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Contents
Fo rew o rd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Ackno w ledgm en ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Co ntributo rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
I Cerebral Traum a and Stro ke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 1: Surger y for Epidural an d Subdural Hem atom as
Shelly D. Tim m ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Chapter 2: Ch ron ic Subdural Hem atom as
Branko Skovrlj, Jonathan Rasouli, A. Stew art Levy,
P. B. Rak sin, and Jam ie S. Ullm an . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Chapter 3: Surger y for Cerebral Con t u sion s of th e Fron t al an d
Tem p oral Lobes, In clu ding Lobar Resect ion s
Pal S. Randhaw a and Craig Rabb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Chapter 4: Decom pressive Cran iectom y for In t racran ial Hyper ten sion an d
St roke, In clu ding Bon e Flap Storage in Abdom in al Fat Layer
Roberto Rey-Dios and Dom enic P. Esposito . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Chapter 5: Surger y for Cerebellar St roke an d Suboccipit al Traum a
Faiz U. Ahm ad and Ross Bullock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
Chapter 6: Elevat ion of Depressed Skull Fract ures
Anand Veeravagu, Bow en Jiang, and Odette A. Harris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
Chapter 7: Invasive Neurom on itoring Tech n iques
Mathieu Laroche, Michael C. Huang, and Geo rey T. Manley . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Chapter 8: Surgical Debridem en t of Pen et rat ing Injuries
Roland A. Torres and P. B. Rak sin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Chapter 9: Man agem en t of Traum at ic Neurovascular Injuries
Boyd F. Richards and Mark R. Harrigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Chapter 10: Man agem en t of Ven ou s Sin u s Inju ries
Laurence Davidson and Rocco A. Arm onda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
vi
Contents
Conte nts
vii
Objectives
1.
2.
3.
4.
Iden t ify n eurosurgical con dit ion s w h ich require em ergen t or urgen t in ter ven t ion
Evaluate th e various opt ion s for m an aging spin e t raum a in th e cer vical, th oracic, an d th oracolum bar region s.
Apply provided tech n iques w h en perform ing urgen t in ter ven t ion s for th e brain an d spin e
Recogn ize key issues of applying brain an d spin al t rau m a surgical tech n iques to m ilitar y an d pediat ric populat ion s.
viii
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interests:
Nam e :
Sergey Abesh au s, MD
P. David Adelson , MD, FAANS
Faiz U. Ah m ad, MD
Rocco A. Arm on da, MD, FAANS
Nelson Ast u r, MD
Josh u a B. Bederson , MD, FAANS
M. Ross Bu llock, MD, Ph D
Lau ren ce Davidson , MD, FAANS
Don iel Gabriel Drazin , MD
Yakov Gologorsky, MD
Mark R. Harrigan , MD, FAANS
Odet te Alth ea Harris, MD, MPH, FAANS
Brian Jam es Hood, MD
Josep h C. Hsieh , MD
Mich ael C. Hu ang, MD
Ash a Mu th uram an Iyer, MD
Joh n A. Jan e, Jr., MD, FAANS
Ar th u r L. Jen kin s III, MD, FAANS
Bow en Jiang, MD
J. Pat rick Joh n son , MD, FAANS
Erin Kieh n a, MD
Pau l Klim o, Jr., MD, FAANS
Math ieu Laroch e, MD
An d rew Stew ard Levy, MD
Ju st in Robert Mascitelli, MD
#
Forew ord
able guide for both residen ts as w ell as for m ore experien ced
neurosurgeons. It w ill ser ve as a quick referen ce before one
em barks on treating a patient w ith a traum atic neurosurgical disorder, or in preparing to take an exam ination.
Alth ough th ere are oth er texts th at deal w ith n eurot raum a,
n on e of th em are as digest ible as th is on e. I could w ax eloquen t on th e m any m erit s of th is book. I dont n eed to. As
you sim ply ip th rough its pages, you w ill see for yourself
th at th is is a book w or th h avingn ot ju st to disp lay on you r
booksh elf, bu t to keep h an dy an d to u se on an ever yday basis. You w ill h ave n o t rouble pu t t ing it to good use.
Raj K. Narayan, MD, FACS, FAANS
Professor an d Ch airm an
Dep ar t m en t of Neu rosu rger y
Hofst ra Nor th Sh ore LIJ Sch ool of Medicin e an d
Director, Cu sh ing Neu roscien ce In st it u te
Man h asset , New York
xi
Acknow ledgments
xii
Preface
Neu rosu rger y is n ot so sim ple. Drilling bu r h oles in th e em ergen cy depart m en t m ay relieve pressu re from an expan ding epidu ral h em atom a, but the ensuing un cont rolled arterial bleeding m ay resu lt in sign i can t blood loss, hypoten sion ,
an d death if on e is n ot skilled in h an dling th is sit u at ion . An d,
alth ough traum a m ay be on e of th e m ore com m on reason s
for em ergen t n eurosu rgical in ter ven t ion , acute care for n eu rosu rgical diseases is as w idely varied as the disciplin e itself.
The ver y eclect ic nat ure of th ese em ergen t and urgent con dit ion s cont in ually ch allenges the skills obtain ed during the long
n eu rosu rger y residen cy t rain ing period, dem an ding n ot on ly
broad kn ow ledge and evolving techn ical skills, but pre-, in tra-,
an d p ostoperat ive clin ical ju dgm en t th at can t ake a lifet im e to
m asterall for th e goal of im proving pat ien t outcom es.
Appreciat ion of th is w eigh t y t ask m ust be cou pled w ith th e idea
th at learn ing in n eurosurger y is a decidedly visual pursuit .
Neu rosu rgeon s-in -t rain ing st u dy an atom ic rep resen t at ion s,
dissect cadavers, an d obser ve th eir m en tors in th e operat ing
room . With clin ical exp erien ce an d kn ow ledge acqu isit ion ,
th ere even t ually com es th e abilit y to t ran slate th e w rit ten
w ords in a textbook in to m en t al im ages, or to im agin e on es
w aystep -by-step an d w ith variat ion sth rough a procedu re
before en tering th e operat ing th eater.
The true value of a surgical atlas, then, lies in the presentation: the
telling of a procedure in pictures. Historically, atlases h ave been
designed to guide the learner through interventions in a step w ise fashion. In 1960, Jam es Leonard Poppen, MD, published his
fam ed atlas entitled, An Atlas of Neurosurgical Techniques. This
tom e presen ted procedures in diagram m atic fashionuseful
to any neurosurgeon beginning to hone h is or her craft. In th at
spirit, and in the spirit of great surgical atlases such as Zollingers
Atlas of Surgical Operations, w e have set out to create a sim ilar
volum e devoted to em ergen cy n eurosurgical procedures.
Th is book w as w rit ten for n eurosurgeon s-in -t rain ing, as w ell
as for th ose already in p ract ice w h o desire to m eet th e ch allenge of w h atever com es in to th e em ergen cy depar t m en t .
Crit ical care pract it ion ers m ay also n d th is book ben e cial to un derstan ding th e surgical m an agem en t of n eurologic
con dit ion s th at w ill dem an d th eir m edical expert ise in th e
p ostop erat ive p eriod.
Th e book is divided in to six sect ion s. Sect ion I (Ch apters 110)
covers th e basic procedures th at form th e bread an d but ter of
cran ial n eu rosurger y for t raum a an d st roke, in cluding cran iotom ies for in t ra- an d ext ra-axial h em atom a, m an agem en t of
p en et rat ing inju ries, an d decom pressive cran iectom y. Excellen t ,
com preh en sive review s of n eurom on itoring an d m an agem en t
of n eurovascular inju ries com plem en t th ese ch apters.
Sect ion II (Ch apters 1118) focu ses on sp in al em ergen cy proceduresboth t raum at ic and n on t raum at ic. Th e im port an t role
of early surger y for acute t raum at ic spin e an d spin al cord in ju ries is in creasingly recogn ized; several ch apters are devoted
to operat ive m an agem en t of th ese injuries. W h ile open procedu res st ill predom in ate in th e em ergen cy m an agem en t of th ese
en t it ies, th e in creasing app licat ion of m in im ally invasive tech n iqu es in th is set t ing can n ot be ign ored. Ch apter 16 ou tlin es
th e m in im ally invasive approach to th oracolum bar t rau m a.
Non t rau m at ic em ergen cies, in clu ding ep id u ral sp in al com pression an d cau da equ in a syn drom e, are also addressed .
Sect ion III (Ch apters 1922) discu sses th e su rgical m an agem en t
of n on t rau m at ic em ergen cies in cluding spon t an eous in t racran ial h em orrh age, in t racran ial in fect ion , p it u it ar y apop lexy, an d
th e ever-h aun t ing ven t ricular sh un t m alfun ct ion . W h ile th e
sequ elae of an eu r ysm al ru pt u re som et im es requ ire em ergen t
su rgical in ter ven t ion , de n it ive m an agem en t often is u n dert aken m ore elect ively w ith in a 12- to 72-h our period. Th e tech n iqu e of an eu r ysm clip ping is th e su bject of several im p or tan t
tom es an d is beyon d th e gen eral scope of this atlas. Sim ilarly,
w h ile su rger y for rupt ured arterioven ous m alform at ion s is often deferred for a period of t im e to perm it resorpt ion of h em orrh age, p at ien ts m ay presen t w ith life-th reaten ing acute bleed s
th at n ecessitate em ergen t in ter ven t ion for relief of m ass e ect .
Th ese clin ical scen arios are addressed in Ch apter 19.
W h ile on ly a select few neurosurgeon s h ave part icipated in th e
th eater of w ar, w e felt it w ould be valuable to in clu de a sect ion
addressing em ergen cy in ter ven t ion s for n eu rologic inju ries in
com bat (Sect ion IV, Ch apters 23 an d 24). Key lesson s learn ed
over th e past t w o decades of con ict h ave led to in creased su rvival from th ese d evast at ing inju ries. With th e loom ing th reat
of terrorism , w e m ust be prepared to apply th ese tech n iques in
civilian populat ion s sh ould th e n eed arise.
xiii
xiv
Preface
Sect ion V (Ch apters 2527) en com p asses basic ten et s of recon st ruct ive su rger y. Th e m an agem en t of fron tal sin us injuries requ ires a com bin at ion of acu te care an d recon st ru ct ive
ap proach es. Any con sid erat ion of decom pressive cran iectom y
w ou ld n ot be com plete w ith ou t a discu ssion of it s n at u ral con sequ en ce: th e n eed for addit ion al, m ostly elect ive, su rger y
to restore th e cran iu m to it s origin al p rotect ive p u rpose. Th e
in form at ion p rovided is design ed to h elp th e su rgeon n ish
th e job.
Fin ally, Sect ion VI (Ch apters 28 an d 29) con siders con cern s speci c to th e t reat m en t of h ead an d spin al injuries in th e pediat ric
popu lat ion , in cluding steps for th e recon st ru ct ive repair of lep tom en ingeal cyst s. Th ese ch apters are d esign ed to h igh ligh t key
di eren ces in th e acute, an d delayed, m an agem en t of injuries in
ch ildren as com pared w ith adu lt s.
Th e ch apters follow a st an dardized form at . In t roductor y
com m en t ar y for each topic is follow ed by an accoun t ing of
in dicat ion s for n eurosurgical in ter ven t ion an d preprocedu ral
con siderat ion s. Th e operat ive procedure form s th e core of each
sect ion . For th e readers conven ien ce, w e design ed th is book to
keep illu st rat ion s an d p rocedu ral step s in close proxim it y. In
add it ion , m any step s are rep eated across ch apters (w ith variat ion ) to keep m ost of th e ch apters self-con t ain ed. Many of th e
procedural steps are accom pan ied by pearlsaddit ion al w isdom from th e su bject exper ts, geared tow ard en h an cing an
operat ions success an d avoiding com plicat ion s. Each ch apter
con cludes w ith a discussion of postoperat ive m an agem en t an d
special con siderat ion s relevan t to th at top ic. Referen ces are kept
to a m in im um .
As th e pract ice of n eu rosurger y is as m uch an ar t as it is a scien ce, th ere w ill be n u an ces an d app roach es p referable to each
in dividu al surgeon , an d th ere are often several w ays to accom plish th e sam e goal. Th e procedures outlin ed in th is book
represen t th e best pract ices of th e various au th ors an d can be
m odi ed based on su rgeon exp erien ce, preferen ce, an d p at ien t
ch aracterist ics. An d, alth ough w e h ave m ade ever y at tem pt
to provide a com preh en sive over view of th e m ost com m on ly
en cou n tered em ergen cy p rocedu res, it is in evit able th at oth er
em ergen cy con dit ion s w ill arise th at fall ou t side th e scope of
th is project . It is our h ope th at th e in form at ion presen ted in
th is book w ill ser ve as a platform upon w h ich to build st rategies for t reat ing m ore com p lex or less com m on em ergen cy
presen t at ions.
