurger y 1994;34(1):812
Th iem e; 2010 21. St arke RM, Kom ot ar RJ, Hw ang BY, et al. Treat m en t guidelin es for
6. Broderick JP, Brot t TG, Du ldn er JE, Tom sick T, Hu ster G. Volu m e of cerebral ar terioven ou s m alform at ion m icrosurger y. Br J Neuro-
in t racerebral h em orrh age. A pow erful an d easy-to-use predictor surg 2009;23(4):376386
of 30-day m or t alit y. St roke 1993;24(7):987993 22. Hau erberg J, Eskesen V, Rosen orn J. Th e progn ost ic signi -
7. Bradley WG Jr. MR ap p earan ce of h em orrh age in th e brain . Radi- can ce of in t racerebral h aem atom a as sh ow n on CT scann ing
ology 1993;189(1):1526 after an eur ysm al subarach n oid h em orrh age. Br J Neurosurg
8. Zh u XL, Ch an MS, Poon WS. Sp on t an eou s in t racran ial h em or- 1994;8(3):333339
rh age: w hich pat ien t s n eed diagn ost ic cerebral angiography? 23. Gueresir E, Beck J, Vat ter H, et al. Subarach n oid h em orrh age an d
A prospect ive st udy of 206 cases and review of th e literat u re. in t racerebral h em atom a: in cidence, progn ost ic factors, an d out-
St roke 1997;28(7):14061409 com e. Neurosurger y 2008;63(6):10881093
9. Diringer MN, Skoln ick BE, Mayer SA, et al. Th rom boem bolic 24. de los Reyes K, Patel A, Bederson JB, Fron tera JA. Man agem en t
even t s w ith recom bin an t act ivated factor VII in Spon t an eous In - of subarach n oid h em orrh age w ith in t racerebral h em atom a: clip -
t racerebral h em orrh age: result s from the factor seven for acute ping an d clot evacuat ion versus coil em bolizat ion follow ed by
h em orrh agic st roke (FAST) t rial. St roke 2010;41:4853 clot evacuat ion . J Neuroin ter v Surg 2013;5(2):99103
10. Clat terbuck RE, Tam argo RJ. Surgical posit ion ing and exposures 25. Bergdal O, Springborg J, Hauerberg J, Eskesen V, Poulsgaard L,
for cran ial procedures. In : Win n HR, ed. Youm ans Neurological Rom n er B. Outcom e after em ergen cy surger y w ith out angiogra-
Surger y. 5th ed. Ph iladelphia: Saun ders; 2004 phy in pat ien t s w ith in t racerebral h aem orrhage after an eur ysm
11. Yasargil MG, Reich m an MV, Ku bik S. Preser vat ion of th e fron to- r u pt u re. Act a Neu roch ir (Wien ) 2009;151(8):911915
tem poral bran ch of th e facial n er ve using th e in terfacial tem po- 26. Engelh ard HH, An drew s CO, Slavin KV, Ch arbel FT. Curren t m an -
ralis ap for pterion al craniotom y. Tech n ical ar t icle. J Neurosurg agem en t of in t raven t ricular h em orrh age. Surg Neurol 2003
1987;67:463466 Ju l;60(1):1521
329
20 Surgery for Acute
Intracranial Infection
P. B. Rak sin
330
20 Surgery for Acute Intracranial Infection
331
III Nontraum atic Em ergencies
a b
c d
e f
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 post-
gadolinium 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 Surgery for Acute Intracranial Infection
Medication 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 age-
Em piric, broad-spect rum an t im icrobial th erapy sh ould be m en t of abscess.
in it iated at th e t im e of presen t at ion . Th e source, an d th erefore Seizu res are com m on in th e set t ing of in t racran ial in fec-
likely path ogen s, sh ou ld be con sidered. Th e au th or prefers a t ion . An t iepilept ic drug prophyla xis sh ould be in it iated upon
regim en of van com ycin , ceft riaxon e (cefep im e if a n osoco- p resen t at ion .
m 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
Operative Field Preparation
of an t ifungal or an t it uberculous coverage. Th e h air is cropped (n ot sh aved) w ith an elect ric razor at th e
In cases w h ere th e p ath ogen is kn ow n , t argeted an t im icrobial p lan n ed surgical site.
th erapy is th e goal. Th e skin is prepared in it ially w ith alcoh ol, follow ed eith er
Corticosteroid therapy m ay be considered on an individual w ith a st an dard povidon e iodin e or ch lorh exidin e scru b.
case basis for m anagem ent of accom panying vasogenic edem a. Th e plan n ed in cision site is in lt rated w ith 1%lidocain e w ith
W hile the use of corticosteroids has been show n to be of som e 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
(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
b
a
(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
337
III Nontraum atic Em ergencies
338
20 Surgery for Acute Intracranial Infection
339
III Nontraum atic Em ergencies
340
20 Surgery for Acute Intracranial Infection
341
III Nontraum atic Em ergencies
342
20 Surgery for Acute Intracranial Infection
343
III Nontraum atic Em ergencies
Fig. 20.11 If feasible, primary closure may be accomplished w ith interrupted Prim ary dural closure m ay not be
4-0 braided nylon stitches. If grafting is necessary, it is preferable feasible in the set ting of m alignant
to incorporate autologous materials in the setting of infection. cerebral edem a. Autologous graft
Pericranium, temporalis fascia, or fascia lata (the latter requiring the material m ay be tacked loosely at the
foresight to prepare the lateral thigh preoperatively) are good options. edges to accom m odate swelling. In
extrem e circum stances, a large piece
In cases of contiguous extension of infection from the frontal air sinus of dural substitute m aterial m ay be laid
to the epidural and/or subdural space, it is necessary to cranialize the over the dural defect.
frontal sinus prior to closure. The dura should be dissected from the roof The author uses dry pieces of gelatin
of the orbit and posterior w all of the frontal sinus (if not already done sponge coated with bacitracin powder
by the abscess itself). The posterior table should be drilled ushed w ith for packing of the frontal sinus.
the frontal fossa oor. Mucosa should be stripped from the sinus and the Alternately, adipose tissue (from a
inner surface of the sinus, in turn, decorticated w ith a diamond bur. The peripheral site) or m uscle (temporalis)
sinus then is packed. The nasofrontal duct is obliterated. The previously may be used.
harvested, vascularized pericranial ap then is folded dow n over the sinus See Chapter 27 for additional discussion
opening and secured to the native dura at multiple points w ith 4-0 braided of techniques for frontal sinus
nylon stitches. A layer of brin glue is applied to the suture line. reconstruction.
344
20 Surgery for Acute Intracranial Infection
345
III Nontraum atic Em ergencies
b c
346
20 Surgery for Acute Intracranial Infection
a b
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 4. Nath oo N, Nadvi SS, van Dellen JR, Gouw s E. In t racran ial su bdu -
to exclu de h em orrh age. 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 py-
Further Management em 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
Reaccum ulat ion of epidu ral, su bdural, an d in t raparen chym al Syst e m . Ph ilad elp h ia: Lip p in cot t W illiam s & W ilkin s; 2 0 04 :
collect ion s m ay occur. Pat ien ts m ay require m ult iple opera- 52 3 53 6
t ive in ter ven t ion s for debridem en t . 6. Riech ers RG, Jarell AD, Ling GSF. In fect ion of th e cen t ral n er vou s
In th e set t ing of in t raven t ricu lar ru pt u re of an abscess, p lace- system . In : Suarez JI, ed. Crit ical Care Neurology an d Neurosur-
m en t of an extern al ven t ricu lar drain is app ropriate to p erm it ger y. New York: Hum an a Press; 2004: 515532
con t in uou s drain age of cerebrospin al uid, as w ell as in t ra- 7. Yang S-Y. Brain abscess: a review of 400 cases. J Neu rosu rg
th ecal adm in ist rat ion of ant im icrobial th erapy. 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.
Special Considerations Prin ciples an d Pract ice of In fect ious Diseases. 6th ed. Ph iladel-
ph ia: Elsevier; 2005: 11501163
If in fect ion arises from th e sin u ses or m astoid p rocess, si- 10. Nath oo N, Nadvi SS, Gouw s E, van Dellen JR. Cran iotom y im -
m u ltan eou s m an agem en t of th e in fect iou s p ath ology by proves ou tcom es for cran ial su bd u ral em pyem as: Com p u ted-
Otolar yngology m ay be in dicated. Otolar yngology sh ou ld be tom ograp hy era experien ce w ith 699 p at ien t s. Neu rosu rger y
involved in th e p reoperat ive p lan n ing for such cases. 2001;49:872878
Form al In fect ious Diseases con sultat ion is appropriate to 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:
gu ide an t im icrobial th erapy.
972989
Suppurative intracranial throm bophlebitis is a feared com plica-
12. Oban a WG, Rosen blu m ML. Non op erat ive t reat m en t of n eu ro-
tion of central nervous system infection. Suppurative throm bo-
surgical in fect ion s. Neurosurg Clin N Am 1992;3:359373
phlebitis m ay begin w ithin the veins or venous sinuses or m ay 13. Rosen blu m M, Ho J, Norm an J, Edw ards M, Berg B. Non op era-
occur after infection of the paranasal sinuses, m iddle ear, m as- t ive t reat m en t of brain abscesses in select h igh -risk pat ien t s.
toid, or oropharynx. MRI of the brain, w ith MRV, is the test of J Neu rosu rg 1980;52:217225
choice. A 3 to 4 week course of intravenous antim icrobial ther- 14. Wong AM, Zim m erm an RA, Sim on EM, et al. Di u sion -w eigh ted
apy is recom m ended. The use of anticoagulation in this setting MR im aging of su bdu ral em pyem as in ch ildren . AJNR Am J Neu -
is controversial.17 It is also im portant to note that relapse m ay roradiol 2004;25:10161021
occur w ithin 6 weeksafter apparent clinical resolutionand 15. Tu n kel AR, Har t m an BJ, Kaplan SL, et al. Pract ice gu idelin es
abscess form ation has been reported up to 8 m onths later.18 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
References Cen t ral Ner vou s System . Ph iladelp h ia: Lipp in cot t William s &
Wilkin s; 2004: 479508
1. Dill SR, Cobbs CG, McDon ald CK. Su bdu ral em pyem a: an alysis of 17. Bh at ia K, Jon es NS. Sept ic cavern ou s sin u s th rom bosis secon dar y
32 cases an d review. Clin In fect Dis 1995;20:372386 to sin u sit is: are an t icoagu lan t s in dicated ? A review of th e litera-
2. Flam m ES. Percivall Pot t: an 18th cen t u r y n eu rosu rgeon . J Neu - t ure. J Lar yngol Otol 2002;116:667676
rosurg 1992;76:319326 18. Tu n kel AR. Su bdu ral em pyem a, epid u ral abscess, an d su p pu-
3. Hall WA. Cerebral in fect iou s p rocesses. In : Loft u s CM, ed . Neu - rat ive in t racran ial throm boph lebit is. In : Man dell GL, Ben n et t
rosurgical Em ergen cies. Vol. 1. Park Ridge, IL: Am erican Associa- JE, Dolin R, eds. Prin cip les an d Pract ice of In fect iou s Diseases.
t ion of Neurological Surgeon s Publicat ions; 1994: 165182 6th ed. Ph iladelph ia: Elsevier; 2005: 11641171
348
21 Ventricular Shunt Malfunction
Sergey Abeshaus, Sam uel R. Brow d, and Richard G. Ellenbogen
349
III Nontraum atic Em ergencies
Sh u n t Sh u n t Revision Sh u n t
Extern alizat ion Extern alizat ion
+ ABx + ABx
Fig. 21.1 Simpli ed algorithm for decision making in ventricular shunt malfunction.
a 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
a b
Fig. 21.3ac Shunt series. (a) Anteroposterior (AP) and (b) lateral
skull showing ventricular catheter disconnection. (c) AP abdom en
c 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 com m u n it y-acquired an d im ipen em /cilast in in stead of cef-
revision . Over 95% of all sh u n t in fect ion s occu r w ith in 1 year t riaxon e in h ospit al-acqu ired in fect ion ).6
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.
Operative Field Preparation
Preparat ion is don e according to follow ing th e Hydroceph alus
Medication Clin ical Research Net w ork (HCRN) p rotocol adopted for Seat tle
Ch ild rens Hospit al (Fig. 21.4).7
Antibiotics Position the patient w ith the head away from the door. Wide ex-
Any n ew sh un t placem en t or revision : t w o doses of cefazolin posure is im portant. Hair is rem oved w ith clippers. Prelim inarily
or any late gen erat ion ceph alosporin ; rst dose is adm in is- prepare the skin w ith chlorhexidine soap, then isopropyl alcohol,
tered during an esth esia in duct ion (45 m in utes to 1 h our prior to rem ove any dirt or debris and allow to dry. Mark the incision.
to th e in cision ) an d th e secon d dose after th e surger y w ith in Previous in cision s on th e scalp m ay be exten ded to get ap -
8 h ours. Som e surgeon s cover th e pat ien ts w ith an t ibiot ics propriate exposu re of ven t ricular cath eter an d sh u n t valve
for 24 h ou rs; h ow ever, th e eviden ce m ostly su pp or t s a single ( con sider vascular supply to scalp so as n ot to devascularize
p reoperat ive dose p rior to skin in cision . Con sid er van co- th e scalp ap). We use 2% ch lorh exidin e glucon ate/70% isopro-
m ycin 1 h ou r in advan ce of surger y in m eth icillin -resistan t pyl alcoh ol solu t ion preparat ion for th e surgical eld an d w ait
Staphylococcus aureuscolon ized pat ien t s. 3 m in utes or longer to dr y. Double gloves are advised. Drape
Sh u n t in fect ion : tap sh u n t , th en im m ed iately begin t riple w ith an t im icrobial in cise lm an d en sure isolat ion of poten t ial
an t ibiot ics (ceft riaxon e, van com ycin , an d m et ron idazole in in fect ion sources (t rach eostom y, gast rostom y t ube, etc.).