Jam ie S. Ullm an , MD, FAANS, FACS
P.B. Raksin , MD, FAANS
Contributors
Sergey Abeshaus, MD
Dep ar t m en t of Neu rosu rger y
Seat tle Ch ildrens Hospit al
Seat tle, Wash ington
P. David Adelso n , MD, FACS, FAAP
Director
Dian e an d Bru ce Halle En dow ed Ch air in
Pediat ric Neu roscien ces
Ch ief, Pediat ric Neurosurger y
Barrow Neurological In st it ute at Ph oen ix
Ch ildrens Hospit al
Ph oen ix, Arizon a
Faiz U. Ahm ad, MD, MCh
Assistan t Professor of Neu rosu rger y
Em or y Un iversit y
Grady Mem orial Hospit al
Atlan ta, Georgia
Ro cco A. Arm o nda, MD
Division of Neurosurger y
Walter Reed Nat ion al Militar y Medical Cen ter
Beth esda, Mar ylan d
Nelso n Astur Neto, MD
Dep ar t m en t of Or th op edic Su rger y
Cam p bell Clin ic Or th op aedics
Mem p h is, Ten n essee
Jo shua Bederso n , MD
Professor an d Ch air
Dep ar t m en t of Neu rosu rger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
Sam uel R. Brow d, MD, PhD
Director
Dep ar t m en t of Neu rosu rger y an d On cology
Cen ter for In tegrat ive Brain Research
Seat tle Ch ildrens Hospit al
Harbor view Medical Cen ter
Un iversit y of Wash ington Medical Cen ter
Seat tle, Wash ington
xv
xvi
Contributors
Antho ny Figaji, MD
Professor an d Head
Pediat ric Neurosurger y
Un iversit y of Cap e Tow n
In st it ute for Ch ild Health
Red Cross Ch ildrens Hospital Cape Tow n
Cap e Tow n , Sou th Africa
Yakov Go lo go rsk y, MD
At ten ding in Neurosurger y
Mou n t Sin ai Medical Cen ter
New York, New York
Abilash Haridas, MD
Assistan t Professor of Neu rosu rger y
Wayn e State Un iversit y Sch ool of Medicin e
Pediat ric Neurosurger y
Cerebrovascu lar Neu rosu rger y
Ch ildrens Hospital of Mich igan
Det roit , Mich igan
Mark R. Harrigan , MD
Associate Professor
Un iversit y of Alabam a Medical Cen ter
Birm ingh am , Alabam a
Odette A. Harris, MD, MPH
Associate Professor of Neu rosu rger y
Director of Brain Inju r y
Stan ford Sch ool of Medicin e Hosp it al an d Clin ics
Stan ford, Californ ia
Jam es S. Harro p, MD
Professor of Or th opedic an d Neurological Su rger y
Director, Sp in e an d Periph eral Ner ve Su rger y
Th om as Je erson Un iversit y
Ph iladelph ia, Pen n sylvan ia
Brian Ho o d, MD
Major USAF, MC
Assistan t Professor of Clin ical Medicin e
Un iform ed Un iversit y of Health Scien ces
San An ton io Milit ar y Medical Cen ter
San An ton io, Texas
Jo seph Hsieh, MD
Assistan t Professor
Th e Vivian L. Sm ith Dep art m en t of Neu rosu rger y
Th e Un iversit y of Texas Health Cen ter
Houston , Texas
Michael C. Huang, MD
Assistan t Clin ical Professor of Neu rological Su rger y
Un iversit y of Californ ia, San Fran cisco
San Fran cisco Gen eral Hospital an d Traum a Cen ter
San Fran cisco, Californ ia
Asha Iyer, MD
Residen t in Neu rosu rger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
Jo hn A. Jane Jr., MD
Associate Professor of Neu rosu rger y an d Pediat rics
Pediat rics Division Director
Un iversit y of Virgin ia
Ch arlot tesville, Virgin ia
Arthur Jenkins, MD, FACS
Associate Professor of Neu rosu rger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
Bow en Jiang, MD
Resid en t in Neu rosu rger y
Joh n s Hopkin s Hospital
Balt im ore, Mar ylan d
J. Patrick Jo hnso n , MD, MS, FACS
Director of Sp in e Edu cat ion an d Neu rosu rger y Spin e
Fellow sh ip Program
Depar t m en t of Neurosurger y
Cedars Sin ai Medical Cen ter
Th e Sp in e In st it u te Fou n dat ion
Los Angeles, Californ ia
Professor of Neu rosurger y
UC Davis Medical Cen ter
Sacram en to, CA
Erin N. Kiehna, MD
Assist an t Professor of Neu rosu rger y
Ch ildrens Hospital Los Angeles
Los Angeles, Californ ia
Kee Kim , MD
Associate Professor an d Ch ief
Depar t m en t of Spin al Neurosurger y
Co-director, Sp in e Cen ter
Un iversit y of Californ ia, Davis Sch ool of Medicin e
Sacram en to, Californ ia
Paul Klim o Jr., MD, MPH
Associate Professor of Neu rosu rger y
Un iversit y of Ten n essee
Associate, Sem m es-Mu rp h ey Neu rologic & Sp in e In st it u te
Mem ph is, Ten n essee
Mathieu Laro che, MD, MSc, FRCSC
Assist an t Professor of Neu rosu rger y
Un iversit y of Mon t ral
Neu rosurgeon
Hpital du Sacr- Coeu r de Mon t ral
Mon t ral, Qu bec, Can ada
A. Stew art Levy, MD
Neu rosurgeon
St . An th ony Hosp ital
Ch ief of Neurosurger y
Cen t u ra Neu roscien ce & Spin e
Lakew ood, Colorado
Casey Madura, MD
Resid en t in Neu rosu rger y
Un iversit y of Wiscon sin Hospital an d Clin ics
Madison , Wiscon sin
Contributors
Geo rey T. Manley, MD, PhD,
Professor in Residen ce an d Vice Ch airm an
Dep ar t m en t of Neu rological Su rger y
Co-Director an d Prin cip al Invest igator
Brain an d Spin al Inju r y Cen ter (BASIC)
Ch ief of Neurosurger y
San Fran cisco Gen eral Hospit al
Un iversit y of Californ ia, San Fran cisco
San Fran cisco, Californ ia
Justin Mascitelli, MD
Residen t in Neurosurger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
Leo n E. Mo o res, MD, MS
Professor of Neurosu rger y
Virgin ia Com m onw ealth Un iversit y
Professor of Surger y an d Pediat rics
Un iform ed Ser vices Un iversit y
CEO, Pediat ric Specialists of Virgin ia
Director of Pediat ric Neuroscien ces
In ova Health System
Fairfax,Virgin ia
Co rey M. Mo sso p, MD
Neurosu rger y Ser vice
Walter Reed Nat ion al Militar y Medical Cen ter
Silver Sp ring, Mar ylan d
So riaya Motivala, MD
Assistan t Professor of Neu rosu rger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
Michael S. Muhlbauer, MD
Dep ar t m en t of Pediat ric Neu rosu rger y
Sem m es-Murph ey Neurologic & Spin e In st it ute
Clin ical Assistan t Professor
Un iversit y of Ten n essee
Le Bon h eur Ch ildrens Hospital
Mem p h is, Ten n essee
Christo pher J. Neal, MD
Neurosu rger y Ser vice
Walter Reed Nat ion al Militar y Medical Cen ter
Beth esda, Mar ylan d
Kalm o n D. Po st, MD
Professor an d Ch airm an -Em erit us
Dep ar t m en ts of Neu rosu rger y, On cological Scien ces,
Medicin e, En docrin ology, Diabetes, an d Bon e Disease
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
Jam es G. Purzner, MD
Residen t in Neurosurger y
Un iversit y of Toron to
Toron to Western Hospit al
Toron to, On t ario, Can ada
Teresa S. Purzner, MD
Residen t in Neu rosurger y
Un iversit y of Toron to
Toron to Western Hospital
Toron to, On tario, Can ada
Craig Rabb, MD
Professor of Neurosurger y
Director
Neurot raum a Program
OU Physician s Neurosurger y
Oklah om a Cit y, Oklah om a
P.B. Raksin, MD, FAANS
Assistan t Professor, Depar t m en t of Neurosurger y
Ru sh Un iversit y Medical Cen ter
Director, Neurosu rger y ICU
Ch ief, Sect ion Neurot raum a & Neurocrit ical Care
Joh n H. St roger Jr Hospital of Cook Cou n t y (form erly Cook
Cou n t y Hospital)
Ch icago, Illin ois
Pal S. Ran dhaw a, MD
Residen t in Neu rosurger y
Un iversit y of Colorado
Au rora, Colorado
Jo nathan Raso uli, MD
Residen t in Neu rosurger y
Icah n Sch ool of Medicin e at Mou n t Sin ai
New York, New York
Daniel Resnick, MD, MS
Professor an d Vice Ch airm an
Residen cy Program Director
Co-Director, Sp in al Su rger y Program
Dep ar t m en t of Neu rological Su rger y
Un iversit y of Wiscon sin Sch ool of Med icin e an d Pu blic
Health
Mad ison , Wiscon sin
Ro berto Rey-Dio s, MD
Assistan t Professor of Neurosurger y
Un iversit y of Mississip pi Medical Cen ter
Jackson , Mississipp i
Boyd F. Richards, DO
Dep ar t m en t of Neu rological Su rger y
St . Joh n Providen ce Health System
Mich igan Spin e an d Brain Su rgeon s
South eld, Mich igan
Michael K. Ro sner, MD
Ch ief of Neurosurger y In tegrated Ser vice
Assistan t Professor
Un iform ed Ser vices Un iversit y
Walter Reed Nat ion al Militar y Medical Cen ter
Wash ington , DC
Ali Shirzadi, MD
Neurosurgeon
South Bay Brain an d Spin e
San Jose, Californ ia
xvii
xviii
Contributors
Branko Skovrlj, MD
Residen t in Neu rosu rger y
Icah n Sch ool of Medicin e at Moun t Sin ai
New York, New York
An an d Veeravagu, MD
Ch ief Residen t in Neurosu rger y
Stan ford Un iversit y
Stan ford, Californ ia
Michael Y. Wang, MD
Depar t m en t s of Neu rological Surger y & Reh abilitat ion
Medicin e
Un iversit y of Miam i
Miller Sch ool of Medicin e
Miam i, Florida
Introduction
Preprocedure Considerations
Radiographic Imaging
Indications
Su rgical in ter ven t ion is app ropriate for epidural hem atom as
Medications
Preoperat ive an t ibiot ics: eith er a ceph alosporin or van com y
h ead h old er, rath er th an a th ree-pin ion h ead h older, to facilit ate m ore rapid progression to brain decom pression .
The operative eld should be prepared using an iodine-based
sterile prep solution, provided the patient has no iodine allergies.
Th e use of ch lorh exidin e is con t roversial; product in ser t in form at ion bars th e u se for p rocedu res exp osing th e cerebral
m en inges. In cases w ith kn ow n bet adin e or iodin e allergies,
ch lorh exidin e or alcoh ol prep can be u sed.
Th e in cision s are m arked an d, after n al sterile draping, in lt rated w ith 1% lidocain e w ith epin eph rin e 1:100,000.
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.
Operative Procedure
Positioning (Fig. 1.2a, b)
Figure
Procedural Steps
Pearls
Fig. 1.2
Discuss positioning with the anesthesiology team . The endotracheal tube (ETT) should
exit the contralateral side of the m outh if placed orally, and should be secured in place
using tape, ETT collar, etc. The eyes should be protected from corneal abrasion by placing
ointm ent under each lid and taping the lids shut.
Allowance for central venous catheters, peripheral intravenous catheters, and arterial
lines should be m ade, with these positioned toward the anesthesiology team if possible.
Foley catheters should always be placed and should be accessible to the anesthesia team .
Pin xation may also be used, but positioning on a doughnut or horseshoe head holder
m ay expedite decompression of the brain.
The head should be positioned just at or slightly overhanging the end of the table and the
sterile craniotomy drape placed so that it hangs vertically to facilitate drainage of irrigation
by gravit y. Final draping should exclude the anesthesia setup, using a vertical drape.
An exit site for a subgaleal drain should be included in the area exposed by the sterile draping.
Reverse Trendelenburg positioning m ay be used to provide elevation of the head to help
reduce cerebral edem a.
Figure
Procedural Steps
Pearls
Fig. 1.3
Other skin incisions m ay be utilized to evacuate sm aller hematom as. However, before
com mit ting to a m ore lim ited exposure, consideration should be given to the degree of brain
swelling anticipated.
When using a question m ark incision, care should be taken not to place the incision too close to
the pinna of the ear. A m argin of at least 1 cm should be used. Likewise, the vertical lim b of the
incision should be placed at least 1 cm anterior to the tragus. The scalp m ay be elevated o of
the underlying bone and retracted out of the way.
Scalp clips m ay be applied to the scalp edges to aid in hem ostasis.
Prior to opening the scalp over the temporalis m uscle, an instrum ent m ay be passed over
the m uscle fascia and the skin divided down to the level of the instrum ent with a scalpel. The
temporalis m ay then be divided in parallel with the incision using Bovie cautery.
Branches of the super cial and m iddle temporal arteries may be encountered and m ay be
ligated and divided sharply, or cauterized with the bipolar cautery.
Figure
Procedural Steps
Pearls
Fig. 1.4
Figure
Procedural Steps
Pearls
Fig. 1.5
Figure
Procedural Steps
Pearls
Fig. 1.6
hem atom a and liquid blood. The hem atom a is often adherent to the
bleeding vessel, com monly the m iddle m eningeal artery in the anterior
temporal area. This, in turn, m ay be associated with a fracture of the
squam ous portion of the temporal bone.
Figure
Procedural Steps
Pearls
Fig. 1.7
For curvilinear incisions, at least 1 cm of dura should be left bet ween the
Figure
Procedural Steps
Pearls
Fig. 1.8
The subdural
hematoma (SDH) is
seen overlying the
surface of the brain
and is evacuated w ith
irrigation and suction.