351
III Nontraum atic Em ergencies
Wait 3 m in u tes
# w h o scru bbed
Han d scrub w ith betad in e or ch lorh exidin e
# w h o w ash ed h an ds correctly
Yes No
An t ibiot ics in ?
Inject ion of van com ycin /gen t am ycin in to shu n t reser voir
Closure
Dressing
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)
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
354
21 Ventricular Shunt Malfunction
Fig. 21.6 Evaluate ventricular catheter skull entry site and valve location based on We use the needle tip monopolar
review of imaging, palpation, and navigation assistance. (a) An incision electrocautery.
is made w ith a no. 10 or no. 15 blade often through a preexisting One can utilize a custom tailored skin
incision w ith extension along the valve for appropriate exposure of incision or curvilinear incision to provide
distal part of the valve. The incision should not be over the hardw are adequate scalp coverage and release
to avoid w ound breakdow n. After w e score the skin w ith a blade, w e tension from the wound. In patients with
use Bovie electrocautery dow n to and around the shunt hardw are a comprom ised scalp, the surgeon m ay
because it does not cause harm to the valve or tubing. (b) The careful need to perform a Z-plast ya rotational
dissection of soft tissue in the galeal-pericranial plane to preserve ap or score the galeal layer to ensure
pericranium and appropriate exposure of both ventricular catheter and adequate scalp coverage over the tubing
valve is performed. Wound edges are retracted carefully w ith Weitlaner without tension.
retractor(s) or retraction sutures. Wound hemostasis is obtained w ith
monopolar or bipolar electrocautery.
355
III Nontraum atic Em ergencies
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
21 Ventricular Shunt Malfunction
357
III Nontraum atic Em ergencies
358
21 Ventricular Shunt Malfunction
359
III Nontraum atic Em ergencies
Fig. 21.11 Subcostal approach: After removal of the distal There are several ways to replace the distal catheter in
(peritoneal) catheter, a super cial abdominal skin cases of obstruction. Either a sm all abdom inal opening,
(linear) incision (usually at the site of the previous blunt abdom inal trochar, or laparoscopic technique are
incision) is made by a no. 15 blade or needle tip perform ed.11,12 For obese patients, we prefer a laparoscopic
cautery. The incision size depends on the patients approach. For an open approach, som e surgeons prefer a
age and body mass index. The incision is usually sub-xiphoid, vertical m idline incision, while others prefer
1020 mm in length but is tailored to the patients a right-sided subcostal lateral incision. Both general
particular anatomic features. The surgeon holds the approaches work well as long as the surgeon is fam iliar with
skin edges gently distracted so that the incision can the anatomy in the abdom en.
be extended through the subcutaneous fat layer and We usually use the preexisting incision. The goal is to avoid
deep membranous layer (Scarpas fascia) dow n to the multiple parallel incisions if possible.
anterior rectus sheath.
360
21 Ventricular Shunt Malfunction
361
III Nontraum atic Em ergencies
362
21 Ventricular Shunt Malfunction
363
III Nontraum atic Em ergencies
364
21 Ventricular Shunt Malfunction
Placement: Ventricular Catheter and Tunneling for External Drainage (Fig. 21.16)
Fig. 21.16 If circumstances require removal of an entire shunt system w ith continued Prevent CSF from leaking to
need for ventricular drainage, then an external drain is placed. Placement improve likelihood of cannulating
of antibiotic-impregnated ventricular catheter9 occurs w ith ideal placement the ventricle.
of the tip anterior to the ipsilateral foramen Monro. We typically utilize
stereotactic navigation or alternatively use anatomic landmarks.
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 t ran sversalis fascia, an terior an d posterior rect u s sh eath s,
su bcu t an eou s an d absorbable m on o lam en t su t u res for skin Scarpas fascia, an d th e skin . Met icu lou s at ten t ion is paid
closure. Cu rren t sut ures are an t ibiot ic im pregn ated. th rough ou t th e closing to m atch up th e an atom ic layers an d
If th e w ou n d is of qu est ion able in tegrit y, w e u t ilize nylon su - avoid kin king or injuring th e sh u n t t ubing.
t ures for closure. Glue is placed on th e skin surface after su bcut icu lar closure.
365
III Nontraum atic Em ergencies
366
21 Ventricular Shunt Malfunction
367
III Nontraum atic Em ergencies
Fig. 21.19 Postoperative CT scan of same patient depicted in Fig. 21.2 after shunt revision.
Special Considerations 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 reso-
In pediat ric pat ien t s w e t yp ically follow -u p at yearly in ter-
n an ce im aging in th e assessm en t of ch ildren w ith hydroceph a-
vals w ith or w ith ou t im aging, dep en d ing on sym ptom s. If th e
lus. World Neurosurg 2013;80(6):e307312
pat ien t is w ell, n o im aging m ay be n eeded except at sur veil- 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
lan ce scan in ter vals of 15 years. We obtain a sh u n t series to m alfun ct ion: is th e sh un t series really n ecessar y? Pediat r Em erg
en su re n o cath eter discon n ect ion s are seen an d to follow th e Care 2007:23;137141
length of th e distal cath eter after th e last sh u n t in sert ion . If th e 6. Kestle JR, Garton HJ, W hitehead W E, et al. Managem ent of shunt in-
pat ien t goes th rough a rapid grow th period or if th ere is any fections: a m ulticenter pilot study. J Neurosurg 2006:105;177181
368
21 Ventricular Shunt Malfunction
7. Kestle JR, Riva- Cam brin J, Wellon s JC, 3rd , et al. A st an dard - 10. Hayh urst C, Beem s T, Jen kin son MD, et al. E ect of elect rom ag-
ized protocol to reduce cerebrospin al uid shu nt in fect ion : th e n et ic-n avigated sh un t placem en t on failure rates: a prospect ive
Hydroceph alu s Clinical Research Net w ork Qu alit y Im provem en t m u lt icen ter st udy. J Neurosu rg 2010:113;12731278
In it iat ive. J Neu rosu rg Pediat r 2011:8;2229 11. Tubbs RS, Maher CO, Young RL, et al. Dist al revision of ven t riculo-
8. Stein bok P, Coch ran e DD Rem oval of ad h eren t ven t ricu lar cath - periton eal sh un t s using a peel-aw ay sh eath . J Neurosurg Pediat r
eter. Ped iat r Neu rosu rg 1992:18;167168 2009:4;402405
9. Parke r SL, An d e rson W N, Lilie n feld S, et al. Ce reb rosp in al 12. Naftel RP, Argo JL, Sh ann on CN, et al. Laparoscopic versus open
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 reg- in sert ion of th e periton eal cath eter in ven t riculoperiton eal
n 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; sh un t placem ent: review of 810 consecut ive cases. J Neurosurg
259265 2011:115;151158
369
22 Pituitary Apoplexy
Kalm on D. Post and Soriaya Mot ivala
370
22 Pituit ary Apoplexy
a b
Fig. 22.1ac (a) Axial and (b, c) coronal CT scans showing hemorrhagic
c cavit y with uid- uid level and surrounding enhancing sellar lesion.
a 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
372
22 Pituit ary Apoplexy
Operative Procedure
Microscopic Pituitary Tumor Resection
Positioning and Fluoroscopy (Fig. 22.3a, b)
a
Fig. 22.3 Patient is placed on far right edge of table in supine position. Right arm Patient is positioned to allow for ease
is bent 90 degrees and secured across chest w ith padding and tape. of trajectory to the sella.
If used, im age guidance system s
(a) Head is placed on a foam holder w ith right ear tilted 45 degrees should be set up to allow ease of
in relation to right shoulder. Head of bed is exed just slightly such that viewing while surgeon is in operative
the chest does not interfere w ith use of instruments. position.
373
III Nontraum atic Em ergencies
374
22 Pituit ary Apoplexy
375
III Nontraum atic Em ergencies
(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
22 Pituit ary Apoplexy
(b) A hands free speculum is then placed w ith one blade on either side of the vomer.
377
III Nontraum atic Em ergencies
378
22 Pituit ary Apoplexy
379
III Nontraum atic Em ergencies
380
22 Pituit ary Apoplexy
381
III Nontraum atic Em ergencies
382
22 Pituit ary Apoplexy
383
III Nontraum atic Em ergencies
Postoperative Management 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 refer-
en ce to pit uit ar y apoplexy. J Neurosurg 1950:7(5):421439
Dexam eth ason e or hydrocort ison e is con t in u ed in th e im m e- 3. Fin dling JW, Tyrrell JB, Aron DC, Fit zgerald PA, Wilson CB,
diate postoperat ive period. Forsh am PH. Silen t p it u it ar y apop lexy: su bclin ical in farct ion
If a left sid ed packing w as placed it is rem oved th at even ing. of an adren ocor t icot ropin -produ cing pit uit ar y aden om a. J Clin
Th e pat ien t is m on itored for any sign s of addison ian crisis En docrin ol Met ab 1981;52(1):9597
as w ell as diabetes in sipidu s. To th at en d st rict m easu re- 4. Moh r G, Hardy J. Hem orrh age, n ecrosis, an d apop lexy in p it u -
m en t s of in t ake an d ou t p u t are t aken as w ell as daily sodiu m it ar y aden om as. Surg Neurol 1982;18(3):181189
an d osm olalit y levels. Sh ou ld th e p at ien t h ave m ore th an 5. On est i ST, Wisn iew ski T, Post KD. Clin ical versu s su bclin ical p it u-
it ar y apoplexy: presen t at ion , surgical m an agem ent , an d out-
200 m L/h r of urin e out put over th e course of 3 con secut ive
com e in 21 pat ien t s. Neurosurger y 1990;26(6):980986
h ou rs repeat sodium level is draw n an d if it is elevated, des-
6. Mu rad-Kejbou S, Eggen berger E. Pit u it ar y ap oplexy: evalu-
m op ressin acetate th erapy is in it iated.
at ion , m an agem en t , an d p rogn osis. Cu rr Op in Op h th alm ol
Postop erat ive day 2 th e righ t p acking is rem oved an d th e
2009;20(6):456461
pat ien t is disch arged if th ey con t in ue to be st able. 7. Su zu ki H, Mu ram at su M, Mu rao K, Kaw agu ch i K, Sh im izu T.
En docrin e labs are sen t as out pat ien t to assess th e level of Pit u it ar y ap op lexy cau sed by ru pt u red in tern al carot id ar ter y
pit uit ar y fun ct ion . an eu r ysm . St roke 2001;32(2):567569
Neu rosu rgical, en docrin e, an d op h th alm ology follow -u p is 8. Okaw ara M, Yam agu ch i H, Hayash i S, Mat su m oto Y, In ou e Y,
provided. 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
384
IV Emergency Operations in Combat
23 Combat Cranial Operations
Leon E. Moores
386
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.
387
IV Em ergency Operations in Com bat
Operative Procedure
Positioning and Preparation (Fig. 23.2)
388
23 Com bat Cranial Operations
389
IV Em ergency Operations in Com bat
390
23 Com bat Cranial Operations
391
IV Em ergency Operations in Com bat
b C
392
23 Com bat Cranial Operations
393
IV Em ergency Operations in Com bat
394
23 Com bat Cranial Operations
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
Sedat ion , p ain con t rol m easu res, an d ven t ricu lar drain age to
Closing 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 Medication
h em ostasis. An t iepilept ic prophylaxis is con t in u ed for 7 days.
An ICP m onitoring device is placed prior to closure. Ventricu- Prophylact ic an t ibiot ics are con t in ued for 4872 h ours.
lostom 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 Radiographic Imaging
w ith absorbable 0 or 2-0 sut ure. Th e scalp t ypically is closed Repeat CT im aging is t ypically obt ain ed postoperat ively, th e
w ith staples. 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 ag-
Low er Extremity Incision ing suite.
After cop iou s an t ibiot ic irrigat ion , th e fascia lat a h ar vest ing We h ave becom e m uch m ore aggressive w ith angiography
site is closed w ith a deep layer of 2-0 absorbable su t u re, fol- due to in creased in ciden ce of vasospasm , pseudoan eur ysm ,
low ed by skin staples. 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
Postoperative Management for occu lt inju r y: p en et rat ing inju r y n ear th e circle of Wil-
lis, Sylvian ssure, or posterior fossa; kn ow n vasospasm ; an d
blast-associated blun t t raum a.
Monitoring 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.
396
23 Com bat Cranial Operations
Special Considerations 3. Fang R, Dorlac GR, Allan PF, Dorlac WC. In tercon t in en t al aero-
m 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 .