The source of any SDH should be sought. The source is often a cortical surface vein or artery.
10
Figure
Procedural Steps
Pearls
Fig. 1.9
Closure of the dura should be a ected in a watertight fashion if possible. Over the
convexit y, watertight closure is not imperative. The dura may be closed with simple
running, running-locking, or interrupted sutures.
For large dural defects not am enable to prim ary closure due to shrunken dura, torn
or adherent dura (com m on in the elderly), and/or brain swelling, a variet y of dural
substitute m aterials are available. The dura m ay be patched with suturable graft
m aterials or autograft from the patients own galea or m uscle fascia, or closed with
graft m aterials alone.
Prior to placing the nal few sutures, the subdural space should be irrigated a nal
tim e. When a large subdural potential space rem ains (as in the case of an elderly
patient and/or one with a slack brain), a sm all am ount of irrigation m ay be left in the
subdural space to lessen the risk of extensive postoperative pneum ocephalus.
11
12
Figure
Procedural Steps
Pearls
Fig. 1.10
and sizes, are available. These are generally m ade of titanium , which is
nonm agnetic, allowing for later m agnetic resonance im aging.
Resorbable plates and screws are available for children. Alternatively, the
bone ap m ay be replaced with silk suture to avoid rigid xation in the
growing skull.
Figure
Procedural Steps
Pearls
Fig. 1.11
The drain should exit from a separate stab incision, formed with a trocar or
no. 11 knife, and should be secured at its skin exit site with a nylon stitch.
The drain is at tached to bulb suction.
13
Closing
Pat ien ts w ith severe inju ries w ill likely h ave addit ion al in -
vasive n eu rom on itoring (an ICP, extern al ven t ricu lar drain ,
brain t issue oxygen m on itor, or a com bin at ion th ereof) to
gu ide m an agem en t . Invasive h em odyn am ic m on itoring (arterial lin e, cen t ral ven ous lin e, Sw an -Gan z cath eter) m ay be
in dicated to assist m an agem en t in crit ically ill pat ien t s.
Drain s sh ou ld be m on itored for ou t pu t ever y 4 h ou rs for th e
rst 8 h ou rs an d th en ever y 8-h ou r sh ift .
Th e in cision an d/or dressing sh ould be m on itored for bleeding in it ially, an d for er yth em a, exudate, an d /or edem a subsequen t to th e in it ial postoperat ive period.
Medication
Postop erat ive an t ibiot ics are con t in u ed for 24 h ou rs u n less
Radiographic Imaging
Postoperative Management
Monitoring
Further Management
Drain s are rem oved on th e rst p ostop erat ive day, provid ed
14
input h as slow ed su cien tly. If th ere is sign i can t out p ut , rem oval m ay be d elayed an oth er 1 to 2 days.
Th e dressing is rem oved an d th e w oun d is clean sed w ith
w arm w ater an d m ild soap or sh am p oo after 24 h ou rs.
Skin su t u res or st ap les are rem oved on or abou t p ostop erat ive day 10 to 14.
b
Fig. 1.12a, b Axial CT images demonstrating resolution of (a) epidural hematoma and (b) subdural hematoma.
Special Considerations
Preoperat ive plan n ing is im port an t in th e m an agem en t of t raum at ic SDHs. Plan n ing for p ossible decom p ressive cran iectom y
m u st often be in corp orated in to th e p osit ion ing, in cision , an d
bon e ap creat ion (see Ch apter 4). Pat ien t s w h o are likely to
require th e bon e ap to be left out in clude th ose w ith m idlin e
sh ift ou t of p roport ion to th e th ickn ess of th e SDH, th ose w ith
e aced cistern s, th ose w ith blu n t vascu lar inju r y or isch em ia to
th e a ected h em isph ere, or th ose w ith a sign i can t am oun t of
u n derlying con t u sion .
References
1. Bu llock MR, Ch esn u t RM, Clifton GL, et al. Man agem en t an d
progn osis of severe t raum at ic brain injur y. J Neu rot raum a 2000;
17:449597
2. Bu llock MR, Ch esn u t R, Gh ajar J, et al. Su rgical m an agem en t of
acute epidural h em atom as. Neurosurger y 2006;58:S7S15
3. Bu llock MR, Ch esn u t R, Gh ajar J, et al. Su rgical m an agem en t of
acute subdural h em atom as. Neurosurger y 2006;58:S1624
4. Bu llock et al. An t iseizu re p rop hylaxis. In : Guidelin es for th e
Man agem en t of Severe Traum at ic Brain Injur y, 3rd ed. J Neurot raum a 2007;24:S8386
15
16
Introduction
Indications
Ch ron ic su bdu ral h em atom a (CSDH) is on e of th e m ost com m on ly t reated n eu rosu rgical disord ers in th e w orld. Th e 2006
Am erican Associat ion of Neurological Surgeons procedural survey rep or ted over 43,000 bu r h oles perform ed for th e evacu at ion of ext ra-axial (subdural/epidural) h em atom as.1 Th e m ost
com m on pat ien t ch aracterist ics are elderly m ales w ith or w ith out a h istor y of h ead t rau m a.2,3 Addit ion al risk factors in clu de a
h istor y of alcoh olism , th e p resen ce of an in tern al cerebrosp in al
u id (CSF) sh u n t , an d acqu ired or congen it al bleeding d iath esis.4 CSDHs are often u n ilateral, bu t p resen t as bilateral in ap p roxim ately 16 to 25%of cases.3,5 Th e m ost com m on presen t ing
sym ptom s in clu de h eadach e, ataxic gait , con fu sion , ap h asia,
an d variou s n on speci c com p lain t s. If th e CSDH is large an d
causes sign i can t m ass e ect , paresis, seizure, an d com a m ay
en su e. Mort alit y st at ist ics var y am ong in st it u t ion s, bu t gen erally range from 5 to 16%.6,7
Several th eories exist to exp lain th e p ath ogen esis of CSDH.
The prevailing hypoth esis is th at m ost start as acute subdural
bleeds th at t rigger a local in am m ator y respon se in th e surroun ding m en inges. In am m at ion t riggers th e m igrat ion of broblast s, w hich th en create m em bran es th at organ ize th e clot
an d secrete vascu lar en doth elial grow th factor (VEGF) th at , in
t urn , prom otes th e form at ion of capillaries w ith in th ese m em bran es.8 Over t im e, th ese m em bran e capillaries bleed an d preven t th e blood from being reabsorbed. Hem oglobin even t u ally
is broken dow n in to h em osiderin , leading to th e ch aracterist ic
ap p earan ce of CSDH on com pu ted tom ograp hy (CT)/m agn et ic
reson an ce (MR) im aging (Fig. 2.1).
Man agem en t of CSDH t yp ically involves su rgical evacu at ion
of th e clot an d placem en t of post surgical drains to preven t reaccum ulation of blood in th e subdural space. In part icular, th e use
of drain s after bur h ole evacuat ion of CSDH has been sh ow n to
redu ce both recu rren ce an d m ort alit y at 6 m on ths.9 Several op erat ive ap proach es are available. Bu r h ole drain age is perform ed
m ost com m on ly. A m in i-cran iotom y m ay augm en t visu alizat ion of th e subdural space. W hen th e radiograph ic appearan ce
is favorable, bedside p roceduressuch as m in im ally invasive
t w ist drill cath eter placem en t or suct ion evacu at ion can be
u sed to good e ect . In addit ion to th ese su rgical tech n iques,
several sm all st u dies h ave suggested th at dexam eth ason e
therapy m igh t sh ow som e prom ise in t reat ing CSDH.10,11 New er
p h arm acological t reat m en t , such as th e u se of t ran exam ic acid
(an an t ith rom bolyt ic agen t), is invest igat ion al.12 CSDH recu rren ce rates var y am ong in st it u t ion s, bu t gen erally range from
8 to 16%.13,14 Several st udies h ave suggested that CSDH recurren ce rates are h igh er w ith bilateral CSDH, w ith large volum es
of pn eum oceph alus after evacuat ion , an d w ith use of an t icoagu lat ion th erapy.13,14
All Procedures
Su bacu te or ch ron ic su bdu ral h em atom a w ith m axim u m
Minimally Invasive
Favorable CT im aging ch aracterist icsa un iform ly isoden se
Preprocedure Considerations
Radiographic Imaging (Figs. 2.1,
2.2, and 2.3)
X-ray: In gen eral, X-ray is a poor diagn ost ic tool for CSDH.
Medications
In t raven ou s (IV) an t ibiot ics sh ou ld be given w ith in 1 h ou r
p rior to in cision . Th e u se of prophylaxis in th e set t ing of m in im ally invasive bedside p rocedu res is left to th e discret ion of
th e su rgeon .
An t iepilept ic drug prophylaxis sh ould be adm in istered.
Sedat ion for bed side procedu res sh ou ld be adm in istered w ith
caut ion . Min im ize dosing or avoid sedat ion , if possible, as pat ien t s w ith CSDH m ay be par t icularly sen sit ive to its e ects.
On e of th e ben e ts of th e bedside SDH drain age p rocedu re
is th e possibilit y to w it n ess rapid n eu rologic im p rovem en t
b
Fig. 2.2a, b Large right frontoparietal subdural hematoma causing mass e ect and right ventricular e acement. There are some septations within
the mixed densit y subdural. A small craniotomy was chosen to evacuate the collection.
17
18
Time
Appearance relative
to brain parenchyma
Hyperacute (, 24 hours)
Acute (12 days)
Subacute (213 days)
Chronic (. 14 days)
Hypo-/isodense
Hyperdense
Isodense
Hypodense
T1
T2
Hypo-/isointense
Hypo-/isointense
Hyperintense
Hyperintense
Hypointense
Hyperintense
Hypointense
Hypointense
Hyperintense
Hyptointense
Operative Procedure
Bur Hole Drainage
Positioning and Skin Incision (Fig. 2.4a, b)
Figure
Procedural Steps
Pearls
Fig. 2.4
a neutral position.
Trace out a reverse question m arkt ype
incision over the a ected hem isphere. This
will facilitate a m ore extensive opening, if
necessary. The planned bur hole incision
sites should fall along the superior lim b of
the question m ark.
If the CT appearance of the extra-axial uid
is both hypodense and homogeneous, it
m ay be possible to drain the collection
through a single bur hole.
19
20
Figure
Procedural Steps
Fig. 2.5
A no. 10 blade is used to open each incision to the level of pericranium. The
pericranium is opened w ith Bovie electrocautery and sw ept to either side
w ith a periosteal elevator. For the craniotomy, scalp clips are applied to the
scalp edges. The temporalis is incised and is re ected w ith the skin incision.
Self-retaining retractors are placed.
Pearls
Bur Holes
Bur holes should be 1.5 to 2 cm
Craniotomy
Resistance m ay be encountered
in diam eter.
Figure
Procedural Steps
Pearls
Fig. 2.6
Bur Holes
The posterior site should be
Craniotomy
When subdural hem atom a is
21
22
Figure
Procedural Steps
Pearls
Fig. 2.7
23
24
Figure
Procedural Steps
Pearls
Fig. 2.8
Bur Holes
On occasion, the brain expands to ll the
Craniotomy
Compressed gelatin sponge can be used to
Closing
25
Operative Procedure
Tw ist Drill Craniostomy
Positioning and Skin Incision (Fig. 2.9)
26
Figure
Procedural Steps
Pearls
Fig. 2.9
Figure
Procedural Steps
Pearls
Fig. 2.10
The dura is usually penetrated w ith the drill bit. Alternatively, a no. 11
blade or spinal needle can be used.
27
28
Figure
Procedural Steps
Pearls
Fig. 2.11
Closing
Th e in sert ion site is closed aroun d th e cath eter w ith 3-0
Postoperative Management
Monitoring
Pat ien t s are m on itored in an in ten sive care u n it to obser ve for
29
a
Fig. 2.13a, b (a) The drain collection bag is initially leveled with the drip chamber 0 mark at or just below the level of the patients ear. Note the
approximately 20-mL chronic subdural hematoma uid already in the drip chamber. (b) As more SDH is evacuated, and the pressure decreases in the
subdural space, the drip chamber is gradually lowered.
Medication
An t iconvu lsan ts are adm in istered for a tot al of 7 days.
For cran iotom ies an d bu r h oles, an t ibiot ics are con t in ued for
24 h ou rs postoperat ively.
Dexam eth ason e, in a 2-w eek tapering dose, m ay be u sed if
m ild exp an sion of th e residu al collect ion is n oted in th e postoperat ive period.
It is recom m en ded th at p at ien t s rem ain o an t icoagu lan t/
an t iplatelet agen ts u n t il th e residu al su bdu ral collect ion s
resolve.
Radiographic Imaging
A postop erat ive CT scan is perform ed to evalu ate th e exten t
30
b
Fig. 2.15a, b (a) Postoperative CT of patient in Fig. 2.2 undergoing craniotomy for subdural evacuation. There is a Jackson-Prat t drain in the
subdural space and mild pneumocephalus with improvement in mass e ect. (b) Delayed scanning after drain removal revealed further decrease in
the residual collection.
Special Considerations
Su bdu ral reaccu m u lat ion is a kn ow n risk of op erat ive t reatm en t . Reop erat ion m ay be n ecessar y. A secon d reaccu m u lat ion
m ay requ ire su bd u ralperiton eal sh u n t ing (w ith ou t a valve),
w h ich m ost often resolves th is di cult problem .