We h ave n oted postoperat ive ch allenges w ith vasospasm , Neurosurg Focus 2010;28(5):E11
p seu doan eu r ysm form at ion , ver y low pressu re hydroceph a- 4. Kim KA, Wang MY, McNat t SA, Pin sky G, Liu CY, Gian n ot t a SL,
lu s, an d m ult idrug resist an t organ ism ven t ricu lit is. Apu zzo ML. Vector an alysis correlat ing bu llet t rajector y to
Additionally, reconstructive procedures for the m ore m assive ou tcom e after civilian th rough -an d-th rough gun sh ot w oun d to
injuries require a m ultidisciplinary e ort involving neurosurgery, th e h ead: u sing im aging cu es to p redict fat al ou tcom e. Neu rosu r-
plastic surgery, oral and m axillofacial surgery, otolaryngology ger y 2005;57(4):737747; d iscu ssion 737747
head and neck surgery, ophthalm ology, prosthodontics, and 5. Arm on da RA, Bell RS, Vo AH, et al. War t im e t rau m at ic cerebral
im aging/three-dim ensional fabrication experts. 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 age-
m en t of in fect ion s associated w ith com bat-related cen t ral ner-
References vous 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 plica-
1. Bell RS, Mossop CM, Dirks MS, et al. Early decom pressive cra- t ion s follow ing w ar t im e decom pressive cran iectom y. Neurosu rg
n iectom y for severe pen et rat ing an d closed h ead injur y du ring Focus 2010;28(5):E3
w ar t im e. Neu rosu rg Focu s 2010;28(5):E1 8. Hou sem an ND, Taylor GI, Pan W R. Th e angiosom es of th e
2. Ragel BT, Klim o P Jr, Mar t in JE, Te RJ, Bakken HE, Arm on da RA. h ead an d n eck: an atom ic st udy an d clin ical applicat ion s. Plast
War t im e d ecom p ressive cran iectom y: tech n iqu e an d lesson s Reconst r Surg 2000;105(7):22872313
learn ed. Neurosu rg Focu s 2010;28(5):E2
397
24 Combat-Associated Penetrating
Spine Injury
Corey M. Mossop, Christopher J. Neal, Michael K. Rosner, and Paul Klim o Jr.
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Com bat-Associated Penetrating Spine Injury
399
IV Em ergency Operations in Com bat
a b
400
24 Com bat-Associated Penetrating Spine Injury
d 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.
a b
401
IV Em ergency Operations in Com bat
402
24 Com bat-Associated Penetrating Spine Injury
syn th et ic du ral su bst it u tes, an d du ral sealan t s for all cases. Ar terial lin e to m ain t ain m ean ar terial pressure . 85 m m Hg
Also, m aterials for th ecal sac ligat ion if in dicated (see Fig. 24.1 for th e en t iret y of th e case
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 diver-
sion in lu m bosacral decom p ression s Neuromonitoring
Recom m en ded if available for m on itoring of som atosen sor y
Anesthesia Issues evoked p oten t ials (SSEPs) an d elect rom yograp hy (EMG)
403
IV Em ergency Operations in Com bat
Operative Procedure
Positioning (Fig. 24.5a, b)
404
24 Com bat-Associated Penetrating Spine Injury
405
IV Em ergency Operations in Com bat
406
24 Com bat-Associated Penetrating Spine Injury
407
IV Em ergency Operations in Com bat
408
24 Com bat-Associated Penetrating Spine Injury
409
IV Em ergency Operations in Com bat
Instrumentation/ Fusion 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.
(See Chapters 14 and 15)
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. 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
Closing 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 ro-
Su ct ion can ister/Jackson -Prat t drain (s) if n eeded (avoid w h en logical fun ct ion in penet rat ing spin al injur y? A review of th e
dural repair perform ed).
m ilitar y an d civilian literat ure an d t reat m en t recom m en dat ion s
Close dorsal fascia in a w atert igh t m an n er w ith in terrupted for m ilit ar y neu rosurgeon s. Neurosurg Focus 2010;28(5):E4
0-0 braided absorbable sut ures. 4. DeMu th W E Jr. Bu llet velocit y as ap p lied to m ilit ar y ri e w ou n d-
Close subcu tan eou s t issu e w ith inverted, in terrupted ing capacit y. J Traum a 1969;9:2738
2-0 braided absorbable sut ures. 5. Blair JA, Pat zkow ski JC, Sch oen feld AJ, et al. Are spin e inju ries
Close skin w ith either staples or running 2-0/3-0 nylon sut ure. 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
Postoperative Management un it or oth er m on itored set t ing. Neurosurger y 2002;50(3 Suppl):
S5157
Adm ission to a m on itored set t ing w ith con t in u ed blood p res- 8. Blood pressu re m an agem en t after acute spin al cord injur y.
su re goals as sp eci ed for u p to 7 days after th e in it ial inju r 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
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
m an agem en t of pat ien t s w ith pen et rat ing spin al cord inju r y:
or if any con cern exists for CSF leakage.
outcom e an alysis. Neurosurger y 1996;39:11411149
Obt ain early p ostop erat ive im aging if in st ru m en t at ion p er-
10. Lin SS, Vaccaro AR, Reisch S, et al. Low -velocit y gu n sh ot w ou n ds
form ed. to th e spin e w ith an associated t ran speriton eal injur y. J Spin al
Main tain ap prop riate an t im icrobial coverage w ith in t rave- Disord 1995;8:136144
n ou s an t ibiot ics for 7 days if visceral injur y is con rm ed. 11. Qu igley KJ, Place HM. Th e role of debridem en t an d an t ibiot ics in
In th e case of a low th oracic or lu m bar du ral rep air, m ain t ain gun sh ot w oun ds to th e spin e. J Trau m a 2006;60:814820
th e pat ien t at for 4872 h ours postoperat ively. For cer vical 12. Aarabi B, Alibaii E, Taghipur M, et al. Com parative study of func-
or proxim al th oracic dural repairs, m ain tain th e pat ien t w ith tional recovery for surgically explored and conservatively m anaged
th e h ead of bed at 90 degrees for 4872 h ours in th e postop - spinal cord m issile injuries. Neurosurgery 1996;39:11331140
erat ive set t ing. In th e case of m id-th oracic du ral rep airs, th e 13. Du z B, Can sever T, Secer HI, et al. Evalu at ion of sp in al m issile
posit ion ing of th e pat ien t postoperat ively is at th e discret ion injuries w ith respect to bullet t rajector y, su rgical in dicat ion s
of th e operat ing surgeon . an d t im ing of su rgical in ter ven t ion : a n ew gu idelin e. Spin e
Mech an ical deep vein th rom bosis (DVT) p rop hylaxis sh ou ld 2008;33:E746E753
14. Ham m ou d MA, Haddad FS, Mou farrij NA. Sp in al cord m issile
be in it iated u pon adm ission an d con t in ued th rough out sur-
injuries during the Leban ese civil w ar. Surg Neu rol 1995;43:
ger y an d p ostop erat ively. W h en it is determ in ed to be ap p ro-
432442
priate, in st it ute ph arm acologic DVT prophylaxis.
15. Velm ah os GC, Degian n is E, Har t K, et al. Ch anging p ro les in sp i-
Recom m en d postoperat ive scoliosis sur vey in th e sit t ing or n al cord injuries an d risk factors in uen cing recover y after pen -
stan ding posit ion (depen ding on th e pat ien ts clin ical st at u s) et rat ing injuries. J Traum a 1995;38:334337
to p rovide baselin e kn ow ledge regarding region al an d global 16. Waters RL, Sie IH. Sp in al cord inju ries from gu n sh ot w ou n ds to
spin al balan ce. Th is sh ou ld be repeated at regu lar in ter vals (as th e sp in e. Clin Or th op Relat Res 2003;408:120125
determ in ed by th e operat ing surgeon ) to m on itor for any de- 17. Possley DR, Blair JA, Sch oen feld AJ, et al. Com plicat ion s associ-
form it y p rogression in th e p ost-su rgical set t ing, part icularly ated w ith m ilit ar y sp in e inju ries. Spin e J 2012;12:756761
410
V 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 cra-
n 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 res-
torat 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 evi-
den ce of sign i can t decubit us ulcers in proxim it y to th e cra-
n ial defect or in cision . Fig. 25.1 Preoperative computed tomography study indicating a large
In creasing leth argy or n ew focal de cit is p resen t on exam i- left cranial defect. The brain is largely ush with the bone edges.
n at ion an d n ot oth er w ise at t ribu ted to m et abolic or st ru c-
t 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 o- Medication
sp h eric pressu re on th e brain .
Th e auth or prefers van com ycin an d gen t am icin for an t ibi-
Th ere m ay be sign i can t brain depression at th e defect an d
ot ic prophylaxis, provided th e pat ien t does n ot h ave ren al
com puted tom ography (CT) m ay reveal brain sh ift ing to th e
failu re or oth er con t rain dicat ion s. Often pat ien t s h ave been
con t ralateral side. Eviden ce suggest s th at earlier restorat ion
h ospit alized for sign i can t p eriods of t im e an d th ere is a pos-
of cran ial in tegrit y can im prove n eurologic de cits in addi-
sibilit y for th e skin to be colon ized w ith m eth icillin -resist an t
t ion to h elping th ose pat ien t s w ho exh ibit early sign s of com -
Staphylococcus aureus.
m u n icat ing hydrocep h alu s.5,7,8
Diphenylhydantoin is adm inistered at 15 m g/kg in nonallergic
patients w ho are not on standing antiepileptic m edication. Leve-
tiracetam can be used alternatively at a 1000-m g loading dose.
Preprocedure Considerations
Operative Field Preparation
Radiographic Imaging 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 idin e application .
relat ion sh ip w ith th e defect prior to perform ing recon st ruc- Th e in cision s are m arked an d in lt rated w ith 1% lidocain e
t ion (Fig. 25.1). w ith epin eph rin e 1:100,000.
412
25 Replacem ent of Cranial Bone Flap
Operative Procedure
Positioning and Preparation (Fig. 25.2a, b)
413
V Reconstructive Surgery
414
25 Replacem ent of Cranial Bone Flap
415
V Reconstructive Surgery
416
25 Replacem ent of Cranial Bone Flap
417
V Reconstructive Surgery
(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
25 Replacem ent of Cranial Bone Flap
419
V Reconstructive Surgery
420
25 Replacem ent of Cranial Bone Flap
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 occurs over tim e. Though this tim e period is not certain, it is
set t ing overn igh t in th e p ostoperat ive period to obser ve for likely to occur som etim e after 3 m onths of storage.14 Su bcu tan e-
seizu re act ivit y or eviden ce of in t racran ial bleeding. ously stored bone grafts have been noted to h ave histological ev-
idence 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.
Medication 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
Th e prophylact ic an t iepilept ic agen t is cont in u ed for a total of m ay also be m it igated by earlier bon e ap replacem en t.6
7 days provided th ere are n o in terim seizures. W h ile th e focus of th is ch apter does n ot in clude in dicat ion s
It is opt ion al to give t w o to th ree doses of prop hylact ic an t ibi- 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
ot ics in th e im m ediate postop erat ive p eriod . h ow to m an age an exist ing sh u n t p rior to bon e ap rep lace-
m 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 de-
velop post t rau m at ic n orm al p ressu re hydroceph alu s w ith n o
Radiographic Imaging prot rusion of brain th rough th e defect an d pat ien ts are ready
A p ostoperat ive CT scan m ay be obtain ed to evalu ate for for bon e ap restorat ion , th e lat ter is perform ed rst w ith care-
ext ra-axial collect ion s or oth er h em orrh age (Fig. 25.10). fu 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
Further Management collect ion in th is space. In pat ien t s w h o h ave sh un t s prior to
Drain s are rem oved in 1 or 2 days. cran ioplast y, th e clin ical con dit ion m ay allow for tem porar y
Skin su t u res or stap les are rem oved after 2 w eeks. 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 -
Special Considerations 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 ad-
Explan ted craniotom y aps can also be stored in sub-zero freez- ju st drain age p ressure to a h igh er set t ing prior to cran ioplast y.
ers u n der aseptic con dit ion s.12,13 Th e available literat u re sug- After w ard, progressive reduct ion s in th e pressure set t ings can
gests th at th e rate of in fection or com plicat ion s do n ot di er h elp p reven t su bdu ral collect ion s.1 Th ese p rogram m able valves
bet w een grafts stored by either m ethod.9,12,13 The disadvan tage m ay also be u sefu l in sh orten ing th e t im e fram e bet w een cra-
of subcutan eously stored bone grafts is that bone rem odeling n ioplast y an d delayed de n ovo sh u n t ing.
422
25 Replacem ent of Cranial Bone Flap
423
26 Techniques of Alloplastic Cranioplasty
Erin N. Kiehna and John A. Jane Jr.
424
26 Techniques of Alloplastic Cranioplast y
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 .
425
V Reconstructive Surgery
Bony defect
If n o sw elling th en
im m ediate
reconst ru ct ion
Bon e flap
fragm en ted or
con tam in ated
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)
427
V Reconstructive Surgery
Fig. 26.5 For bifrontal cranioplasties, the patient is For bilateral hem icraniectom ies it m ay be necessary to do one
positioned supine w ith the head in a neutral side at a tim e, reprepping and redraping in bet ween.
position on either a gel donut or three -point
xation.
428
26 Techniques of Alloplastic Cranioplast y
The incision is made w ith a no. 10 blade from the sagittal suture
dow n to the zygoma bilaterally.
429
V Reconstructive Surgery
430
26 Techniques of Alloplastic Cranioplast y
431
V Reconstructive Surgery
432
26 Techniques of Alloplastic Cranioplast y
433
V Reconstructive Surgery
434
26 Techniques of Alloplastic Cranioplast y
Fig. 26.10 A combination of monopolar cautery and curettes may If there is protrusion of the brain through the defect during
be used to re ect all of the soft tissue o of the bony surgery it can be controlled with head of bed elevation,
edges to allow for a tight t. m annitol, and/or m ild hyperventilation.
If it persists, one m ay pass a brain needle into the
Any lacerations of the dura should be closed ventricles using anatom ic landmarks or ultrasound
primarily. If there is a large dural defect, one may use guidance to allow for enough decompression to perform
pericranium or a dural substitute to close it (depicted the cranioplast y.
in the unilateral approach).
435
V Reconstructive Surgery
436
26 Techniques of Alloplastic Cranioplast y
437
V Reconstructive Surgery
438
26 Techniques of Alloplastic Cranioplast y
Fig. 26.11d Titanium m esh High strength and stabilit y Radiopaque with artifact on imaging
Easily contoured More time spent contouring and
Easily xated plating in the surgical eld.
Fig. 26.11f PMMA Radiolucent Long surgical tim e for set up and
(polym ethylm ethacrylate) May be contoured in the eld contouring, hypertherm ic reaction
No advance planning needed while solidifying requiring irrigation
May require mesh for strength,
stabilit y, and contouring in larger
areas
439
V Reconstructive Surgery
440
26 Techniques of Alloplastic Cranioplast y
441
V Reconstructive Surgery
442
26 Techniques of Alloplastic Cranioplast y
resh aped w ith h ot salin e at th e t im e of su rger y,10 an d prem ade 3. Ch im H, Sch an t z JT. New fron t iers in calvarial recon st r u ct ion :
an atom ic con tou rs, sh eet s, an d blocks are available at a d e- in tegrat ing com puter-assisted design an d t issue engin eering in
creased cost com pared to custom im plan t s.11 cran ioplast y. Plast Recon st r Surg 2005;116(6):17261741
Cu stom t itan iu m im plan t s o er a good ch oice for cran ioplast y 4. Moreira- Gon zalez A, Jackson IT, Miyaw aki T, et al. Clin ical ou t-
based on th eir st rength , biocom pat ibilit y, h an dling ch aracter- com e in cran ioplast y: crit ical review in long-term follow -u p.
J Cran iofac Su rg 2003;14(2):144153
istics, an d su it abilit y for postoperat ive im aging tech n iques.12
5. Lara WC, Sch w eit zer J, Lew is RP, et al. Tech n ical con siderat ion s in
How ever, th ey are m ore di cu lt to sh ap e in th e eld an d m ay
th e use of polym ethylm eth acr ylate in cranioplast y. J Long Term
requ ire sp ecial xat ion system s. In addit ion , th e t it an ium art i-
E Med Im plan t s 1998;8(1):4353
fact m ay be su bopt im al for th e follow -u p of m en ingiom a an d 6. Verheggen R, Merten HA. Correction of skull defects using hydroxy-
oth er t u m ors. apatite cem ent (HAC)evidence derived from anim al experim ents
An other con siderat ion after recon st ru ct ing th e calvarial de- and clinical experience. Acta Neurochir 2001;143(9):919926
fect is soft t issu e recon st ru ct ion over th e calvariu m /allop last ic 7. Tadros M, Cost an t in o PD. Advan ces in cran iop last y: a sim p li ed
cran ioplast y. Often w h en a decom pressive cran iectom y h as algorith m to guide cran ial recon st ruct ion of acqu ired defect s.
been perform ed, an d th e tem poralis m u scle u n dergoes w ast- Facial Plast Su rg 2008;24(1):135145
ing an d is n ever restored to it s previou s bulk, cau sing tem po- 8. Hanasono MM, Goel N, DeMonte F. Calvarial reconstruction w ith
ral h allow ing. Both porou s p olyethylen e pterion al im p lan ts polyetheretherketone im plants. Ann Plast Surg 2009;62(6):653655
(Fig. 26.14) an d/or hydroxyap at ite cem en t m ay be u sed to aug- 9. Lin AY, Kin sella CR, Rot tgers SA, et al. Cu stom p orou s p olyethyl-
m en t th e tem poralis an d restore aesth et ics.7 en 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
References 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
1. Goodrich, JT. Cranioplast y. In: Albright AL, ed. Principles and Prac- 1992;3(2):101107
tice of Pediatric Neurosurgery. New York: Thiem e; 2008:864877 12. Cabraja M, Klein M, Leh m an n TN. Long-term resu lt s follow ing
2. San an A, Hain es SJ. Repairing h oles in th e h ead: a h istor y of t it an ium cran ioplast y of large sku ll defect s. Neurosurg Focus
cran ioplast y. Neu rosurger y 1997;40(3):588603 2009;26(6):E10
443
27 Surgery for Frontal Sinus Injuries
Abilash Haridas and Peter J. Taub
444
27 Surgery for Front al Sinus Injuries
Fig. 27.1 CT demonstrating an isolated fracture of the anterior table of Fig. 27.2 CT demonstrating an isolated fracture (arrow) of the posterior
the frontal sinus. table of the frontal sinus. Note the presence of pneumocephalus.
445
V Reconstructive Surgery
Operative Procedure
Bicoronal Incision (Fig. 27.4)
446
27 Surgery for Front al Sinus Injuries
(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
448
27 Surgery for Front al Sinus Injuries
449
V Reconstructive Surgery
450
27 Surgery for Front al Sinus Injuries
451
V Reconstructive Surgery
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.
452
27 Surgery for Front al Sinus Injuries
a b
(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
454
27 Surgery for Front al Sinus Injuries
455
V Reconstructive Surgery
456
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
458
28 Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury
a b
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
460
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. p ar t icu lar h azard in ch ildren due to th e poten t ial for rapid
If th e ven t ricle is n ot en tered w ith th e rst p ass, a sligh tly blood loss in th e set t ing of an already sm all tot al blood vol-
m ore m ed ial t rajector y m ay be at tem pted . u m e. If th e h em atom a m ust be evacuated, prepare for blood
No m ore th an th ree p asses sh ou ld be at tem pted . loss from th e sin us an d m on itor for possible air em boli. Plan
TBI-related brain sw elling in ch ildren m ay resu lt in com - a skin an d bon e ap th at allow s for ad equ ate exp osu re an d
p ression of th e lateral ven t ricle; h ow ever, w ith experien ce, con t rol of th e sin us both proxim ally an d distally. If a sin us
th e ven t ricle st ill can be can n ulated in m ost cases. If n euro- tear is iden t i ed, th is m ust be con t rolled w ith im m ediate
n avigat ion is available, in t rodu ct ion of th e n avigat ion p robe p ressure over th e sin us to stem bleeding, sur veillan ce for
th rough th e lu m en of th e ven t ricu lar cath eter m ay assist air em boli, an d repair of th e sin u s u sing a pericran ial patch
accu rate p lacem en t in di cu lt cases. graft . If bleeding is too vigorou s to allow ad equ ate visu aliza-
An t ibiot ic-im pregn ated cath eters an d periprocedural an - t ion , m ain t ain pressure over th e tear an d tem porarily con t rol
t ibiot ics are opt ion s th at m ay reduce th e in ciden ce of th e sin us proxim ally an d distally to en able sut uring of th e
ven t ricu lostom y-related in fect ion s. 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
Surgery for Depressed Fractures
th e lesion . Th e prin ciples of depressed fract ure m an agem en t in ch ildren
Typically, for a un ilateral lesion , an ipsilateral quest ion m ark are sim ilar to th ose of ad u lt s, w ith a few except ion s.
or T-sh aped in cision is perform ed to en able w ide access to If th e depressed fract u re is closed, th e skin in cision is p lan n ed
th e h em isph ere. based on th e locat ion of th e depressed fragm en t , blood sup -
In gen eral, aim for as large a ap as p ossible. Th e base of th e p ly to th e ap, an d cosm esis. If th e fract ure is com pou n d,
skin ap sh ou ld be broad en ough to en su re adequ ate perfu- th e w oun d m ust be debrided an d exten ded in a cu r vilin ear,
sion to th e skin . S-sh ap e to exp ose th e exten t of th e fract u re.
W h en th e ap is t urn ed, w rap an d t u ck an an t ibiot ic-soaked Bon e is m u ch th in n er an d softer in ch ildren . Often a ping-
sw ab or cot ton sp onge ben eath th e ap to preven t th e cre- p ong t ype fract ure can be elevated by drilling a bu r h ole to
at ion of an acu te angle th at m igh t com p rom ise perfu sion th e side of th e fract ure an d by posit ion ing a sligh tly angled
to th e ap. Th is m ay be a par t icular problem in ver y you ng in st rum en t (e.g., a n o. 3 Pen eld or sm all periosteal elevator)
ch ildren . In term it ten tly m oisten th e sponge during th e th rough th e bur h ole, elevat ing th e fract ure from in side.
p roced ure. If th e du ra is torn , a bu r h ole sh ou ld be placed at th e m argin
Dissect th e ap in a su bgaleal p lan e to p rep are a free bon e of th e depressed fract ureover in t act dura. Th en th e cran i-
ap. Preser ve th e p ericran iu m as th is can be u sed later for a ectom y, or cran iotom y, can be perform ed to u n cover th e area
dural graft if n eeded. of dural violat ion . Th e dural tear is sut ured, an d bon e frag-
Th e exten t of th e bony open ing is plan n ed according to th e m en t s, if clean , m ay be laid over th e defect .
u n derlying lesion . If th ere is gen eralized sw elling, th e bon e Bony defect s in ch ild ren u su ally h eal ver y w ell w ith n ew
sh ou ld be rem oved dow n to th e tem p oral base to m axim ize bon e grow th , as long as th e du ra is in t act . Larger lesion s m ay
th e space ach ieved at th e level of th e ten torial hiat us. require later cran ioplast y if adequate rem odeling does n ot
If du ral op en ing is n ecessar y to evacu ate a h em atom a, a cru - occur an d th e resu lt is a sign i can t cosm et ic an d/or fun c-
ciate in cision is perform ed over th e h em isph ere. Any su bdu- t ion al defect . Th e u se of autologous bon e is opt im al. Th e
ral h em atom a th en m ay be evacu ated. best bon e is split calvarial bon e, preferably t aken from th e
If evacu at ion of a con t u sion is p lan n ed, carefu l preopera- correspon ding locat ion on th e opposite side. Th e h ar vested
t ive plan n ing or n euron avigat ion is required to opt im ize th e bon e can be split th rough th e diploic space, creat ing t w o
locat ion of th e cort icectom y. Often a subdu ral h em atom a is p ieces: on e for th e defect an d th e oth er to be rep laced at th e
associated w ith a bu rst lobe in w h ich th e con t u sion can d on or site. In you ng ch ildren , th is m ay n ot be possible. Rib
be iden t i ed at th e surface. A discrete h em atom a can be graft or cran ioplast ic m aterialresorbable or n on resorbable,
evacu ated aggressively. A con t u sion m ixed w ith brain t issu e p refabricated or n ot (i.e., m ethylm eth acr ylate)m ay also
sh ou ld be h an dled w ith greater cau t ion , d ep en ding on sev- be con sidered.
eral factors, in clu ding th e eloqu en ce of th e involved brain an d Du ral d efects m u st alw ays be rep aired to avoid th e p oten t ial
th e degree of brain sw elling. Th e con ser vat ive approach of com plicat ion s of a CSF leak an d/or a grow ing skull fract ure.
allow ing th e con t u sion /h em atom a to decom p ress it self m ay Devit alized skin m u st be d ebr id ed an d t h e w ou n d t h orough -
be all th at is required. ly ir r igated . If t h e skin can n ot be closed p rim ar ily, t h e h elp
If th e brain is sw ollen , th e du ra sh ou ld be exp an ded w ith a of a p last ic su rgeon m ay be valu able to p lan a rot ated skin
dural graft h ar vested from local pericran ium . Use n on absorb - ap .