References
Fig. 2.16 Post-drainage CT of patient in Fig. 2.3 shows a signi cant
decrease in the size of the chronic subdural hematoma, and decreased
midline shift. The tip of the subdural catheter can be seen in the subdural
space (arrow).
1. Nat ion al Neu rosu rgical Procedu ral St at ist ics. Rolling Meadow s,
IL: Am erican Associat ion of Neu rological Su rgeon s; 2006
2. Mori K, Maeda M. Su rgical t reat m en t of ch ron ic su bdu ral h em atom a in 500 con secu t ive cases: clin ical ch aracterist ics, surgical
ou tcom e, com plicat ions, an d recurrence rate. Neurol Med Ch ir
2011;41(8):371381
31
32
Introduction
Cerebral con t usion s are obser ved in up to 8.2% of all t raum at ic
brain injuries 1,2 an d are m ore com m on (1335% of pat ien ts) in
th e set t ing of severe t raum at ic brain injur y.1,37 W h ile con t usion s can occu r in alm ost any lobe, m ost occu r in th e fron t al an d
tem poral lobes.8,9 Most sm all lesion s w ill n ot require su rgical
in ter ven t ion 1,3,10,11 ; th e m ajorit y w ill reabsorb in 4 to 6 w eeks.
Indications
Guidelin es m ay assist clin ical decision m aking w ith respect
to w h ich con t u sion s m igh t requ ire su rgical in ter ven t ion .1
Operat ive in ter ven t ion is in dicated in th e set t ing of:
A fron t al or tem p oral con t u sion of greater th an 20 cm 3 in
volu m e an d associated w ith any of th e follow ing:
Glasgow Com a Scale (GCS) score 6 to 8
Midlin e sh ift at least 5 m m
Cistern al com pression
Preprocedure Considerations
Radiographic Imaging
Non con t rast h ead CT is vit al in th e evalu at ion of all severe
t raum at ic brain injuries. CT allow s for an atom ic localizat ion of
su rgical path ology an d, in t u rn , facilitates p lan n ing of p at ien t
posit ion ing an d operat ive approach .
Pre o pe rative im aging (Fig 3.1).
a
Fig. 3.1a, b Axial CT images demonstrating (a) frontal and (b) temporal lobe cerebral contusions.
33
Medication
p rop hyla xis, p rovid ed t h e p at ien t d oes n ot h ave ren al failu re or any ot h er con t rain d icat ion s. Given t h e in creasin g
p revalen ce of m et h icillin -resist an t Staphylococcus aureus,
it is p ossible t h at t h e skin can or w ill be colon ized by t h is
m icroorgan ism .
An t ie p ile p t ic p rop h yla xis sh ou ld be p rovid e d . Fosp h e nyt oin m ay b e a d m in ist e re d in a loa d in g d ose of 1 7 t o 2 0 m g
p h e n yt oin e qu ivale n t s (PE)/kg in n on a lle r gic p at ie n t s w h o
are n ot on st a n d in g a n t ie p ile p t ic m e d icat ion ; a lt e r n at ely,
levet ira cet a m m ay b e ad m in ist e re d at a load in g d ose of
2 0 m g/kg.
34
Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
Operative Procedure
Bicoronal Approach
Positioning (Fig. 3.2)
Figure
Procedural Steps
Pearls
Fig. 3.2
35
Figure
Procedural Steps
Pearls
Fig. 3.3
Mark out a bicoronal incision, starting at the level of zygoma and extending
superiorly tow ard the midline, just posterior to the hairline. Carry the
incision across midline, in a mirror fashion, to the contralateral zygoma.
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
Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
Figure
Procedural Steps
Pearls
Fig. 3.4
37
38
Figure
Procedural Steps
Pearls
Fig. 3.5
Bur holes are placed w ith a high-speed drill at the follow ing sites: just
above the root of zygoma; at the keyhole ; and just above superior temporal
line, anterior to coronal suture. An additional pair of holes are placed
straddling the midline, anterior to coronal suture. The base of each hole
is cleared w ith a curette. The dura is stripped from the undersurface of
the bone, locally and betw een each pair of holes, w ith a separator (e.g.,
Pen eld no. 3, Hoen, or similar).
Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
Figure
Procedural Steps
Fig. 3.6
The craniotome is used to connect each pair of bur holes circumferentially, taking
care to stay low in the frontal and temporal regions and making the nal cut in the
region of the superior sagittal sinus. The bone ap is carefully elevated aw ay from
the underlying dura and set aside in antibiotic solution.
Bone w ax is applied to the bony edges w here necessary. Bleeding along the
midline sagittal sinus may be controlled w ith a combination of brillar hemostatic
material, thrombin-soaked gelatin sponge, and hemostatic matrix sealant. If all
other measures fail, the superior sagittal sinus may be ligated anteriorly, at the
level of the crista galli.
39
Figure
Procedural Steps
Pearls
Fig. 3.7
(a) The dural opening is initiated w ith a no. 15 blade and enlarged
w ith tenotomy scissors. A strip of moistened nonadherent bandage
or a cotton pattie may be introduced into the subdural space to
protect the underlying cortex. A trap-door type opening ( apped
tow ard the midline) provides w ide access to the frontal lobe. If access
to the temporal fossa is necessary and/or ligation of the sagittal
sinus anticipated, dural slits are made initially parallel to the anterior
portion of the sinus and the dural opening extending laterally and
inferiorly tow ard the middle fossa on either side. The dural aps are
secured under modest tension w ith 4-0 braided nylon stitches.
40
(b) It may be necessary to divide the superior sagittal sinus and falx
in order to achieve adequate decompression of the frontal lobes.
After release of the sinus, use a double ligature technique to occlude
the sinus, using a 2-0 polypropylene or nylon suture. Make a double
circular course across the falx, just below the level of the sinus,
and cinched tightly to occlude the sinus. Repeat this process w ith a
second stitch, anterior to the rst.
(c) Sever the sinus between the ligatures and divide the subadjacent falx
in its entirety to complete the exposure.
Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
Figure
Procedural Steps
Pearls
Fig. 3.8
(a) Inspect the cortical surface. Select your site for entryan
area of obvious contusion or cortical disruption is ideal.
41
42
Figure
Procedural Steps
Pearls
Fig. 3.9
Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
Figure
Procedural Steps
Pearls
Fig. 3.10
43
Figure
Procedural Steps
Pearls
Fig. 3.11
44
Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
Figure
Procedural Steps
Pearls
Fig. 3.12
The pericranium and temporal fascia and muscle are opened in line w ith the
scalp incision, using monopolar electrocautery.
45
46
Figure
Procedural Steps
Fig. 3.13
Bur holes are placed w ith a high-speed drill at the follow ing sites: just above
the root of zygoma; at the keyhole ; over the parietal eminence ; and at a point
1 cm lateral to the midline and anterior to coronal suture. The base of each
hole is cleared w ith a curette. The dura is stripped from the undersurface of
the bone, locally and betw een each pair of holes, w ith a separator (e.g., no. 3
Pen eld, Hoen, or similar).
Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
Figure
Procedural Steps
Pearls
Fig. 3.14
The craniotome is used to connect each pair of bur holes circumferentially. It may
be necessary to thin the bone crossing the sphenoid ridge w ith a bur. A no. 3
Pen eld or small, curved periosteal may be introduced along the posterior
margin of the craniotomy to initiate elevation of the bone ap aw ay from the
underlying dura. Once removed, the bone ap is set aside in antibiotic solution.
Temporal exposure m ay be
The dural surface is irrigated. Branches of the middle meningeal artery observed
on the exposed dural surface are coagulated w ith bipolar electrocautery.
47
48
Figure
Procedural Steps
Pearls
Fig. 3.15
The dural opening is initiated over the frontal area with a no. 15
blade and enlarged with tenotomy scissors. A strip of moistened
nonadherent bandage or a cotton pattie may be introduced into
the subdural space to protect the underlying cortex. The dural ap
is secured under modest tension with 4-0 braided nylon stitches.
Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
Figure
Procedural Steps
Pearls
Fig. 3.16
Inspect the cortical surface. Select your site for entry. An area of
obvious contusion or cortical disruption is ideal.
Cauterize the super cial vessels and pia mater at the planned
entry site. Use a no. 11 or no. 15 blade to open the pia. Approach
the hematoma cavity in the subpial plane w ith a combination of
gentle suction and bipolar electrocautery.
(b) Upon entry to the hematoma, suction out any liquid clot and
remove solid clot in a piecemeal fashion. Continue evacuation of
hematoma until gliotic brain is visible on all sides.
49
50
Figure
Procedural Steps
Fig. 3.17
In the event that the temporal lobe is severely contused, consideration may be
given to an anterior temporal lobectomy. While one may resect up to 5 to 6 cm
of the anterior, nondominant temporal lobecarrying out the resection to the
junction of the Rolandic and Sylvian ssures to demarcate the posterior limit
of resection (as in tumor cases)the posterior limit ultimately w ill depend on
w hat the surgeon feels necessary for the patients survival.
Surgery for Cerebral Contusions of the Front al and Tem poral Lobes
Closing
Hem ostasis is at tain ed w ith in th e h em atom a cavit y u sing a
Postoperative Management
Monitoring
It is th e au th ors p ract ice to p lace th e p at ien t in a m on itored
set t ing (e.g., th e in ten sive care u n it) overn igh t in th e p ostop erat ive p eriod to obser ve for seizu re act ivit y or eviden ce of
in t racran ial bleeding or any oth er n eurologic com p licat ion s.
It is also au th ors pract ice to give th ree doses of p rop hylact ic
an t ibiot ics in th e im m ediate postop erat ive p eriod .
Medication
Antiepileptic prophylaxis of choice (phenytoin or levetiracetam )
is m aintained for a total of 7 days.
Radiographic Imaging
Postoperat ive im aging (Fig. 3.18).
Further Management
Skin su t u res or staples are rem oved after 2 w eeks.
b
Fig. 3.18a, b Axial CT images after evacuation of (a) frontal and (b) temporal lobe contusions. In each case, an external ventricular drain has been
placed to facilitate monitoring of intracranial pressure and therapeutic drainage of cerebrospinal uid.
51
References
1. Bullock MR, Chesnut R, Ghajar J, et al. Surgical m anagem ent
of traum atic parenchym al lesions. Neurosurger y 2006;58(3):
S2546
2. Singou n as EG. Severe h ead inju r y in a p aediat ric pop u lat ion .
J Neu rosu rg Sci 1992;36:201206
3. Gallbraith S, Teasdale G. Pred ict ing th e n eed for op erat ion in th e
pat ien t w ith an occult t raum at ic in t racran ial h em atom a. J Neurosurg 1981;55:7581
4. Gen n arelli T, Spielm an GM, Lang t t T, et al. In u en ce of th e t yp e
of in t racran ial lesion on outcom e from severe h ead inju r y. J Neurosurg 982;56:2632
5. Jallo J, Narayan RK. Gen eral prin cip les of cran iocerebral t rau m a an d t raum at ic hem atom as. In : Sekhar LN, Fessler RG, eds.
Atlas of Neurosurgical Tech n iques. New York: Th iem e; 2006:
895905
52
Introduction
The use of a decom pressive craniectom y to treat the sym ptom s of
intracranial hypertension w as rst proposed in the late 19th cen tur y by Sir Victor Horsley.1 Koch er popularized its use in Europe.
Cushing introduced it in the United States in the early 20th
cent ur y as a palliative treatm ent for m ultiple conditions causing intracranial hypertension, including tum ors, hydrocephalus,
an d traum a.2 Th e operation fell in to disfavor as advances in neurosurgery during the rst half of the 20th century transform ed
m ost of the original indications for decom pressive craniectom y
into treatable conditions. In the 1970s, advances in life support
increased the sur vival of patients w ith severe head injuries. This
operation was revisited w ith the goal of treating traum atic brain
injury patients w ith intracranial hypertension not responsive to
m edical treatm ent.3,4 A collection of good results over th e past
t wo decades 57 h as turn ed decom pressive craniectom y surgery
into an accepted option for the m anagem ent of severe traum atic
brain injury w ith refractory intracranial hypertension; new indications are being explored. Several st udies have dem onstrated a
decrease in m ortalit y and im proved outcom es w hen this operation is perform ed in the correct patient population.810
Indications
Th ere is accum ulated eviden ce to suppor t th e use of decom -
Preprocedure Considerations
Radiographic Imaging
Com pu ted tom ography (CT) is th e m ost com m on im aging
m odalit y u sed to evalu ate poten t ial can didates for a decom pressive cran iectom y. CT im ages n ot on ly dem on st rate acu te
in t racran ial path ology bu t also provide in form at ion con cern ing bony an atom ic lan dm arksuseful for surgical p lan n ing
an d allow for iden t i cat ion of sku ll fract u res th at m igh t
com plicate th e operat ion .
53
a
Fig. 4.1a, b Axial CT images for t wo patients(a) one with traum atic brain injury and (b) one with a large right MCA strokeselected for
decompressive craniectomy.
Medication
If the patien t is sh ow ing sign s of im m inent neurologic deterio-
54
Operative Procedure
Decompressive Hemicraniectomy (Frontotemporoparietal [Occipital]
Craniectomy)
Positioning (Fig. 4.2)
Figure
Procedural Steps
Pearls
Fig. 4.2
55
Figure
Procedural Steps
Pearls
Fig. 4.3
56
Figure
Procedural Steps
Pearls
Fig. 4.4
57
Figure
Procedural Steps
Pearls
Fig. 4.5
A no. 3 Pen eld is used to strip the dural attachments from the
undersurface of the calvarium at each bur hole site (and betw een
holes, w here feasible). The craniotomy is performed using a
craniotome. At the level of the sphenoid w ing, a small bur can be
used to thin the bone betw een the craniotome cuts above and
below the ridge.
58
Figure
Procedural Steps
Pearls
Fig. 4.6
59
60
Figure
Procedural Steps
Pearls
Fig. 4.7
Figure
Procedural Steps
Pearls
Fig. 4.8
61
62
Figure
Procedural Steps
Pearls
Fig. 4.9
Figure
Procedural Steps
Pearls
Fig. 4.10
63
64
Figure
Procedural Steps
Fig. 4.11
Figure
Procedural Steps
Pearls
Fig. 4.12
65
66
Figure
Procedural Steps
Pearls
Fig. 4.13
Figure
Procedural Steps
Pearls
Fig. 4.14
67
68
Figure
Procedural Steps
Pearls
Fig. 4.15
(a) The dura is opened in a broad, U-shaped fashion w ith the base oriented
posteriorly. The initial opening is made anteriorly, on either side of the
midline. (b) The anterior portion of the sagittal sinus is ligated using tw o
silk sutures and severed betw een the ligatures. (c) The opening is carried
laterally and once enough exposure is obtained, the falx should be divided
completely. At the temporal corners of the opening, a Y-shape incision can be
performed to release tension and allow the dural ap to fall posteriorly.
Figure
Procedural Steps
Pearls
Fig. 4.16
69
Closing
tem p oralis m u scle su r faces to avoid su bgaleal h em atom a accu m u lat ion , w h ich w ou ld d efeat t h e p u r p ose of t h e
op erat ion .
If act ive bleeding is p resen t at th e in terface bet w een th e du ra
an d bon e edge, ep idu ral tack-u p su t u res can be p laced . Th is
is m ostly h elp fu l along th e superior fron topariet al edge (adjacen t to th e m idlin e), w h ere ven ous bleeding can som et im es
be profu se.
A su bgaleal d rain (u su ally a 10-m m Jackson -Prat t [JP]) is left
in p lace.
Th e scalp is closed in a single layer, using 2-0 vert ical m att ress m on o lam en t sut ures.
Postoperative Management
Monitoring
Im m ed iately p ostop, th e blood p ressu re m u st be m on itored
closely an d kept w ith in a t igh t rangeh igh en ough to guaran tee good cerebral p erfu sion pressu re bu t n ot so h igh as to
risk h em orrh age.
Placem en t of an invasive pressu re m on itor is st rongly recom m en ded, if n ot already don e, to p erm it accu rate assessm en t
of ICP in th e postop period.
JP drain ou t pu t sh ou ld be m on itored . Th e drain is u su ally
left in p lace for up to 48 h ou rs. CSF in th e drain is n orm al
an d act u ally ben e cialboth for ICP con t rol an d to preven t
leakage from th e in cision . Focal p oin t s of leakage along th e
in cision lin e sh ou ld be addressed prom ptly w ith sut ure rein forcem en t an d, if persisten t , prom pt con sid erat ion of fur th er
radiograp h ic invest igat ion .
Nu rsing st a m u st be in st ru cted to exercise st rict cran iectom y p recau t ion s, in cluding posit ion ing of th e h ead to preven t
any pressu re on th e defect , avoidan ce of t igh t dressings, an d
rem oval of any equ ipm en t in th e vicin it y th at could injure th e
u np rotected brain .
Medication
Radiographic Imaging
Mobilizat ion of th e pat ien t du ring th e rst 24 h ou rs m u st
Further Management
Th e ICP m on itor can be rem oved if th e values h ave been sta
70
th e postoperat ive period, w h ile th e pat ien t rem ain s in t u bated an d at risk for in t racran ial hyp erten sion . Neu rom u scu lar
blockade can be in t roduced for pat ien t s w ith h igh er ICP valu es or severe respirator y com plicat ion s.
Hyperosm olar th erapyw ith m an n itol or hyper ton ic salin e
is app ropriate if th e ICP rem ain s h igh after decom pression
an d rep eat CT iden t i es n o sp ace-occu pying lesion s am en able to surgical th erapy.
Periop erat ive an t im icrobial prop hylaxis is given for 24 h ou rs
(or un t il th e JP drain is rem oved).
If th e pat ien t p resen ted w ith an op en sku ll fract u re, pen et rat ing brain inju r y, or degloving injur y of the scalp, a lon ger cou rse of t riple an t ibiot ic th erapy sh ou ld be con sidered .
Fig. 4.17a, b Axial CT images for t wo patients who underwent decompressive craniectomies for (a) traumatic brain injury and for (b) a large MCA
stroke. Note that in the case of the MCA stroke, the craniectomy was tailored to encompass the infarcted area only.
Special Considerations
Intraoperative ultrasound can be useful in this context. Postoperative im aging should be obtained as soon as possible.
A severely dam aged scalp an d/or sign i can t soft t issue loss
of the dura. W hen this happens, it m ust be addressed expedien tly to prevent herniation of the brain and shearing against
the dural and bone edge. Earlier in this chapter w e explained
our technique of slow ly opening the dura as the duraplast y
graft is being sut ured in place to allow for gradual expan sion
of the brain. If the surgeon instead has opened the dura com pletely and brain herniation occurs, the follow ing m easures
should be taken :
References
1. Horsley V. Address in Su rger y: Delivered at th e seven t y-fou r th
an n ual m eet ing of th e brit ish m edical associat ion . Br Med J
1906;2(2382):411423
2. Cu sh ing H. Tech n ical m eth ods of p erform ing cer t ain cran ial op erat ion s. Surg Gyn ecol Obstet 1908;3(6):227246
3. Kjellberg RN, Prieto A Jr. Bifron t al d ecom p ressive cran iotom y for
m assive cerebral edem a. J Neurosurg 1971;34(4):488493
71
72
13. Sch irm er CM, Hoit DA, Malek AM. Decom p ressive h em icran iectom y for th e t reat m en t of in t ract able int racranial hyperten sion after an eur ysm al subarach n oid h em orrh age. St roke
2007;38(3):987992
14. Ste n i R, Lat ron ico N, Corn ali C, Rasu lo F, Bollat i A. Em ergen t
decom pressive cran iectom y in p at ien t s w ith xed dilated p u p ils
du e to cerebral ven ou s an d du ral sin u s th rom bosis: rep or t of
th ree cases. Neu rosu rger y 1999;45(3):626629
15. Adam o MA, Desh aies EM. Em ergen cy decom pressive cran iectom y for fulm in at ing infect ious en ceph alit is. J Neu rosurg
2008;108(1):174176
16. Coloh an AR, Gh ost in e S, Esp osito D. Exploring th e lim it s of su rvivabilit y: rat ion al in dicat ion s for decom p ressive cran iectom y
an d resect ion of cerebral con t u sion s in adu lt s. Clin Neu rosu rg
2005;52:1923
17. Flan n er y T, McCon n ell RS. Cran iop last y: w hy th row th e bon e ap
out? Br J Neurosurg 2001;15(6):518520
18. In am asu J, Ku ram ae T, Nakat su kasa M. Does di eren ce in th e
storage m eth od of bon e ap s after d ecom p ressive cran iectom y
a ect th e in ciden ce of su rgical site in fect ion after cran iop last y?
Com parison bet w een su bcu t an eou s p ocket an d cr yopreser vat ion . J Traum a 2010;68(1):183187; discussion 187
19. Jiang JY, Xu W, Li W P, et al. E cacy of st an dard t rau m a cran iectom y for refractor y in t racran ial hyper ten sion w ith severe
t raum at ic brain injur y: a m ult icenter, prospect ive, ran dom ized
cont rolled st udy. J Neurot rau m a 2005;22(6):623628
20. Ch oi I, Park HK, Ch ang JC, Ch o SJ, Ch oi SK, Byu n BJ. Clin ical
factors for th e develop m en t of p ost t rau m at ic hydrocep h alus after decom pressive cran iectom y. J Korean Neurosurg Soc
2008;43(5):227231
Introduction
Acu te cerebellar p ath ologyin th e form of h em orrh age, sw elling, an d/or in farct ion rep resen ts on e of th e m ost urgent an d
t reach erou s of n eurosurgical em ergen cies. Pat ien ts presen t ing
w ith th ese con dit ion s can deteriorate rapidly an d irreversibly.
Posterior fossa h em atom as an d in farct s m ay com p ress th e low er brain stem respirator y an d cardiovascu lar cen ters, t riggering
respirator y arrest an d cardiac in st abilit y.
Em ergen t surgical in ter ven t ion is usually life-saving.14
Tim ely in ter ven t ion len ds it self to a bet ter overall progn osis in
su ch p at ien t s becau se com a often resu lt s from hydrocep h alu s
(u sually reversible) an d brain stem com pression (rath er th an
d est ru ct ion ).510 Also, th e fact th at th e cerebral h em isph eres
rem ain relat ively u n a ected allow s m any of th ese pat ien t s to
retain th eir prem orbid person alit ies an d h igh er-order cogn it ive
fu n ct ion d esp ite presen t ing in com a before su rger y.
Indications
Spontaneous Cerebellar
Hemorrhage
Several factors m u st be con sidered before deciding to op erate:
Size of h em atom a: Surgical in ter ven t ion gen erally is in dicated for lesion s of greater th an 3 to 4 cm to im prove clin ical
con dit ion an d preven t secon dar y deteriorat ion du e to cerebellar sw elling an d h ern iat ion .9,11
Neu rologic st at u s: Th e p resen ce of sign s an d sym ptom s att ribut able to hydroceph alus (agitat ion , con fusion , leth argy),
brain stem com pression (sixth or seven th n er ve palsy, h orizon t al gaze paresis, hem iparesis), or com a sh ould prom pt
em ergen t su rgical in ter ven t ion .
Tim e sin ce ict u s: Pat ien t s presen t ing w ith in 6 to 48 h ou rs of
h em orrh age often experien ce n eu rologic deteriorat ion due to
a com bin at ion of sw elling an d re-h em orrh age. By con t rast ,
th ose presen t ing 5 to 7 days after th e in it ial bleed t ypically
im p rove or rem ain st able.
Issu es t angen t ial to th e p rim ar y path ology: Age, com orbidit ies, social sit u at ion , an d advan ce direct ives also m ust be
taken in to accoun t . A n u rsing h om econ n ed, 80-year-old
pat ien t w ith dem en t ia an d m ult iple m edical com orbidit ies,
presen t ing in com a, m ay n ot an appropriate can didate for
su rgical m an agem en t .1114
Cerebellar Infarction
Th e in dicat ion s for decom pressive surger y are broadly th e
sam e as th ose for h em orrh age. How ever, th e clin ical cou rse
ten ds to evolve m ore slow ly.15,16 Resect ion of th e in farcted
cerebellum itself is seldom h elpful.
Cerebellar h em isph ere in farct ion (due to dist al posterior
in ferior cerebellar arter y [PICA] occlusion ) cau sing brain stem
com pression sh ould be di eren t iatedby com puted tom ography (CT) an d/or m agn et ic reson an ce im aging (MRI)from
brain stem dest ruct ion due to proxim al isch em ia, as th e lat ter
w ill n ot im prove w ith surger y.
Trauma
Pat ien ts p resen t ing w ith posterior fossa epidu ral h em atom a
Preprocedure Considerations
Radiographic Imaging
Non con t rast CT p rovides ad equ ate in it ial im aging in th e set
73
Ventriculostomy
Th e propen sit y of posterior fossa m ass lesions to cause
obst ruct ive hydroceph alu s m ean s th at a presurgical ven t ricu lostom y is alm ost alw ays m an dator y before decom pression .
Failure to do so m ay result in m assive hern iat ion of th e posterior fossa con ten t s in to th e decom pression , cau sing death on
th e operat ing table. Th e ven t riculostom y sh ould be in serted
ver y rap idly to avoid delay in th e deteriorat ing pat ien t , an d
m ay be don e as a p ar t of th e decom pression (see below ).
Occasion ally, in m oribu n d pat ien t s, or in th ose w ith sm aller
posterior fossa h em orrh agic lesion s, a ven t riculostom y m ay
be placed, an d th e pat ien t obser ved an d re-scan n ed in 3 to
4 h ours to determ in e if de n it ive su rger y is in dicated (e.g., if
clin ical im provem en t or en largem en t of h em atom a occurs).
Many au th ors advocate carefu l t it rat ion of th e h eigh t of th e
drain (e.g., st art ing at 30 cm w ater an d th en low ering it by
5 cm w ater decrem en t s ever y h our un t il 10 cm w ater is
reached) in order to avoid upw ard t ran sten torial h ern iat ion .
Th is m ay be m ore im por tan t in th e set t ing of n eoplast ic posterior fossa m ass lesion s, w h ere edem a an d a m ore prot racted
clin ical cou rse m ake th is com plicat ion m uch m ore com m on .
Medication
Th e use of sedat ive-hypn ot ic agen t s sh ould be avoided. Such
m edicat ion s m ay con fou n d th e clin ical exam in at ion an d p recipit ate respirator y depression .