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 ici-
Decompressive Craniectomy
p ated postop erat ive risk for ongoing in creased ICP. If th e bon e Several di eren t ap p roach es h ave been d escribed for decom -
ap is left ou t , it sh ou ld be m an aged as below for decom pres- p ressive cran iectom y (DC). Th e follow ing re ects a com bin a-
sive cran iectom y. t 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 of th e brain . W h en doing th is, t ake care to preser ve cort ical
u n ilateral or bilateral app roach as approp riate, m ake th e cra- vein s, esp ecially bridging vein s leading to th e sagit tal sin u s.
n iectom y as large as possible, an d con t rol th e brain sw elling Th e h ar vested pericran ial graft is used to expan d th e dura.
before open ing th e dura. Regardless of approach , it is of ut m ost im port an ce th at th e
Th e ch oice of a bifron t al or h em icran iectom y depen ds both dura n ot be open ed abruptly if ten se to th e tou ch . Oth er w ise,
on person al preferen ce an d th e n at ure of th e injur y. Pre- m assive brain sw elling m ay p rodu ce rap id , u n con t rolled h er-
dom in an tly un ilateral h em isph eric injur y m ay be bet ter n iat ion of th e brain th rough th e du ral op en ing w ith resu lt an t
su ited to h em icran iectom y, w h ereas di u se inju r y or fron - com pression of super cial drain ing vein s an d progressive en -
tal con t usion s m ay be bet ter suited to bifron t al cran iectom y. gorgem en t of th e en t rapp ed brain . Alth ough , by de n it ion ,
Th ough th e speci cs of each tech n ique di er, th e prin ciples th e pat ien t is in surger y for refractor y in t racran ial hyper ten -
of decom pression are th e sam e. sion , it is n early alw ays p ossible to con t rol th e sw elling for th e
Du rap last y in creases th e com p licat ion s associated w ith cra- sh ort period of t im e it t akes to open th e du ra an d secu re th e
n iectom y; h ow ever, open ing an d expan ding th e dura leads graft in p lace. Th e su rgeon m u st w ork w ith th e an esth esiolo-
to su bst an t ially low er ICP, an d com p licat ion s are gen erally gist to m axim ize brain relaxat ion by th e t im e of du ral op en -
avoidable if don e correctly. ing. Poten t ial in ter ven t ion s in clude con t rolling blood pres-
Th e h em icran iectom y is perform ed sim ilar to th e h em isph eric su re, adm in istering m an n itol an d/or hyp erton ic salin e at th e
cran iotom y. Maxim izing th e bony open ing h elps m in im ize t im e of skin in cision , elevat ing th e h ead of th e bed, an d low -
th e degree to w h ich th e sw ollen brain push es again st th e ering th e ar terial CO2 (w h ile in creasing th e FiO2 ). Th e pericra-
bony lim it s. Pressure at th e bony edges m ay fu rther injure n ial graft m u st be p rep ared p rior to th e du ral open ing. W h en
th e sw ollen brain an d con st rict ven ou s out ow of th at seg- pressu re m an agem en t h as been opt im ized, th e du ra sh ould
m en t . Th e tem poral bon e is rem oved as low as possible d ow n be open ed quickly an d th e graft in corporated w ith sut ure.
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 Repair of Grow ing Skull Fractures (Lep-
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 .
tomeningeal Cyst)
Th e bifron tal cran iectom y is perform ed th rough a bicoron al Th ough n ot requiring em ergen t in ter ven t ion , grow ing skull
skin in cision , posit ion ed beh in d th e h airlin e. Th e scalp is fract u res do rep resen t a late con sequ en ce of t rau m a an d, as
re ected an teriorly, preser ving th e pericran ium for a dural su ch , deser ve m en t ion h ere.
graft . Keyh ole an d p aram edian bu r h oles lateral to th e sagit- Opt im al t reat m en t of a grow ing sku ll fract u re requ ires u n -
tal sin us are used to create a large bifron tal, single-piece bon e derst an ding of th e path ology (see In dicat ion s).
ap exten ding posteriorly to th e coron al su t u re. Pay part icu - Th e du ra is alw ays torn ; th is tear w iden s w ith t im e as th e
lar at ten t ion w h en separat ing th e dura from th e bon e, esp e- bon e edges separate. Usually th e dural edges ret ract w ell be-
cially over th e m idlin e, to avoid injur y to th e sagit t al sinu s yon d th e bon e edge so th at th e du ral defect is larger th an th e
an d it s bridging vein s. Th e du ra is in cised in a U-sh ap e from bony defect .
lateral to m edial. Th e m idlin e sagit tal sin us is t ied o at th e Th e a ected pat ien t s are young, so th ere m ust be adequ ate
fron t al base an d th e falx is sect ion ed from an terior to p os- preparat ion for blood loss. Do n ot un derest im ate th e poten -
terior along th e skull base to allow for m a xim al expan sion t ial for blood loss in th ese operat ion s.
462
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)
463
VI Special Considerations in Pediatric Em ergency Neurosurgery
464
28 Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury
465
VI Special Considerations in Pediatric Em ergency Neurosurgery
466
28 Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury
467
VI Special Considerations in Pediatric Em ergency Neurosurgery
468
28 Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury
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 radia-
t 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 life-
saving. Th ere sh ou ld alw ays be a clear in dicat ion for rep eat Fig. 28.8 Axial CT im age demonstrating repair of the dural tear and
im aging, su ch as clin ical deteriorat ion . W h en th e in it ial scan 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
Indications
Pediat ric cer vical spin e inju ries can be divided in to inju ries th at
Preoperative Considerations
a ect th e u p p er cer vical sp in e (occip u tC2) an d th ose th at af-
fect th e su baxial sp in e (C3C7). Below is a list of th e inju ries Field and Emergency Room
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
Management
adu lt spin e, an d th u s, th e sp in e inju ries are sim ilar to th ose Field m an agem en t follow s th e basic prin ciples of th e Advan ced
seen in adu lt s. Th ere is a m yriad of congen it al cer vical an om a- Trau m a Life Suppor t (ATLS). Air w ay, breath ing, an d circu la-
lies th at m ay cause or place a ch ild at risk for spin al cord inju r y. t ion (ABCs) m ust be addressed. Because of a relat ively larger
470
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 fract u re. Fu rth erm ore, a persisten t n eu rocen t ral syn ch on drosis
p laced sup in e on a st an dard h orizon t al backboard.6 A recessed of C2 can be m isdiagn osed as a h angm ans fract ure. Th e atlan -
h ead backboard, or elevat ion of th e t ru n k by ap proxim ately toden tal in ter val (ADI) in th e ch ild spin e is greater th an in th e
25 m m , m ust be con sidered prim arily in ch ildren aged less adu lt , bu t sh ou ld n ot exceed 5 m m ; th is lim it is becau se of th e
th an 8 years of age w ith suspected n eck injur y (Fig. 29.1a, b).6,7 th icker ch ild cart ilage th at does n ot appear in radiograph s. Any
On ce th e ch ild arrives in th e em ergen cy room , th e ABCs m u st p ersist ing doubt w ith st an dard radiograph s sh ould be furth er
be repeated, and disabilit y an d exposure sh ou ld be added. In evalu ated w ith CT an d MR.
p at ien ts presen t ing w ith hypoten sion in th e presen ce of bra- Preoperat ive im aging (Fig. 29.2a c).
dycardia, n eu rogen ic sh ock m u st be di eren t iated from hypo-
volem 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 scita-
t ion . Neurologic im pairm en t sh ould focus th e em ergen cy team
Medication
on a possible h ead or spin e injur y or both . 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
Radiographic Imaging supporting the use of neuroprotective interventions for the treat-
m ent of spinal cord injury in children, including hypotherm ia and
After a careful n eurologic evaluat ion , cer vical spin al im aging steroids.7 Furtherm ore, all studies that have evaluated steroids in
sh ou ld be obt ain ed . Plain radiograph s, com p u ted tom ograp hy spinal cord injury have speci cally targeted the adult population.
(CT), an d m agn et ic reson an ce im aging (MRI) m ay be con sid-
ered. 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
Surgical Timing
Som e varian t s of th e n orm al an atom y or congen ital an om alies Th e opt im al t im ing for surgical decom pression an d xat ion is
m ay be m isin terp reted as t rau m at ic inju r y.9,10 An an terolisth e- also con t roversial. A recen t system at ic review st ates th at early
sis of C2C3 is a ver y com m on n ding an d cou ld be m isdiag- su rgical d ecom p ression (i.e., in less th an 72 h ou rs) m ay im p rove
n osed as a ligam en tou s inju r y w h en , m ost of th e t im e, it is a n eu rologic ou tcom esespecially in th e set t ing of in com plete
p hysiologic pseu dosublu xat ion cau sed by th e hyper exibil- SCI an d w h en p erform ed in less th an 24 h ou rs.11 W h ile th is
it y of th e im m at ure cer vical spin e. A syn ch on drosis bet w een review suggest s early decom pression m ay ben e t th e gen eral
th e odon toid an d th e body of C2w h ich m ay persist un t il a SCI p opu lat ion , n eu rologic recover y seem s to be bet ter in th e
ch ild is 12 years of agem ay be m isin terpreted as an odon toid 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
c the widened intervals bet ween C0C1 and C1C2.
Operative Management that alterations in anesthetic depth can a ect the abilit y to ob -
tain useful signals; the use of bispectral index (BIS) m onitoring
Su ccessfu l in t raop erat ive m an agem en t of th e ch ild w ith a cer- can m inim ize this e ect. It is im perative that the anesthesiologist
vical spin e inju r y dep en d s on a team ap p roach w ith th e sp in al avoid hypotension and hypovolem ia during surgery.
su rgeon , pediat ric t rau m a su rgeon , an esth esiologist , an d su rgi-
cal an d radiology tech n ician s.
Positioning
Anterior Cervical Approach
Anesthesia Su pin e p osit ion
In cervical spin e injuries w ith gross in stabilit y, the neck m ust be Pad or tow el roll bet w een scap u las for sligh t n eck exten sion
m ain tained in a n eutral position throughout the procedure; in - St abilize h ead w ith a ch in or foreh ead st rap
tubation m ay be challenging. In-line beroptic intubation should Neck in n eu t ral p osit ion or rot ated to con t ralateral su rgical
be considered, followed by induction of general anesthesia. Care ap p roach site
to prevent both sublu xation an d distraction is im perative w h en Pull both arm s togeth er caudally an d t ape th em on th e sh oul-
intubating, turning, or transferring. Preoperatively, antibiotics ders for bet ter uoroscopic view of th e cer vical spin e
are adm in istered at least 30 m inutes before the procedure; the Use in t raoperat ive u oroscopy to m ark th e correct level on
authors prefer van com ycin an d cefazolin. If neurom onitoring th e skin
(e.g., m otor-evoked potentials [MEPs] and som atosensory-evoked Som e su rgeon s advocate a left-sided ap proach becau se of
potentials [SSEPs]) is used, the anesthesia team should be alert th e low er rates of recurren t lar yngeal n er ve inju ries 12
472
29 Special Considerations in Pediatric Cervical Spine Injury
Longit u din al in cision p rovides a greater exp osu re (u su ally Occipitocervical Arthrodesis
w h en th ree or m ore levels are exposed) w h ereas a t ran s-
verse in cision h eals w ith bet ter cosm esis Indications
Care m ust be taken not to dist ract the injured spine w ith either Atlan to-occipit al dislocat ion s, atlas fract u res, congen it al occip i-
m anipulat ion or inadvertent elevat ion of the head of bed w hen tocer vical an om alies.
the pat ient is in Mayf eld f xat ion.
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)
474
29 Special Considerations in Pediatric Cervical Spine Injury
475
VI Special Considerations in Pediatric Em ergency Neurosurgery
Fig. 29.5 Extend the dissection deep w ithin the Cerebrospinal uid leak is not an unusual nding while dissecting. It is
relatively avascular intermuscular septum very di cult to repair the dural tear prim arily. Use gelatin sponge or
(aka ligamentum nuchae). The suboccipital onlay dural graft substitutes. Lam inectomy is not recomm ended for
regionas w ell as the entire posterior repair.
arch of C1, C2, and other desired levelsis While dissecting bet ween C1 and C2 laterally, there is often a robust
exposed subperiosteally. 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.
476
29 Special Considerations in Pediatric Cervical Spine Injury
a b
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
478
29 Special Considerations in Pediatric Cervical Spine Injury
Other Options for Occipitocervical 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
Fixation 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
Technique : Occipital Plate t h e rst p reviou sly m arked bicor t ical h ole w it h a p ow er d rill
Th is tech n iqu e is best in skelet ally m at u re p at ien t s. After su b - an d t ap it . Rep lace t h e p late an d secu re it w it h an ap p rop ri-
p eriosteal d issect ion an d exp osu re of t h e su boccip it al bon e ate screw . Place th e ot h er screw s w it h t h e p late in p lace in or-
w ith Bovie elect rocau ter y, p lace th e p late in p osit ion an d m ark d 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
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 xat ion . Th e occip it al p late sh ou ld be fu lly covered by m u scle
p laced closer to th e in ion th an to th e foram en m agn u m so w h en closing.
479
VI Special Considerations in Pediatric Em ergency Neurosurgery
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.
480
29 Special Considerations in Pediatric Cervical Spine Injury
481
VI Special Considerations in Pediatric Em ergency Neurosurgery
Atlantoaxial Arthrodesis
Technique : Brooks and Jenkins 15 (Fig. 29.11)
Fig. 29.11 Brooks and Jenkins xation. C1-C2 sublaminar w ires are secured Postoperative rigid im mobilization is required
over bilateral interposition bone grafts to provide a measure of with a Minerva cast or halo brace.
stability. A standard midline longitudinal posterior approach is Despite the appearance and the feeling of
used to expose the arch of the atlas and lamina/spinous process being very stable at placem ent, the wiring
of the axis. Tw o double 20-gauge w ires should be inserted under constructs lack the rigidit y and stabilit y of the
each side of the posterior arch of C1 and the lamina of C2. Tw o Harm s or transarticular con gurations.16
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.
482
29 Special Considerations in Pediatric Cervical Spine Injury
483
VI Special Considerations in Pediatric Em ergency Neurosurgery
484
29 Special Considerations in Pediatric Cervical Spine Injury
Fig. 29.13 Reduction of C1C2 to anatomic or near anatomic alignment must Frequently, a separate stab incision is
be achieved preoperatively and con rmed w ith radiographs. A CT of made caudal to the operative opening
the upper cervical spine is mandatory to rule out an aberrant position to allow the proper angulation of the
of the vertebral artery. Slight exion of the neck helps the exposure. drill bit.