74
exion an d rot at ion , a th reepin ion h ead h older is essen t ial. Th e cross bar sh ou ld be
padded to preven t pressure injur y w ere slippage of th e pin s
to occur (e.g., w h ere th e bridge of th e n ose or foreh ead w ould
con t act th at cross bar).
For evacu at ion of a p red om in an t ly u n ilateral h em atom a,
t h e lateral p ark ben ch p osit ion w it h t h e h ead t u r n ed to
t h e con t ralateral sid e an d exed is su it able. For su bd u ral
or ext rad u ral h em atom as exten d in g bilaterally, an d for
u n ilateral cerebellar in farct ion s (w h ere exten sive foram en
m agn u m d ecom p ression is n eed ed), t h e p ron e p osit ion is
ch osen . For t rau m a cases, w e at tem pt to red u ce/m in im ize
cer vical exion d u r in g p osit ion ing if t h e cer vical sp in e h as
n ot been cleared . Th e cer vical collar is rep laced after t h e
p roced u re.
Eith er an iodin e-based prep arat ion or ch lorh exidin e/alcoh olbased solut ion is u sed for skin preparat ion , taking care th at
th e solut ion does n ot en ter th e eyes, especially in pron e
posit ion . We use a t ran sparen t adh esive dressing lm over
th e eyes to protect th e corn ea.
Th e in cision is m arked an d in lt rated w ith 1% lidocain e w ith
ep in ep h rin e 1:100,000.
75
Operative Procedure
Positioning (Fig. 5.2a, b)
76
Figure
Procedural Steps
Pearls
Fig. 5.2
Make sure to protect the eyes, face, and cervical spine (if not
cleared). Ensure that an arm ored endotracheal tube is used
and secured well (by suture or tape and ties) to the external
face and head holder.
Figure
Procedural Steps
Pearls
Fig. 5.3
The skin incision is alw ays marked prior to skin preparation to avoid confusion after
draping. If positioned prone, a midline incision is planned from the inion to the
spinous process of C2. It can be extended later, if needed. A paramedian incision is
used for unilateral intraparenchymal hematomas.
The entry point for a ventriculostomy (if not placed preoperatively) should be
planned and marked, using anatomic landmarks: 5 cm above the inion and 3 cm
lateral to midline.
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
78
Figure
Procedural Steps
Pearls
Fig. 5.4
Figure
Procedural Steps
Pearls
Fig. 5.5
The bony exposure should extend from the inion to the foramen
magnum. A w ide exposure is needed for cerebellar infarcts,
extending laterally to a centimeter from the mastoid process.
This essentially means incorporating the w hole of the w ide
bony exposure into the craniotomy. A smaller exposure (either
unilateral or bilateral depending upon the pathology) is needed for
hematomas. Additional exposure can be obtained if necessary based
on the CT scan ndings.
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
80
Figure
Procedural Steps
Pearls
Fig. 5.6
(a) Bur holes are placed at the level of the transverse sinus (approximately
1 cm below the inion), to either side of midline. We typically use a perforator
drill; alternately, a matchstick or acorn bur may be employed. A second set of
bur holes can be made at the lateral edge of the craniotomy if the dura is very
stuck to the bone, but typically only tw o are required. (b) For a paramedian
approach, one bur hole is placed in the midline position and one at the lateral
edge of the planned opening.
Figure
Procedural Steps
Pearls
Fig. 5.7
81
Figure
Procedural Steps
Pearls
Fig. 5.8
Clot removal over the sinus may produce heavy bleeding from a sinus tear.
Small amounts of clot stuck to the sinuses should be left intact.
There is no need to open the dura if the brain appears slack after evacuation
of the epidural hematoma. How ever, if the dura is tense, subdural
exploration is indicated to look for any additional clots (subdural or
intracerebellar hematoma).
82
Figure
Procedural Steps
Pearls
Fig. 5.9
83
84
Figure
Procedural Steps
Pearls
Fig. 5.10
The clot is gently suctioned out using no. 9 or no. 12 suction tips. Discrete
bleeding points are identi ed and coagulated. Self-retaining brain
retractors assist the exposure during hemostasis. Fukushima (teardrop side
port) suction tips (e.g., no. 7) may be useful during the hemostasis stage.
The brain w ill usually be slack after clot removal. If not, cerebrospinal uid
drainage from the cisterna magna should be attempted prior to resection
of edematous cerebellum.
Figure
Procedural Steps
Pearls
Fig. 5.11
85
86
Figure
Procedural Steps
Fig. 5.12
Figure
Procedural Steps
Pearls
Fig. 5.13
87
Closing
Postoperative Management
Ventriculostomy
Ven t ricu lostom y is m an dator y to p reem pt recu rren ce of
d
Fig. 5.14ad (a) Axial CT image demonstrating resolution of hydrocephalus following evacuation of a posterior fossa
epidural hem atoma. (b) Axial CT soft tissue and (c) bone windows dem onstrating a tailored approach for evacuation
of an intracerebellar hematoma. (d) Axial CT bone window demonstrating the bony margins of a wide suboccipital
craniectomy for decompression in the set ting of ischemic stroke.
88
Monitoring
Th e pat ien t is obser ved in a m on itored set t ing (in ten sive care
Medication
Prophylact ic an t ibiot ics are con t in ued for 24 h ours, regardless of th e p resen ce of ven t ricu lostom y.
Radiographic Imaging
A n on con t rast CT scan is obt ain ed in th e early postopera-
t ive period to assess th e st at us of th e h em orrh age, decom p ression , an d ven t ricular size. Th e early postoperat ive st udy
also allow s screen ing for th e develop m en t of a delayed epidural or in t racerebral h em orrh age at a dist an t , supraten torial
locat ion w h ich is n ot un com m on .
Po sto perative im aging (Fig 5.14).
Further Management
Th e drain (if presen t) is rem oved over th e n ext 24 to 48 h ours.
Skin su t u res or st aples are rem oved after 1 to 2 w eeks.
References
1. Hayash i T, Kam eyam a M, Im aizu m i S, Kam ii H, On u m a T. Acu te
epidural h em atom a of the posterior fossacases of acute clin ical
deteriorat ion . Am J Em erg Med 2007;25:989995
2. Elliot t J, Sm it h M. Th e acu t e m an age m e n t of in t race reb ral
h e m or rh age: a clin ical review . An est h An alg 2010;110:1419
1427
3. Karasu A, Saban ci PA, Izgi N, Im er M, Sen cer A, Can sever T,
Can bolat A. Trau m at ic epid u ral h em atom as of th e p osterior
cran ial fossa. Surg Neurol 2008;69:247251
4. Koc RK, Pasaoglu A, Men ku A, Oktem S, Meral M. Ext radu ral
h em atom a of th e posterior cran ial fossa. Neu rosurg Rev
1998;21:5257
89
Elevation of Depressed
Skull Fractures
Anand Veeravagu, Bow en Jiang, and Odet te A. Harris
Introduction
Preprocedure Considerations
Depressed cran ial sku ll fract u res often resu lt from h igh en ergy,
blun t , t rau m at ic im pact s. Most depressed fract ures are located
in th e fron topariet al region . Alth ough clin ical p resen tat ion is
variable, ap p roxim ately 25% of p at ien ts w ith dep ressed fract ures presen t w ith loss of con sciousn ess an d clin ical sequelae
of in t racran ial h em orrh age.1
A depressed cran ial fract ure m ay be ch aracterized fu rth er as
open or closed, based on th e in tegrit y of th e overlying scalp .
Closed fract u res, w h erein th e scalp is in tact , m ay be t reated
n on su rgically if th e depth of th e dep ressed segm en t is less th an
th e m easu red w idth of th e calvarial bon e adjacen t to th e fract ure. Open fract ures com m un icate w ith th e extern al environ m en t an d, as su ch , are presu m ed con tam in ated. Su rgical in terven t ion is often requ ired in th ese cases for debridem en t , rep air
of dural lacerat ion s, clean sing of bon e fragm en ts, evacu at ion of
u n derlying h em atom a, an d elevat ion of th e depressed fract u re.
Radiographic Imaging
Com puted tom ography (CT) is th e st an dard im aging m odalit y
Medication
Op en fract u res sh ou ld be t reated con sisten t w ith oth er op en
Indications
90
ch ild .
Dep ression of t h e fract u re segm en t greater t h an 5 m m
below t h e in n er t able of t h e adjacen t calvar ial bon e in an
ad u lt .
Presence of gross contam ination, signi cant ext ra- or int raaxial h em atom a, an d/or pn eum oceph alus suggest ive of a dural tear.
Neu rologic p rogression in th e set t ing of a closed fract u re m ay
be due to an associated expan ding h em atom a or com pressive
e ect of th e depressed bon e fragm en t . In th is case, elevat ion
of th e fract ure is in dicated.
Depressed fract u res crossing du ral ven ou s sin u ses d eser ve
sp ecial con siderat ion . W h ile com pression of a du ral ven ou s
sin u s m ay in du ce elevated in t racran ial p ressu re an d h eigh ten
th e risk of ven ous th rom bosis, th e risk of h em orrh age w ith
fract u re m obilizat ion m ay also be sign i can t . Th erefore, it is
reason able to obser ve a n eurologically st able pat ien t w ith a
closed fract u re overlying a du ral ven ous sin u s. Likew ise, scalp
debridem en t alon e (w ith out fract ure elevat ion ) is an opt ion
for a n eu rologically stable p at ien t w ith an op en fract u re overlying a paten t sin us. A n eu rologically un st able pat ien t , h ow ever, sh ou ld u n dergo elevat ion u rgen tly.
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
Operative Procedure
Positioning (Fig. 6.2)
92
Figure
Procedural Steps
Pearls
Fig. 6.2
Figure
Procedural Steps
Pearls
Fig. 6.3
Super cial debridement may be necessary at the planned incision site for open fractures.
A (a) linear, (a) inverted horseshoe, or (b) lazy-S incision may be selected, based on the
actual fracture location and the presence of a scalp disruption. (b) Scalp lacerations should
be excised as an ellipse and incorporated into the incision if possible. A bicoronal incision is
preferred for access to depressed fractures in the forehead area.
93
Figure
Procedural Steps
Pearls
Fig. 6.4
Bipolar electrocautery is used for hemostasis. The scalp ap can be separated from
the pericranium using a periosteal elevator. The plane betw een pericranium and
galea may be developed w ith sharp dissection.
The temporalis muscle may be exposed and the fascia incised for dissection using
monopolar cautery. Well-preserved muscle can be separated from the underlying
bone using sharp dissection. The muscle should be re ected inferiorly and secured
w ith suture or hook-based retraction.
For closed fractures, the underlying skull is inspected and loose fragments
removed. Contused pericranium in an open fracture is incised, w ith the
corresponding clean pericranium elevated to allow for inspection of the bone.
94
Figure
Procedural Steps
Pearls
Fig. 6.5
95
Figure
Procedural Steps
Pearls
Fig. 6.6
The depressed bone is elevated w ith a no. 1 Pen eld. Epidural hematoma, if
present, is evacuated. Bleeding dural vessels are cauterized. Any area of dural
penetration should be explored. This may require extension of the dural defect
to permit adequate visualization of the subdural space and cortex. If the dural
tear cannot be approximated primarily, interposition of a pericranial graft may
be necessary.
Autograft m ay be preferable
96
Figure
Procedural Steps
Pearls
Fig. 6.7
(a) If initial mechanical maneuvers to achieve hemostasis fail, the anterior one third of the sinus can be ligated w ithout serious adverse e ects. (b) How ever,
injury involving the posterior tw o -thirds requires repair w ith a galeal or
pericranial patch.
97
Figure
Procedural Steps
Pearls
Fig. 6.8
98
Closing
Th e w oun d is irrigated w ith copious am ou n ts of an t ibiot ic
solu t ion .
Depen ding on t ype of t rau m at ic inju r y, sterile drain age t u bing m ay be im p lan ted an d secu red.
Tem poralis m uscle an d fascia are reapproxim ated w ith
2-0 braided nylon sut ures.
Th e galea is closed w ith inverted, in terrupted 3-0 braided
absorbable su t u res.
Th e skin is closed eith er w ith st aples or 3-0 nylon vert ical
m at t ress st itch es.
A sterile dressing is applied an d accom pan ied by a com pressive h ead w rap , if n ecessar y.
Postoperative Management
Radiographic Imaging
Patients w ith contam inated, open depressed fractures m an -
Special Considerations
Further Management
in accordan ce w ith p ublish ed TBI gu idelin es.
Skin su t u res or st ap les m ay be rem oved in 7 to 10 days,
dep en ding on t ype of injur y an d w ou n d closu re.
Prophylact ic an t ibiot ics are given for 5 to 7 days to lessen th e
risk of cen t ral n er vou s system in fect ion . Th e au th ors p refer
in t raven ou s cefazolin or piperacillin -t azobact am . How ever,
th ere is in su cien t eviden ce to support a speci c agen t or
durat ion of th erapy in th is set t ing.
An t iconvulsan t s are often given to reduce risk of seizures,
alth ough th e su pp or t ing eviden ce is equ ivocal.
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
References
1. Qu resh i N, Harsh G. Sku ll fract u re. Availab le on lin e at: h t t p ://
em e d icin e.m e d scap e.com /ar t icle /248108- ove r view
2. Bullock MR, Chesnut R, Ghajar J, et al. Surgical m anagem ent of depressed cranial fract ures. Neurosurger y 2006;58(3 Suppl):S5660
100
3. Con n olly ES. Fu n dam en t als of Op erat ive Tech n iqu es in Neu rosurger y, 2n d ed. New York: Th iem e Medical Publish ers; 2010
4. Sekh ar LN, Fessler RG. Atlas of Neu rosu rgical Tech n iqu es: Brain .
New York: Th iem e Medical Publish ers; 2006
5. March er S, An dres RH, Fath i AR, Fan din o J. Prim ar y recon st ru ct ion of open depressed skull fract ures w ith t it aniu m m esh . J Cran iofac Surg 2008;19(2):490495
Introduction
Invasive neurom onitoring assists the diagnosis and treatm ent of
patients presenting w ithor at risk forintracranial hypertension,
de ned as intracranial pressure (ICP) greater than 20 m m Hg.
A variety of intracranial pathologies such as traum atic brain injury,
subarachnoid hem orrhage, intracerebral hem orrhage, and ischem ic stroke (associated w ith m alignant edem a) m ay contribute to
an altered level of consciousness and, therefore, an unreliable neurologic exam . Further decline in neurologic status m ay be di cult
to detect based on serial clinical evaluation alone. Invasive neurom onitoring can point to signs of deterioration and trigger appropriate interventions. Although ICP m onitoring is m ost com m on,
additional advanced m odalities for the m onitoring of brain tissue
oxygen tension, m icrodialysis, cerebral blood ow, and jugular
venous saturation can help the practitioner achieve a m ore com prehensive understanding of pathologic cerebral physiology and,
in turn, provide individualized treatm ent w ith targeted therapies.
Microdialysis 4
An cillar y m on itoring of cerebral m et abolic param eters m ay
Indications
Monitoring of ICP by
External Ventricular Drain or
Intraparenchymal Pressure Probe 1
Diagn osis an d t reat m en t of in t racran ial hyper ten sion
An extern al ven t ricu lar drain (EVD) is con sidered th e gold
Preprocedure Considerations
Radiographic Imaging
Non con t rast h ead CT sh ou ld be review ed for:
Size of th e ven t ricular system
In t raven t ricu lar h em orrh age
Mass e ect or focal lesion
Sku ll fract u res
Distan ce from th e bon e to th e fron tal h orn (for EVD
placem en t)
Coagulation Parameters
In tern at ion al n orm alized rat io (INR), p ar t ial th rom boplast in
101
Medication
Lidocain e 1%w ith epin ep h rin e 1:100,000 for local an esth esia
Midazolam or prop ofol for sedat ion
Fen t anyl for an algesia
bean bag, or xat ion w ith t ape are e ect ive w ays to ach ieve
th is at th e bedside).
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
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
Operative Procedure
Placement of Intracranial Monitors
Positioning (Fig. 7.2)
Figure
Procedural Steps
Pearls
Fig. 7.2
104
neutral position.
EKG electrodes can be placed on the nasion and tragus for easier
palpation of the landm arks after draping.
Figure
Procedural Steps
Pearls
Fig. 7.3
105
Figure
Procedural Steps
Pearls
Fig. 7.4
An assistant is helpful to stabilize the head during drilling to m aintain neutral positioning.
106
As a general rule, each cannulation system com es equipped with a proprietary drill bit. For
an EVD, a 5.3-m m drill bit is provided. If available, a drill safet y stop should be used.
It is important to perform the craniostomy absolutely perpendicular to the plane of the
skull. The trajectory m ay be assisted by aim ing at the ipsilateral inner canthus in the coronal
plane and just anterior to the tragus in the sagit tal plane or with the use of a tripod device.
The operator is able to feel a change in the resistance as the drill travels through the outer
cortex (hard), diploe (soft), and inner cortex (hard). The operator should slow down as
more resistance is felt while the drill penetrates into the inner cortex to avoid plunging
into the brain tissue. After rem oving the t wist drill, the dura can be palpated using a spinal
needle or a small blunt instrum ent.
Figure
Procedural Steps
Pearls
Fig. 7.5
107
Figure
Procedural Steps
Pearls
Fig. 7.6
108
Figure
Procedural Steps
Pearls
Fig. 7.7
109
110
Figure
Procedural Steps
Pearls
Fig. 7.8
(b) After removing the trocar, a Luer lock and cap are
applied. The EVD is secured to the skin at multiple
points w ith 3-0 nylon stitches.
111
Figure
Procedural Steps
Pearls
Fig. 7.9
Intraparenchymal Monitor
The probe then is introduced into the central
opening of the bolt apparatus and advanced into
the brain parenchymadeep enough to obtain a
reliable ICP measurement (no more than 2.5 cm).
The pressure probe then is secured to the bolt
system or tunneled and secured to the skin
depending on the system.
112
brain tissue oxygen probe are inserted if the dura is widely open
and the pia has been pierced. Any signi cant resistance during
placem ent of the inner sleeve indicates a need for wider dural
opening. Resistance during probe placem ent could m ean that
the probe is m igrating in the epidural space or sliding over the
brain. An FiO2 challenge (rapid increase in inspired oxygen to
100%) should be used to verify that the probe is functioning.
Figure
Procedural Steps
Pearls
Fig. 7.10
113
114
Figure
Procedural Steps
Pearls
Fig. 7.11
Figure
Procedural Steps
Pearls
Fig. 7.12
The tip of the beroptic catheter should be high in the jugular bulb to m axim ize the
likelihood of m easuring the venous blood draining from the brain and to m inim ize
contam ination from extracranial blood. X-ray veri cation is recom m ended to ensure
that the tip of the catheter is just m edial to the base of the m astoid bone in the AP
plane and at the lower portion of C1 in the lateral plane. The position of the catheter
can also be veri ed with a head CT, where it should be seen in the jugular foram en at
the base of the skull.
115
Closing
Th e in cision site is irrigated. Th e skin in cision is closed w ith
Radiographic Imaging
It is com m on pract ice to p erform a p ost-procedu re n on con
Further Management
Advan ces in th e elds of n eu roin ten sive care an d m u lt im odal
Postoperative Management
Monitoring
Patients for w hom invasive neurom onitoring is indicated generally w ill be housed in the intensive care unit setting. The m ajorit y w ill be intubated. Intensive adjunctive m onitoring w ith
a com bination of frequent neurologic checks, an arterial line, a
central venous catheter, telem etry, pulse oxim etry, and, in som e
cases, end-tidal CO2 capnography is routine in this population.
Medication
Sedat ion w ith prop ofol or dexm edetom id in e is preferred
116
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.
117
Special Considerations
ICP rem ain s th e corn erston e of invasive brain m on itoring. Advan ced n eu rom on itoring tech n iqu es p rovide an op port u n it y
for bet ter u n derstan ding of cerebral path ophysiology; h ow ever,
e ect ive u se of th is tech n ology requ ires an u n d erst an ding of
h ow to both properly p lace th e p robe an d in terpret th e dat a.
Dat a derived from th ese m odalit ies are ext rem ely depen den t
on th e posit ion of each probe. Th erefore, veri cat ion of probe
posit ion is essen t ial prior in it iat ing sign i can t ch anges in clin ical m an agem en t . Fu rth erm ore, pat ien t s requiring su ch m on itoring t yp ically are com p lex an d m ay p resen t w ith a variet y of
cerebral path ophysiologic abn orm alit ies. Th e pract it ion er m ust
possess a deep an d clear un derst an ding of cerebral physiology
an d m et abolism in order to u se th e in form at ion e ect ively in
th e pat ien t-speci c t reat m en t of TBI. In sum m ar y, w h ile th ere
does exist a role for th e use of advan ced n eu rom on itoring tech n iques, th e resu lt s m ust be in terp reted an d ap plied crit ically.
References
1. Brat ton SL, Ch est n u t RM, Gh ajar J, et al. Gu idelin es for th e
m an agem en t of severe t rau m at ic brain injur y. VII. In t racran ial
pressure m on itoring tech n ology. J Neu rot raum a 2007;24 Suppl
1:S4554
2. Brat ton SL, Ch est n u t RM, Gh ajar J, et al. Gu idelin es for th e m an agem en t of severe t raum at ic brain injur y. VI. Indicat ion s for in t racranial pressu re m on itoring. J Neurot raum a 2007;24 Suppl
1:S3744
3. Brat ton SL, Ch est n u t RM, Gh ajar J, et al. Gu idelin es for th e m an agem en t of severe t raum at ic brain inju r y. X. Brain oxygen m on itoring an d th resh old s. J Neu rot rau m a 2007;24 Su p pl 1:S6570
118
4. Bellan der BM, Can t ais E, En blad P, et al. Con sen su s m eet ing
on m icrodialysis in neu roin ten sive care. In ten sive Care Med
2004;30(12):21662169
5. OLear y ST, Kole MK, Hoover DA, Hysell SE, Th om as A, Sh a rey
CI. E cacy of th e Gh ajar Guide revisited: a prospect ive st udy.
J Neu rosurg 2000;92(5):801803
6. Tom a AK, Cam p S, Watkin s LD, Grieve J, Kitch en ND. Extern al
ven t ricu lar drain in ser t ion accu racy: is th ere a n eed for ch ange
in pract ice? Neurosurger y 2009;65(6):11971200; discussion
12001191
7. Gh ajar JB. A gu ide for ven t ricu lar cath eter p lacem en t . Tech n ical
n ote. J Neurosu rg 1985;63(6):985986
8. Poca MA, Sah u qu illo J, Vilalt a A, d e los Rios J, Robles A, Exp osito
L. Percut an eous im plan t at ion of cerebral m icrodialysis cath eters
by t w ist-drill cran iostom y in n eurocrit ical pat ien t s: descript ion
of th e tech n ique an d resu lt s of a feasibilit y st udy in 97 pat ien t s.
J Neu rot raum a 2006;23(10):15101517
9. Narot am PK, Morrison JF, Nath oo N. Brain t issu e oxygen m on itoring in t rau m at ic brain inju r y an d m ajor t rau m a: ou tcom e
an alysis of a brain t issue oxygen -directed th erapy. J Neurosurg
2009;111(4):672682
10. Rose JC, Neill TA, Hem p h ill JC, 3rd. Con t in u ou s m on itoring of th e
m icrocircu lat ion in n eurocrit ical care: an update on brain t issue
oxygen at ion . Cu rr Op in Crit Care 2006;12(2):97102
11. Spiot t a AM, St iefel MF, Gracias VH, et al. Brain t issu e oxygen directed m an agem en t an d ou tcom e in pat ien t s w ith severe t rau m at ic brain injur y. J Neurosurg 2010;113(3):571580
12. Fan din o J, Stocker R. Cath eterizat ion of th e in tern al jugu lar vein
for jugular bulb oxygen sat urat ion m on itoring after brain injur y.
J In ten Care Med 1999;14:270290
13. Bh at ia A, Gu pt a AK. Neu rom on itoring in th e in ten sive care u n it .
II. Cerebral oxygen at ion m on itoring and m icrodialysis. In ten sive
Care Med 2007;33(8):13221328
14. Jaeger M, Soeh le M, Sch u h m an n MU, Win kler D, Meixen sberger J. Correlat ion of con t in u ously m onitored region al cerebral
blood ow an d brain t issue oxygen . Act a Neuroch ir (Wien )
2005;147(1):5156; discussion 56
15. Bh at ia A, Gu pt a AK. Neu rom on itoring in th e in ten sive care u n it . I.
In t racran ial pressure an d cerebral blood ow m on itoring. In ten sive Care Med 2007;33(7):12631271
16. Vajkoczy P, Roth H, Horn P, et al. Con t in u ou s m on itoring of
region al cerebral blood ow : experim en t al an d clin ical validat ion of a n ovel th erm al di usion m icroprobe. J Neurosurg
2000;93(2):265274
17. Engst rom M, Polito A, Rein st ru p P, et al. In t racerebral m icrodialysis in severe brain t raum a: th e im por t an ce of catheter locat ion .
J Neu rosu rg 2005;102(3):460469
Surgical Debridement of
Penetrating Injuries
Roland A. Torres and P.B. Rak sin
Introduction
Indications
119
Non con t rast CT p rovides th e m ost com preh en sive sou rce
Preprocedure Considerations
General
At ten d to th e ABCs of resu scitat ion (air w ay, breath ing,
circulat ion ).
Con t rol brisk bleeding from th e scalp an d associated w oun ds
w ith h em ost at s or tem porar y st aple closure, as w ell as a pressu re dressing. Large, isolated scalp w ou n d s m ay lead to fat al
blood loss.
Docu m en t en t ran ce an d exit (if p resen t) w ou n ds, as w ell as
th e presen ce of pow der burn s, CSF leak, an d brain h ern iat ion .
Early invasive ICP m on itoring is an opt ion w h en un able to
follow a serial n eurologic exam , w h en th e n eed to evacu ate
an obser ved m ass lesion is u n cert ain , an d/or w h en im aging
suggest s in creased in t racran ial p ressu re.9 Brain t issu e oxygen
m on itoring m ay be con sidered as w ell.
Radiographic Imaging
Anteroposterior and lateral skull X-rays m ay provide general inform ation regarding the presence of radiopaque foreign bodies
as well as entrance and exit sites. The ease w ith w hich m ultiplanar CT can be obtained in m ost settings has largely obviated the
need for this diagnostic m odalit y.