A routine midline longitudinal posterior approach is performed to Tapping with an appropriately sized
expose the posterior elements of C1 to C3. Identi cation of the C2C3 tap is recom m ended, especially with
facet joint w ill determine the entry point: 2 to 3 mm lateral and 2 to grossly unstable spines to prevent
3 mm rostral to the inferior, medial portion of the C2C3 facet joint. distraction of the C1C2 joint space.
(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.
Once the screw is in place and reduction is achieved, the contralateral A unilateral transarticular screw,
screw is placed, keeping the same reduction. Each screw should pass married with contralateral wire
through four cortical surfaces (the entry point just above the inferior construct, is preferable where a
C2 face, each surface of the C12 joint space, and the anterior C1 suspected or known preexisting
lateral mass), making it a very strong construct. If a vertebral artery vertebral artery injury is present.
injury is suspected, continue placing the w orking screw and abort
placement on the contralateral side.
If there is no concern for an arterial injury, then proceed w ith There is no need for halo or Minerva
placement of the contralateral screw w ith the same technique. cast postoperatively. A rigid cervical
The arthrodesis is reinforced w ith a corticocancellous bone graft collar only is used.
harvested from the iliac crest and xed w ith sublaminar w ires around
the posterior elements of C1 and C2.
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)
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
487
VI Special Considerations in Pediatric Em ergency Neurosurgery
Technique : Posterior Arthrodesis w ith Lateral Mass Screw Fixation (Fig. 29.16ac)
488
29 Special Considerations in Pediatric Cervical Spine Injury
a b
Fig. 29.17a, b (a) AP and (b) lateral radiographs showing the nal occipitocervical construct.
489
VI Special Considerations in Pediatric Em ergency Neurosurgery
Special Considerations 6. Herzen berg JE, Hen singer RN, Dedrick DK, Ph illip s WA. Em er-
gen cy t ran spor t an d posit ion ing of young ch ildren w h o h ave an
injur y of th e cer vical spin e: th e st an dard backboard m ay be h az-
490
Index
491
492 Inde x
bicoron al surgical ap proach , for cerebral con t u sion s (cont inued) op erat ive procedu re
closing, 51 bolt-t ype m on itor variat ion , 107, 107f
cran iotom y, 39, 39f brain t issu e oxygen m on itor variat ion , 112
dural open ing, 40, 40f op en ing of du ra an d leptom en inges, 108, 108f
posit ion ing, 35, 35f posit ion ing, 104, 104f
skin in cision , 36, 36f skin in cision , 105, 105f
subcut an eous dissect ion , 37, 37f t w ist drill cran iostom y, 106, 106f
bifron t al cran iectom y pediat ric, 458, 459
for alloplast ic cran ioplast y postoperat ive m an agem en t
cran iectom y site preparat ion , 435, 435f furth er m an agem en t , 116
im plan t t ypes, 436f438f, 439 m edicat ion , 116
posit ion ing, 428, 428f m on itoring, 116
subcut an eous dissect ion , 430432, 430f, 431f432f radiograp h ic im aging, 116, 117f
tem poral defect repair, 440, 440f preprocedu re con siderat ion s
tem poralis m u scle dissect ion , 433434, 433f434f coagulat ion p aram eters, 101
tem poralis t ran sp osit ion , 441, 441f equ ip m en t availabilit y, 102
decom pressive, 53 m edicat ion , 102
closing, 70 op erat ive eld preparat ion , 102, 102f103f
cran iotom y, 67, 67f radiograp h ic im aging, 101
dural open ing, 68, 68f special con siderat ion s, 118
du rap last y, 69, 69f bur h ole drain age, for CSDH, 16
in cision plan n ing, 65, 65f bur h ole placem en t , 20, 20f
pediat ric, 462 closing, 25
posit ion ing, 64, 64f drain p lacem en t , 24, 24f
subcu t an eous dissect ion , 66, 66f dural op en ing, 21, 21f
blu n t vascular injuries h em atom a evacuat ion , 22f, 23
h ead. See in t racran ial blu n t TCVI posit ion ing, 19, 19f
n eck. See ext racran ial blu n t TCVI skin in cision , 19, 19f
bolt-t ype in t racran ial m on itors, placem en t of, 107, 107f burst fract u res
bon e ap replacem en t cer vical. See cer vical bu rst fract ures
closing th oracic, 239
abdom in al in cision , 422 th oracolu m bar, 266
cran ial in cision , 422
in d icat ion s for, 412 C
operat ive p rocedure C1-C2 fu sion w ith p olyaxial screw s an d rods
com pleted con st ruct , 421, 421f in dicat ion s for, 179
ap replacem en t , 419, 419f op erat ive procedu re
iden t i cat ion an d separat ion of tem poralis m u scle, C1 screw t rajector y an d p lacem en t , 193, 193f
416417, 416f417f C2 screw t rajector y an d p lacem en t , 194, 194f
posit ion ing an d prep arat ion , 413, 413f closing, 195
skin in cision , 414, 414f n al con st ru ct , 195, 195f
subcu t an eous abdom in al bon e ap ret rieval, 418, 418f posit ion ing an d su rgical site preparat ion , 191, 191f
subcu t an eous dissect ion , 415, 415f t issu e dissect ion an d exp osure, 192, 192f
tem poralis t ran sp osit ion , 420, 420f for pediat ric cer vical sp in e inju r y, 486, 486f
postoperat ive m an agem en t postoperat ive m an agem en t
m edicat ion , 422 m edicat ion , 195
m on itoring, 422 m on itoring, 195
radiograph ic im aging, 422, 422f preprocedu re con siderat ion s
preprocedu re con siderat ion s m edicat ion , 179
m edicat ion , 412 radiograp h ic im aging, 179, 180f
operat ive eld preparat ion , 412 special con siderat ion s, 195196
radiograph ic im aging, 412, 412f C1-C2 t ran sart icular screw
special con siderat ion s, 422 in dicat ion s for, 179
bon e ap storage, in abdom in al fat layer, 54, 63, 63f op erat ive procedu re
ap ret rieval after, 418, 418f closing, 190
bony debridem en t , for com bat inju ries, 391, 391f n al con st ru ct , 190, 190f
brain debridem en t , for com bat inju ries, 394, 394f posit ion ing, 186, 186f
brain decom p ression , for cerebellar in farct ion , 85, 85f screw t rajector y an d p lacem en t , 189, 189f
brain t issue oxygen ten sion m on itoring su rgical site preparat ion , 187, 187f
closu re, 116 t issu e dissect ion an d exp osure, 188, 188f
in d icat ion s for, 101, 458 for pediat ric cer vical sp in e inju r y, 484485, 484f
Inde x 493
cerebral edem a, during decom pressive cran iectom y, 71 postoperat ive m an agem en t
cerebrospin al uid (CSF) m edicat ion , 234
com bat-associated leak of, 398, 400f m on itoring, 234
pen et rat ing h ead inju ries w ith leak of, 119120, 132 radiograp h ic im aging, 234, 235f
t rau m at ic rhin orrh ea of. See t rau m at ic CSF rh in orrh ea rep air preprocedu re con siderat ion s
cerebrovascular injur y, t rau m at ic. See t raum at ic cerebrovascular m edicat ion , 215
inju r y op erat ive eld preparat ion , 215
cer vical bu rst fract ures radiograp h ic im aging, 215
closing, 212 special con siderat ion s, 234
in d icat ion s for su rger y, 197, 197t, 198f199f, 200 cervical sp in e inju r y, pediat ric. See p ediat ric cer vical spin e injur y
in it ial evaluat ion of, 200 cervical t ract ion . See closed spin al t ract ion
m ech an ism s of inju r y, 197, 198f199f Chan ce fract u re. See exion -dist ract ion fract u res
m edical m an agem en t of, 200 ch ron ic su bd ural h em atom a (CSDH)
operat ive p rocedure, 197t, 200201 bur h ole drain age operat ive procedu re
allograft placem en t , 210, 210f bur h ole placem en t , 20, 20f
an terior locking p late placem en t , 211, 211f closing, 25
corp ectom y, 209, 209f drain p lacem en t , 24, 24f
deep cer vical invest ing fascia iden t i cat ion , 205, 205f dural op en ing, 21, 21f
diskectom y, 208, 208f h em atom a evacuat ion , 22f, 23
incision an d subp lat ysm al dissect ion , 204, 204f posit ion ing, 19, 19f
om ohyoid iden t i cat ion , 204, 204f skin in cision , 19, 19f
posit ion ing, 203, 203f ch aracterist ics of, 17, 17f
prevertebral fascia iden t i cat ion , 206, 206f in dicat ion s for su rger y
self-ret ain ing ret ractor p lacem en t , 207, 207f all procedu res, 16
postoperat ive m an agem en t m in im ally invasive procedu res, 16
m edicat ion , 212 postoperat ive m an agem en t
m on itoring, 212 m edicat ion , 30
radiograph ic im aging, 212, 212f m on itoring, 29
prep rocedure con siderat ion s radiograp h ic im aging, 30, 30f, 31f
op erat ive eld preparat ion , 201 t w ist drill cran iostom y care, 29, 30f
radiograph ic im aging, 201, 202f preprocedu re con siderat ion s
special con siderat ion s, 212 m edicat ion , 1718
cer vical collar, for pediat ric cer vical sp in e injur y, 490 op erat ive eld preparat ion , 18
cer vical epidu ral spin al cord com p ression , su rgical app roach es radiograp h ic im aging, 1617, 17f, 18f, 18t
to, 291 sm all cran iotom y op erat ive p rocedu re
cer vical facet d islocat ion bur h ole placem en t , 20, 20f
an terior approach op erat ive p rocedure, 225f closing, 25
closing, 234 drain p lacem en t , 24, 24f
diskectom y, 230, 230f dural op en ing, 21, 21f
graft placem en t an d fu sion , 232, 232f h em atom a evacuat ion , 22f, 23
op en ing, 227, 227f posit ion ing, 19, 19f
plat ing, 233, 233f skin in cision , 19, 19f
posit ion ing, 226, 226f special con siderat ion s, 31
redu ct ion , 231, 231f t w ist drill cran iostom y operat ive procedu re
spin al colum n exposure, 228, 228f cath eter p lacem en t , 28, 28f
ve r t eb ra l b od y an d in t e r ve r t eb ra l d isk exp osu re, 2 2 9 , closing, 29, 29f
229f drilling, 27, 27f
closed reduct ion , 215 posit ion ing, 26, 26f
exam in at ion , 214 skin in cision , 26, 26f
indicat ion s for su rger y, 214 closed cran ial fract ures, 90, 99
op erat ive m anagem en t closed sp inal t ract ion
approach , 215 in dicat ion s for, 170
tech n iqu es, 215 op erat ive procedu re
posterior approach operat ive p rocedu re, 216f pin p lacem en t , 174, 174f
closing, 225 pin site select ion , 173, 173f
decom pression an d redu ct ion , 220, 220f posit ion ing, 172, 172f
fusion preparat ion , 221, 221f vest p lacem en t , 176f
posit ion ing, 217, 217f w eigh t placem en t an d cou n ter t ract ion , 175, 175f
posterolateral fusion , 224, 224f pediat ric, 490
rod placem en t , 223, 223f postoperat ive m an agem en t
screw placem en t , 222, 222f m edicat ion , 177
subcut an eous dissect ion , 218219, 218f, 219f m on itoring, 177
Inde x 495
pin site m an agem en t , 177 com bat cran ial op erat ion s, 386, 387f, 396, 396f
radiograph ic im aging, 176f, 177 CSDH, 1617, 17f, 18f, 18t, 30, 30f, 31f
preprocedu re con siderat ion s d ecom pressive cran iectom y, 5354, 54f, 70, 71f
m edicat ion , 170 d epressed sku ll fract u re elevat ion , 90, 91f, 99, 99f
operat ive eld p reparat ion , 170 epidu ral h em atom a, 2, 3f, 14, 15f
radiograph ic im aging, 170, 171f fron t al sin u s inju ries, 444, 445f, 456
special con siderat ion s, 177 ICH, 312, 312f, 320, 320f, 327, 327f, 328f
com bat-associated pen et rat ing sp in e inju r y (PSI) in t racran ial in fect ion , 331, 332f, 347, 347f
closu re, 410 invasive n eu rom on itoring, 116, 117f
in dicat ion s for su rger y, 398, 399f, 400f, 401f odon toid fract u res, 179, 180f
operat ive tech n iqu e p ediat ric cer vical sp in e inju r y, 471, 472f
decom pression , 408, 408f p ediat ric TBI, 459, 459f
dissect ion , 406, 406f p it u it ar y ap oplexy, 370, 371f
du ral explorat ion /repair, 409, 409f sp in al epid u ral com pression , 288, 290f
in st ru m en t at ion /fu sion, 410 su bd u ral h em atom a, 2, 3f, 14, 15f
lam in ectom y, 407, 407f su boccipit al t raum a, 7374, 75f, 88f, 89
posit ion ing, 404405, 404f405f su rgical debridem en t of p en et rat ing h ead inju ries, 120, 121f,
postoperat ive m an agem en t , 410 131, 131f
preprocedu re con siderat ion s th oracic fract u res, 239
an esth esia issu es, 403 th oracolu m bar fract ures, 267, 267f
associated inju ries, 402 t rau m at ic CSF rh in orrh ea repair, 444, 445f, 456
equ ipm en t/set-u p, 402403 ven ou s sin us injuries, 153, 154f, 168, 168f
in it ial evaluat ion , 402 ven t ricu lar sh u n t m alfu n ct ion , 350, 350f, 368, 368f
in it ial m edical m an agem en t , 402 com p u ted tom ograp hy angiogram (CTA)
n eurom on itoring, 403 com bat-associated p en et rat ing sp in e inju r y, 402
prepping/in cision , 403 ICH, 312, 313f, 320, 320f
radiograph ic im aging, 402 TCVI, 136137, 136f, 151
t act ical scen ario, 402 com p u ted tom ograp hy ven ography (CTV), ven ou s sin u s injuries,
com bat cran ial operat ion s 153, 154f, 168, 168f
closing, 396 corpectom y
in dicat ion s for, 386 for cer vical burst fract u res, 209, 209f
operat ive proced ure for th oracic fract u res, 251f
bony debridem en t , 391, 391f corpectom y an d diskectom y, 254, 254f
brain debridem en t , 394, 394f d rilling, 253, 253f
h em icran iectom y, 393, 393f p edicle screw s, 256, 256f
pericran ial graft , 395, 395f rem oval of facet com plex, 252, 252f
posit ion ing an d p reparat ion , 388, 388f rib h ead t rap door osteotom y, 255, 255f
scalp in cision , 392, 392f cor t icosteroids. See steroids
skull base recon st ru ct ion , 395, 395f costot ran sversectom y, for th oracic fract ures, 264
soft t issue debridem en t , 390, 390f cran ial bon e ap rep lacem en t . See bon e ap replacem en t
urgen t h em ost asis, 389, 389f cran ial fract u re, d epressed. See depressed sku ll fract ure elevat ion
postoperat ive m an agem en t cran iectom y
m edicat ion , 396 for allop last ic cran ioplast y. See bifron t al cran iectom y;
m on itoring, 396 u n ilateral cran iectom y
radiograph ic im aging, 396, 396f for cerebellar stroke or hem orrhage or suboccipital traum a, 81, 81f
preprocedu re con siderat ion s d ecom pressive. See decom pressive cran iectom y
con su ltat ion /team w ork, 386 for dep ressed sku ll fract u re elevat ion , 95, 95f
m edicat ion s, 387 for ICH. See m idlin e su boccipit al cran iectom y
operat ive eld p reparat ion , 387 p ediat ric, 458, 460461
radiograph ic im aging, 386, 387f for p en et rat ing h ead injuries, 119120
special con siderat ion s, 397 cran iop last y
com pression fract u res alloplast ic. See allop last ic cran iop last y
th oracic, 239 au tologou s, 424
th oracolum bar, 266 p ediat ric, 458
com puted tom ograp hy (CT) cran iostom y. See t w ist drill cran iostom y
bon e ap replacem en t , 412, 412f, 422, 422f cran iotom y
cerebellar st roke or h em orrh age, 7374, 75f, 88f, 89 for cerebral con t usion
cerebral con t u sion s, 33, 33f, 51, 51f bicoron al ap p roach , 39, 39f
cer vical bu rst fract ures, 201 m od i ed pterion al ap p roach , 47, 47f
cer vical facet dislocat ion , 215, 234 for CSDH, 16
closed sp in al t ract ion , 170, 171f bu r h ole p lacem en t , 20, 20f
com bat-associated pen et rat ing sp in e inju r y, 402 closing, 25
496 Inde x
cran iotom y (cont inued) den s fract u res. See odon toid fract ures
drain p lacem en t , 24, 24f dep ressed sku ll fract ure elevat ion
du ral op en ing, 21, 21f closing, 99
h em atom a evacu at ion , 22f, 23 in dicat ion s for, 90, 458
posit ion ing, 19, 19f op erat ive procedu re
skin incision , 19, 19f calvarial recon st ru ct ion , 98, 98f
for decom pressive h em icran iectom y cran iectom y, 95, 95f
bifron t al, 67, 67f dural tear exp lorat ion , 96, 96f
fron totem poropariet al, 59, 59f fract u re elevat ion , 96, 96f
for ep idu ral or su bdu ral h em atom a, 7, 7f posit ion ing, 92, 92f
for ICH. See fron t al cran iotom y skin in cision , 93, 93f
for in t racerebral abscess, 343, 343f su bcut an eous dissect ion , 94, 94f
pediat ric, 458, 460, 465, 465f ven ou s sin u s rep air, 97, 97f
for p en et rat ing h ead inju ries, 119120, 126, 126f pediat ric, 458, 460
for ven ou s sin u s inju ries postoperat ive m an agem en t
an terior on e-th ird superior sagit t al sin u s, 157, 157f m edicat ion , 99
posterior t w o-th irds su perior sagit tal sin u s, torcu lar radiograp h ic im aging, 99, 99f
h eroph ili, an d dom in an t t ran sverse sin u s, 164, 164f preprocedu re con siderat ion s
CSDH. See ch ron ic su bdural h em atom a m edicat ion , 90
CSF. See cerebrospin al uid op erat ive eld preparat ion , 90
CT. See com pu ted tom ography radiograp h ic im aging, 90, 91f
CTA. See com p uted tom ography angiogram special con siderat ion s, 99
CTV. See com pu ted tom ography ven ograp hy diskectom y
for cau da equ in a syn drom e, 308, 308f
D for cer vical bu rst fract u res, 208, 208f
DC. See decom pressive cran iectom y for cer vical facet dislocat ion s, 230, 230f
d ebridem en t . See surgical debridem en t of pen et rat ing h ead for th oracic fract ures, 254, 254f
inju ries dom in an t t ran sverse sin u s inju ries
d ecom pressive cran iectom y (DC) closing, 165
bifron t al operat ive procedure in dicat ion s for su rger y, 153
closing, 70 op erat ive procedu re
cran iotom y, 67, 67f cran iotom y, 164, 164f
du ral open ing, 68, 68f direct repair, 165, 165f
du raplast y, 69, 69f gen eral con siderat ion s, 154
in cision plann ing, 65, 65f posit ion ing, 162, 162f
posit ion ing, 64, 64f sin u s in terposit ion graft , 167
subcu t an eous dissect ion , 66, 66f sin u s patch , 166, 166f
fron t ot e m p orop ar iet al h e m icran ie ctom y op e rat ive skin in cision , 163, 163f
p roced u re tam pon ade, 165
bon e ap elevat ion , 59, 59f postoperat ive m an agem en t
bon e ap storage, 63, 63f m edicat ion , 168
bur h ole placem en t , 58, 58f m on itoring, 168
closing, 70 radiograp h ic im aging, 168, 168f
du ral open ing, 61, 61f preprocedu re con siderat ion s
du raplast y, 62, 62f m edicat ion , 153
posit ion ing, 55, 55f op erat ive eld preparat ion , 153154
skin in cision , 56, 56f radiograp h ic im aging, 153, 154f
subcu t an eous dissect ion , 57, 57f special con siderat ion s, 168
tem poral cran iectom y re n em en t , 60, 60f drain p lacem en t
in d icat ion s for, 53, 458 for CSDH, 24, 24f, 29, 30f
pediat ric, 458, 460461 for epidu ral or su bdu ral h em atom a, 13, 13f
postoperat ive m an agem en t EVD. See extern al ven t ricu lar drain
m edicat ion , 70 dura
m onitoring, 70 closu re of
radiograph ic im aging, 70, 71f after cerebellar st roke or h em orrh age or su boccipit al t raum a
preprocedu re con siderat ion s su rger y, 87, 87f
m edicat ion , 54 after grow ing sku ll fract ure rep air, 467, 467f
operat ive eld preparat ion , 54 after h em atom a evacuat ion , 11, 11f
radiograph ic im aging, 5354, 54f after in t racran ial in fect ion , 344, 344f
special con siderat ion s, 71 explorat ion of, for com bat-associated pen et rat ing spin e inju r y,
Den is classi cat ion , 266 409, 409f
Inde x 497
ext racran ial pen et rat ing TCVI (cont inued) skin in cision , 56, 56f
repair of arterial inju r y, 150, 150f su bcut an eous dissect ion , 57, 57f
skin in cision , 146, 146f tem p oral cran iectom y re n em en t , 60, 60f
postoperat ive m an agem en t
m edicat ion , 151 G
m on itoring, 151 Gardn er-Wells tongs
radiograph ic im aging, 151 in dicat ion s for, 170
prep rocedure con siderat ion s, 137 op erat ive procedu re
special con siderat ion s, 151 pin p lacem en t , 174, 174f
pin site select ion , 173, 173f
F posit ion ing, 172, 172f
facetectom y, for th oracolum bar fract u res, 272273, 272f w eigh t placem en t an d cou n ter t ract ion , 175, 175f
facet fusion , for th oracolu m bar fract u res, 281, 281f postoperat ive m an agem en t
facet join t dislocat ion . See cer vical facet dislocat ion m edicat ion , 177
facet s, an atom y of, 237 m on itoring, 177
brin sealan t applicat ion , for fron t al sin u s su rger y, 454, 454f pin site m an agem en t , 177
exion -dist ract ion fract ures radiograp h ic im aging, 176f, 177
th oracic, 239 preprocedu re con siderat ion s
th oracolu m bar, 266 m edicat ion , 170
uoroscopy, for p it uit ar y apoplexy, 373374, 373f, 374f op erat ive eld preparat ion , 170
foreign body rem oval, for in t racran ial p en et rat ing injur y, 144, radiograp h ic im aging, 170, 171f
144f special con siderat ion s, 177
fract ure-dislocat ion inju r y grow ing sku ll fract ure repair
th oracic spin e, 239 closing, 469
th oracolu m bar, 266 gen eral su rgical prin cip les, 460
fract ure elevat ion . See depressed skull fract u re elevat ion in dicat ion s for, 458
fron tal cran iotom y, for su praten torial ICH op erat ive procedu re, 462
cran iotom y, 316, 316f bony defect rep air, 468, 468f
dural open ing, 317, 317f cran iotom y, 466, 466f
hem atom a evacuat ion , 318319, 318f, 319f dural defect closu re, 467, 467f
posit ion ing an d skin in cision , 314, 314f in cision , 464, 464f
subcu t an eous dissect ion , 315, 315f posit ion ing, 463, 463f
fron tal lobe con t usion . See cerebral con t usion s su bcut an eous dissect ion , 465, 465f
fron tal lobectom y, for cerebral con t usion , 42, 42f postoperat ive m an agem en t
fron t al sin u s cran ializat ion , after in t racran ial in fect ion , 344, m on itoring, 469
344f radiograp h ic im aging, 469, 469f
fron tal sin u s inju ries w ou n d m an agem en t , 469
closing, 456 preprocedu re con siderat ion s
in d icat ion s for su rger y, 444 an esth esia, 459460
operat ive p rocedure op erat ive eld preparat ion , 460
bicoron al in cision, 446, 446f radiograp h ic im aging, 459, 459f
cran ial bon e ap replacem en t , 455, 455f
brin sealan t ap plicat ion , 454, 454f H
fragm en t rem oval an d cat alogu ing, 448, 448f h alo ring t ract ion
fron ton asal du ct packing, 452, 452f in dicat ion s for, 170
fron ton asal du ct paten cy con rm at ion , 449, 449f op erat ive procedu re
pericran ial ap elevat ion an d rot at ion , 453, 453f pin p lacem en t , 174, 174f
posterior t able rem oval, 450, 450f pin site select ion , 173, 173f
sin us m ucosa bu rn ing, 451, 451f posit ion ing, 172, 172f
subperiosteal dissect ion , 447, 447f vest p lacem en t , 176f
postoperat ive m an agem en t , 456 w eigh t placem en t an d cou n ter t ract ion , 175, 175f
prep rocedure con siderat ion s, 444, 445f pediat ric, 490
special con siderat ion s, 456 postoperat ive m an agem en t
fron totem poropariet al decom p ressive h em icran iectom y, 53 m edicat ion , 177
bon e ap elevat ion , 59, 59f m on itoring, 177
bon e ap storage, 63, 63f pin site m an agem en t , 177
bur h ole placem en t , 58, 58f radiograp h ic im aging, 176f, 177
closing, 70 preprocedu re con siderat ion s
du ral open ing, 61, 61f m edicat ion , 170
du raplast y, 62, 62f op erat ive eld preparat ion , 170
pediat ric, 462 radiograp h ic im aging, 170, 171f
posit ion ing, 55, 55f special con siderat ion s, 177
Inde x 499
h alo vest t ract ion , 170, 172, 176f op erat ive procedu re
h ead injuries bon e ap elevat ion , 339, 339f
pen et rat ing. See pen et rat ing h ead inju ries d u r al clo su re a n d cr a n ia lizat io n o f fron t a l sin u s, 3 4 4 ,
TBI. See t raum at ic brain injur y 344f
TCVI. See t raum at ic cerebrovascular injur y d u ral op en ing, 341, 341f
h em atom a evacu at ion in cision , 336, 336f
CSDH, 22f, 23 op en cran iotom y, 343, 343f
epidural, 8, 8f, 82, 82f p ericran ial ap h ar vest , 337, 337f
ICH p osit ion ing, 334335, 334f335f
in fraten torial, 326, 326f stereot act ic approach , 345346, 345f346f
su praten torial, 318319, 318f, 319f tem poralis division an d bu r h ole placem en t , 338, 338f
in t racerebellar, 84, 84f p ostop erat ive m an agem en t
spin al epidu ral, 294, 294f fu rth er m an agem en t , 348
su bdu ral, 10, 10f m edicat ion , 347
h em icran iectom y m on itoring, 347
for com bat h ead inju ries, 393, 393f radiograp h ic im aging, 347, 347f
decom pressive. See fron totem poropariet al decom p ressive p reprocedu re con siderat ions
h em icran iectom y m edicat ion , 333
h em orrh age op erat ive eld p reparat ion , 333
cerebellar. See cerebellar st roke or h em orrh age radiograp h ic im aging, 331, 332f
in t racerebral. See in t racerebral h em orrh age sp ecial con siderat ion s, 348
ven ou s sin u s injuries w ith , 153 in t racerebral h em orrh age (ICH), 312. See cerebellar st roke or
h ep arin , for TCVI, 137 h em orrh age
hyd roceph alus, after decom p ressive cran iectom y, 70 in fraten torial. See in fraten torial ICH
hyd roxyap at ite cem en t com pou n d , for alloplast ic cran iop last y, su praten torial. See su p raten torial ICH
438f, 439, 442 in t racran ial blu n t TCVI
in dicat ion s for su rger y, 134136
I m an agem en t , 142, 143f
ICA. See in tern al carot id arter y algorith m for, 142f
ICH. See in t racerebral h em orrh age p ostop erat ive m an agem en t
ICP m on itoring. See in t racran ial pressu re m on itoring m edicat ion , 151
in fect ion m on itoring, 151
epidural. See epidu ral abscess radiograp h ic im aging, 151
in t racran ial. See in t racran ial in fect ion p reprocedu re con siderat ions, 137
pen et rat ing h ead inju ries w ith , 119120, 132 sp ecial con siderat ion s, 151
sh un t , 351 in t racran ial hyp erten sion , decom p ressive cran iectom y for.
sp in al. See sp in al ep idu ral abscess See decom p ressive cran iectom y
in fraten torial ICH in t racran ial in fect ion
closing, 327 closu re, 347
in dicat ions for surger y, 320 in dicat ion s for su rger y, 331
m idlin e suboccip it al cran iectom y operat ive procedu re op erat ive procedu re
cran iectom y, 323324, 323f324f bon e ap elevat ion , 339, 339f
du ral open ing, 325, 325f d u ral closu re an d cran ializat ion of fron t al sin us, 344, 344f
h em atom a evacuat ion , 326, 326f d u ral op en ing, 341, 341f
posit ion ing, 321, 321f epidu ral abscess rem oval, 340, 340f
skin in cision an d su bcu t an eou s dissect ion , 322, 322f in cision , 336, 336f
postop erat ive m an agem en t , 327, 327f, 328f op en cran iotom y, 343, 343f
preprocedu re con sid erat ion s p ericran ial ap h ar vest , 337, 337f
in it ial m an agem en t , 320 p osit ion ing, 334335, 334f335f
m edicat ion , 320 stereot act ic approach to in t raparen chym al abscess,
operat ive eld preparat ion , 320 345346, 345f346f
radiograph ic im aging, 320, 320f su bd u ral em pyem a rem oval, 342, 342f
special con siderat ion s, 327329 tem poralis division an d bu r h ole placem en t , 338, 338f
in tern al carot id arter y (ICA), TCVI of p ostop erat ive m an agem en t
en dovascular m an agem en t , 138, 141f fu rth er m an agem en t , 348
in dicat ions for surger y, 133134 m edicat ion , 347
in terspin ou s w iring arth rod esis, for pediat ric cer vical sp in e m on itoring, 347
injur y, 487, 487f radiograp h ic im aging, 347, 347f
in t racerebellar h em atom a, 73, 73f, 84, 84f p reprocedu re con siderat ions
in t racerebral abscess, 330 m edicat ion , 333
closu re, 347 op erat ive eld p rep arat ion , 333
in dicat ions for surger y, 331 radiograp h ic im aging, 331, 332f
500 Inde x
occlusion , t rau m at ic vascular. See vascular occlusion postoperat ive m an agem en t , 489, 489f
odon toid fract ures preprocedu re con siderat ion s
C1- C2 lateral m ass fu sion w ith polyaxial screw s an d rods m edicat ion , 471
operat ive procedu re op erat ive eld an d em ergen cy room m an agem en t , 470471,
C1 screw t rajector y an d p lacem en t , 193, 193f 471f
C2 screw t rajector y an d p lacem en t , 194, 194f radiograp h ic im aging, 471, 472f
closing, 195 su rgical t im ing, 471
n al con st ruct , 195, 195f special con siderat ion s, 490
posit ion ing an d surgical site prep arat ion , 191, 191f su baxial cer vical posterior arth rodesis for, 470, 487
t issue dissect ion an d exp osure, 192, 192f in terspin ou s w iring arth rodesis, 487, 487f
C1- C2 t ran sart icular screw op erat ive procedu re posterior arth rodesis w ith lateral m ass screw xat ion, 488,
closing, 190 488f
n al con st ruct , 190, 190f pediat ric TBI
posit ion ing, 186, 186f closing, 469
screw t rajector y an d placem en t , 189, 189f gen eral su rgical prin cip les, 460
surgical site prep arat ion , 187, 187f in dicat ion s for su rger y, 458
t issue dissect ion an d exp osure, 188, 188f op erat ive procedu res
in d icat ion s for surger y, 179 cran iotom y, 461
odon toid screw operat ive p rocedure decom p ressive cran iectom y, 461462
cer vical dissect ion an d en t r y site prep arat ion , 182183, dep ressed sku ll fract ure su rger y, 461
182f183f EVD, 460461
closing, 185 grow ing sku ll fract u re repair. See grow ing sku ll fract u re
com pleted con st ruct , 185, 185f rep air
posit ion ing, 181, 181f ICP an d oth er paren chym al brain m on itors, 460
screw t rajector y an d placem en t , 184, 184f postoperat ive m an agem en t
postoperat ive m an agem en t m on itoring, 469
m edicat ion , 185, 190, 195 radiograp h ic im aging, 469, 469f
m onitoring, 185, 190, 195 w ou n d m an agem en t , 469
preprocedu re con siderat ion s preprocedu re con siderat ion s
m edicat ion , 179 an esth esia, 459460
radiograph ic im aging, 179, 180f op erat ive eld preparat ion , 460
special con siderat ion s, 195196 radiograp h ic im aging, 459, 459f
op en cran ial fract ures, 90, 99 pedicle can n u lat ion , for th oracolu m bar fract u res, 272273, 272f
orth oses pedicle screw s
for cer vical spin e inju ries, 490 for occip itocer vical xat ion , 480, 480f
for th oracic fract ures, 238 for th oracic fract ures
posterior decom pression , 248249, 248f, 249f
P t ran sped icu lar corpectom y, 256, 256f
p aren chym al brain m on itors. See invasive n eu rom on itoring for th oracolu m bar fract u res
p aren chym al injur y, p en et rat ing h ead inju ries w ith , 128129, op en p osterior decom p ression , 274, 274f
128f129f percut an eous p osterior decom p ression , 282, 282f
p ediat ric cer vical spin e inju r y pedicu lectom y, for spin al epidu ral com pression , 298, 298f
an esth esia, 472 PEEK. See polyeth ereth erketon e
atlan toaxial arth rodesis, 470, 482 pen et rat ing h ead inju ries, 119
Brooks an d Jen kin s tech n iqu e, 482, 482f com bat-associated. See com bat cran ial operat ion s
Gallie tech n iqu e, 483, 483f su rgical debrid em en t for. See su rgical debrid em en t of
Harm s p osterior C1- C2 fu sion w ith p olyaxial screw an d rod pen et rat ing h ead inju ries
xat ion , 486, 486f TCVI. See in t racran ial p en et rat ing TCVI
posterior C1-C2 t ran sart icular screw xat ion , 484485, 484f pen et rat ing n eck inju ries, TCVI. See ext racran ial pen et rat ing TCVI
closing, 489 pen et rat ing sp in e injuries, com bat-associated. See com bat-
in d icat ion s for su rger y, 470, 473, 482, 487 associated pen et rat ing spin e inju r y
occipitocer vical xat ion percu t an eou s p osterior sp in al decom pression , for th oracolu m bar
ar th rodesis. See occipitocer vical ar th rodesis fract u res
C1 lateral m ass screw s, 479, 479f bon e t reph in e n eedle p lacem en t , 278279, 278f
C2 pars screw, 480 closu re, 284
C2 pedicle screw, 480, 480f facet fu sion , 281, 281f
C2 t ran slam in ar screw, 481, 481f gu id ew ire p lacem en t , 280, 280f
plate, 479 posit ion ing an d pedicle t arget ing, 277, 277f
posit ion ing based on ap proach rod placem en t an d deform it y correct ion , 283, 283f
an terior cer vical, 472473 screw p lacem en t , 282, 282f
posterior cer vical, 473 perforat ing h ead inju ries, 119
Inde x 503
spin al epidu ral com p ression , m etast at ic. See m etast at ic epidu ral d u ral op en ing, 341, 341f
spin al cord com pression em pyem a rem oval, 342, 342f
spin al epidu ral h em atom a (SEH) in cision , 336, 336f
an esth esia, 289290 p ericran ial ap h ar vest , 337, 337f
closu re, 300 p osit ion ing, 334335, 334f335f
et iologies of, 286 tem poralis division an d bu r h ole placem en t , 338, 338f
in ciden ce of, 286 p ostop erat ive m an agem en t
in dicat ion s for su rger y, 287 fu rth er m an agem en t , 348
path ophysiology of, 287 m edicat ion , 347
posterior and p osterolateral posit ion ing an d incision , 292, 292f m on itoring, 347
postoperat ive m an agem en t radiograp h ic im aging, 347, 347f
adjuvan t t reat m en t s, 300 p rep rocedu re con siderat ion s
m edicat ion , 300 m edicat ion , 333
m on itoring, 300 op erat ive eld p reparat ion , 333
radiograph ic im aging, 300 radiograp h ic im aging, 331, 332f
preprocedu re con siderat ion s special con siderat ion s, 348
m edicat ion , 288 su bdu ral h em atom a (SDH)
radiograph ic im aging, 288, 289f, 290f ch ron ic. See ch ron ic subd u ral h em atom a
presen t at ion of, 287 in dicat ion s for su rger y, 2, 458
special con siderat ion s, 300 operat ive p rocedu re
su rgical approach es bon e ap replacem en t , 12, 12f
an terior, 291 closing, 14
gen eral prin ciples, 290291 cran iotom y, 7, 7f
posterior, 291 d rain p lacem en t , 13, 13f
th oracic lam in ectom y op erat ive proced ure d u ral closu re, 11, 11f
h em atom a rem oval, 294, 294f d u ral op en ing, 9, 9f
lam in ectom y, 293, 293f h em atom a evacu at ion , 10, 10f
spin al fract ures p osit ion ing, 4, 4f
cer vical. See cer vical bu rst fract ures skin in cision , 5, 5f
th oracic. See th oracic fract ures su bcu t an eou s dissect ion , 6, 6f
th oracolum bar. See th oracolu m bar fract u res p ediat ric, 458, 460
spin al fusion p en et rat ing h ead inju ries w ith , 129
an terior. See an terior sp in al fu sion p ostop erat ive m an agem en t
posterior. See posterior spin al fu sion m edicat ion , 14
spin al inju r y m on itoring, 14
com bat-associated. See com bat-associated pen et rat ing spin e radiograp h ic im aging, 14, 15f
injur y p rep rocedu re con siderat ion s
pediat ric. See p ediat ric cer vical spin e injur y m edicat ion , 2
spin al t ract ion , closed. See closed sp in al t ract ion op erat ive eld p reparat ion , 2
spin ou s process rem oval, for th oracic fract ures, 245, 245f radiograp h ic im aging, 2, 3f
sten t ing special con siderat ion s, 15
of ext racran ial blu n t TCVI, 137138, 139f su boccip it al t rau m a
of ext racran ial pen et rat ing TCVI, 138, 141f closing, 88
steroid s in dicat ion s for su rger y, 73
for CSDH, 31 operat ive p rocedu re
for in t racran ial in fect ion , 333 bony exposu re, 79, 79f
for SCI, 215, 239, 267, 302, 471 bu r h ole p lacem en t , 80, 80f
st roke cran iectom y, 81, 81f
cerebellar. See cerebellar st roke or h em orrh age d ecom pression of in farcted brain , 85, 85f
decom pressive cran iectom y for. See decom pressive d u ral closu re, 87, 87f
cran iectom y d u ral op en ing, 83, 83f
spon t an eou s ICH cau sing. See in t racerebral h em orrh age epidu ral h em atom a evacu at ion , 82, 82f
su baxial cer vical posterior arth rodesis, 470, 487 h em ost asis, 86, 86f
in terspin ou s w iring arth rodesis, 487, 487f in t racerebellar h em atom a evacuat ion , 84, 84f
posterior arth rodesis w ith lateral m ass screw xat ion , 488, p osit ion ing, 76, 76f
488f skin in cision , 77, 77f
su bdural em pyem a, 330 su bcu t an eou s dissect ion , 78, 78f
closu re, 347 p ostop erat ive m an agem en t
in dicat ion s for su rger y, 331 m edicat ion , 89
operat ive procedu re m on itoring, 89
bon e ap elevat ion , 339, 339f radiograp h ic im aging, 88f, 89
du ral closure, 344, 344f ven t ricu lostom y, 88
506 Inde x