120
Medication
An t im icrobial prophylaxis is adm in istered. Broad-spect rum
Fig. 8.1ac Axial CT (a) brain and (b) bone windows demonstrating
a comminuted bilateral frontal bone fracture, associated with a
large left frontal intraparenchymal hematoma, in-driven bone,
and pneum ocephalus. (c) Three-dimensional reconstructed image
demonstrates the full extent of the bony injury; note that the missile is
actually lodged in the extracranial space, just posterior and lateral to the
depressed fracture.
121
Operative Procedure
Positioning (Fig. 8.2)
Figure
Procedural Steps
Pearls
Fig. 8.2
122
Figure
Procedural Steps
Pearls
Fig. 8.3
123
124
Figure
Procedural Steps
Pearls
Fig. 8.4
Figure
Procedural Steps
Pearls
Fig. 8.5
For a unilateral approach, bur holes are placed at the key hole,
just above the root of zygoma, over the parietal eminence,
and at a point that is just anterior to coronal suture and 1 cm
lateral to midline.
125
Figure
Procedural Steps
Pearls
Fig. 8.6
126
Figure
Procedural Steps
Fig. 8.7
By de nition, the dura is already open. In certain cases, it may be appropriate simply to enlarge the existing
dural opening to permit the necessary exposure for local debridement.
If a need for broad exposure is anticipated, a cruciate or reverse C-shaped dural opening should be considered.
In the setting of a bicoronal approach, trap-door dural aps can be re ected tow ard the midline sagittal sinus.
127
128
Figure
Procedural Steps
Pearls
Fig. 8.8
129
Figure
Procedural Steps
Pearls
Fig. 8.9
130
Closing
Th e surgical site is irrigated w ith an t ibiot ic solu t ion .
Th e decision of w h eth er to replace th e bon e ap at th e con -
Medication
Th e opt im al prophylact ic an t im icrobial regim en an d durat ion
Postoperative Management
Monitoring
Radiographic Imaging
Further Management
Invasive n eu rom on itoring devices are rem oved w h en n eu ro
logic st at u s dictates.
Skin su t u res or staples are rem oved at an in ter val of 10 to
14 days.
c
a
b
Fig. 8.10ac Axial CT (a) brain and (b) bone windows demonstrating evacuation of the frontal hematoma and accessible foreign body fragment s.
A bony defect remains. (c) CT obtained approximately 3 months later (at the tim e of cranioplast y) demonstrates expected frontal encephalomalacia.
131
Special Considerations
CSF leak
The inciden ce of CSF leak follow ing m issile injury approached
132
References
1. Aarabi B. Cau ses of in fect ion s in pen et rat ing h ead w ou n d s in th e
Iran -Iraq War. Neurosurger y 1989;25:923926
2. Am irjam sh idi A. Min im al debrid em en t or sim p le w ou n d closu re
as th e on ly su rgical t reat m en t in w ar vict im s w ith low -velocit y
pen et rat ing h ead inju ries. In dicat ion s an d m an agem en t p rotocol based upon m ore th an 8 years follow up of 99 cases from
Iran -Iraq con ict . Surg Neurol 2003;60:105111
3. Tah a JM, Haddad FS, Brow n JA. In t racran ial in fect ion after m issile injuries to th e brain : repor t of 30 cases from th e Lebanese
con ict . Neurosurger y 1991;29:864868
4. Ch au dh ri KA, Ch ou dh u r y AR, al Mou t aer y KR, et al. Pen et rating cran iocerebral sh rap n el inju ries during Operat ion Desert
Storm : early resu lt s of a con ser vat ive su rgical t reat m en t . Act a
Neuroch ir (Wien ) 1994;126:120123
5. Esp osito DP, Walker JB. Con tem p orar y m an agem en t of p en et rating brain injur y. Neurosurg Q 2009;19(4):249254
6. Mu en ch E, Horn P, Bau h u f C, et al. E ect s of hyp er volem ia an d
hyperten sion on region al cerebral blood ow, in t racran ial pressure, an d brain t issue oxygen at ion after subarach n oid h em orrhage. Crit ical Care Med 2007;35:18441851
7. Bran dvold B, Levi L, Fein sod M, et al. Pen et rat ing cran iocerebral
injuries in th e Israeli involvem en t in the Leban ese con ict . J Neurosurg 1990;72:1521
8. George ED, Diet ze JB. Pat ien t select ion : determ in ing th e n eed
for and t ype of su rger y. In : Bizh an A, ed. Missile Woun ds of th e
Head an d Neck. Neurosurgical Topics Volum e I. New York: AANS;
1999:127134
9. Aarabi B, Alden TD, Ch est n u t RM, et al. Gu idelin es for th e
m an agem en t of pen et rat ing brain injur y. J Traum a 2001;
51(supplem en t):S186
10. Helling TS, McNabn ey W K, W h it t aker CK, et al. Th e role of early
surgical in ter ven t ion in civilian gun sh ot w oun ds to th e h ead.
J Traum a 1992;32:398400
11. Hu bsch m an n O, Sh ap iro K, Bad en M, et al. Cran iocerebral gu n sh ot injuries in civilian pract ice: progn ost ic criteria an d surgical
m an agem en t experien ce w ith 82 cases. J Traum a 1979;19:612
12. Gon u l E, Baysefer A, Kah ram an S. Cau ses of in fect ion s an d m an agem en t resu lt s in p en et rat ing cran iocerebral inju ries. Neu rosurg Rev 1997;20:177181
13. Aren dall RE, Mein ow sky AM. Air sin u s w ou n d s: an an alysis of
163 con secut ive cases in curred in the Korean War, 1950-1952.
Neurosu rger y 1983;13:377380
14. Meirow sky AM, Caven ess W F, Dillon JD, et al. Cerebrospin al u id
st ulas com plicat ing m issile w oun ds of th e brain . J Neurosurg
1981;54:4448
15. Aarabi B, Tagh ipou r M, Alibaii E, Kam garp ou r A. Cen t ral n er vou s
system in fect ion s after m ilit ar y m issile h ead w oun ds. Neu rosurger y 1998;42:500509
16. Tah a JM, Saba MI, Brow n JA. Missile inju ries to th e brain t reated by sim ple w oun d closure: result s of a protocol during th e
Lebanese con ict . Neurosurger y 1991;29:380383
Management of Traumatic
Neurovascular Injuries
Boyd F. Richards and Mark R. Harrigan
Introduction
All t rau m at ic cerebrovascu lar inju r ies (TCVI) involve eit h er
p ar t ial or com p lete d isr u pt ion of t h e vessel w all. Trau m at ic
ar ter ial cerebrovascu lar inju r ies con st it u te a con t in u ou s
sp ect r u m of d isease, ran gin g from m in im al d isr u pt ion of
t h e in t im a to occlu sion or t ran sect ion of t h e ar ter y. TCVI can
also lead to t h e for m at ion of ar ter ioven ou s st u las an d an eu r ysm s. Th ese inju r ies can be classi ed accord in g to locat ion (ext racran ial or in t racran ial) an d by m ech an ism (blu n t
or p en et rat in g).
Th is ch ap t e r is d ivid e d in t o fou r cat e gor ies b ase d on locat ion an d m e ch an ism . Th e a u t h ors p rese n t a lgor it h m s b ase d
on ou r p refe r re d t reat m e n t st rat e gy for m ost ca ses at ou r
in st it u t ion .
Indications
Extracranial Blunt Injury
TCVI occu rs in abou t 1%of all blu n t t rau m a pat ien t s.1 Carot id
inju r y occurs in 0.1 to 1.55% of blun t t raum a pat ien t s. Vertebral injur y occurs in 0.2 to 0.77% of t raum a pat ien t s.
Motor veh icle collision s accou n t for 41 to 70%of cases.2 Oth er
m ech an ism s of inju r y in clu de assau lt , p ed est rian versu s veh icle, an d h anging.
Th e inju r y m ay result from a direct vascular blow, ext rem e
hyperexten sion /rotat ion , or lacerat ion by bony fragm en ts.
In depen den t risk factors for carot id ar ter y inju r y in clu d e:
closed h ead inju r y (w ith Glasgow Com a Scale [GCS] score
6), pet rou s bon e fract u re, d i u se axon al inju r y, an d
LeFor t II or III fract u re.
Cer vical spin e injur yC1, 2, or 3 fract u re; t ran sverse foram en fract u re; or su blu xat ion is an in dep en d en t risk factor
for vertebral ar ter y inju r y.
Th e m ost com m on ly used classi cat ion system divides TCVI
in to ve t yp es (Table 9.1).3,4
Ar t er ia l dissect ion (t ype I a n d II in ju r ies)
Results from rapid decelerat ion of th e body w ith subsequen t st retch ing of th e involved vessel.
Tw o m ech an ism s h ave been proposed (Figs. 9.1 an d 9.2):
(1) in t ram ural h em atom a form at ion bet w een layers of
th e arter y w all; an d (2) an in t im al tear leading to exposed
su ben d oth elial collagen , in it iat ing p latelet aggregat ion an d
leading to th rom bus form at ion .
Description
II
III
IV
Complete occlusion
Source: Bi WL, Moore EE, O ner PJ, et al. Blunt carotid arterial injuries:
implications of a new grading scale. J Trauma 1999;47(5):845853; Bi
WL, Moore EE, Elliot t JP, et al. The devastating potential of blunt vertebral
arterial injuries. Ann Surg 2000;231(5):672681.
133
Physical Findings
Physical ndings of penetrating, extracranial cerebrovascular
injury
Act ive bleeding
Hem atom a
Th rill or bruit
Absen ce of carot id pulse
Neu rologic de cit
134
Fig. 9.2a, b Type II traumatic cerebrovascular injury, t wo examples: (a) focal dissection, likely an intimal ap, with thrombus (arrow) and (b) di use
injury, likely an intramural hem atoma (arrows).
set t ing of blu n t inju r y in clu de brom u scu lar hyp erp lasia, cyst ic m edial degen erat ion , Marfan syn drom e, h om ocyst in u ria, an d syph ilis.
Pat ien t s m ay p resen t w ith u n ilateral h eadach e,
cran ial n er ve palsy (from m ech an ical com pression or
n eurap raxia from th e expan ded ar ter y or t ran sien t im p airm en t of blood su pply), Horn ers syn drom e, an d/or
focal cerebral isch em ia.
An eu r ysm
Trau m at ic an eu r ysm s accou n t for , 1%of all in t racran ial
an eu r ysm s in adu lt s, bu t com prise abou t on e-th ird of
p ediat ric an eu r ysm s.13
An eur ysm s in th is set t ing result from rapid decelerat ion ,
w h ich cau ses sudden brain m ovem en t an d arterial w all
injur y from stat ion ar y st ru ct ures su ch as th e skull base
or falx cerebri.
Pe r icallosal bran ch (an t e r ior com m u n icat in g ar te r y
[ACA]) an e u r ysm s, resu lt in g from collision b et w e e n
t h e ar t e r y an d t h e e dge of t h e falx, are m ost com m on .
Basilar arter y an d pet rocavern ou s segm en t an eu r ysm s
often are associated w ith skull base fract ures.
Ar t er ioven ou s f st u la
Ar terioven ous st ulasarising from eith er th e carot id
135
Preprocedure Considerations
Radiographic Imaging
Extracranial Blunt Injury
A screening com puted tom ography angiogram (CTA) or m agnetic resonance angiogram (MRA) should be perform ed for any
patient w ith risk factors for TCVI and/or any unexplained neurologic de cit (Fig. 9.3). In the setting of TCVI, CTA m ay reveal:
Eccen t ric vessel lum en com bin ed w ith m ural th icken ing
Sten osis
Fig. 9.3ad Patterns of injury in blunt, extracranial traumatic cerebrovascular injury. Common t ypes of injury include: (a) intimal tear,
(b) intimal tear with associated thrombosis, (c) dissecting aneurysm formation due to disruption of the internal elastic lamina and bulging of the
adventitia, and (d) intramural hematoma.
136
9
Occlu sion
Dissect ing an eu r ysm
Mu ral th icken ing
Cerebral angiography is in dicated w h en n ecessar y for claricat ion of th e diagn osis or w h en en dovascu lar t reat m en t is
p lan n ed . In th e set t ing of TCVI, angiograp hy m ay reveal:
Eccen t ric, sm ooth , or t apered sten osis
In t im al ap an d associated false lu m en
Tapered sten osis proxim al to a dissect ing an eur ysm (st ring
an d p earl sign )
Flam e-sh ap ed occlu sion
Dissect ing an eu r ysm
In t ralu m in al th rom bu s
p erform ed for any pat ien t presen t ing w ith p en et rat ing h ead
inju r y.
Met allic foreign bodies m ay com p rom ise CT im ages secon dar y to scat ter art ifact . Th ey m ay also ren der an MRA im p ossible. In th is case, an angiogram m ay be n ecessar y p rior to
rem oval of th e foreign object .
Management
sh ou ld u n d ergo a CTA or MRA as a rst-lin e im aging m odalit y. How ever, if a dissect ion is st rongly suspected, con ven t ion al angiography rem ain s th e gold st an dard.
An eu r ysm
CTA is th e recom m en ded screen ing m odalit y. How ever,
t raum at ic an eur ysm s are often located dist ally an d can be
dangerous even w h en , 3 m m . Th ese t w o feat ures ren der
CTA less reliable.
Angiography is recom m en ded for all pat ien t s in w h om a
t raum at ic an eur ysm is suspected.
Ar t er ioven ou s f st u la
Angiography is th e gold st an dard to im age ar terioven ous
st u las.
An early- lling vein m ay be a path ogn om on ic sign .
Assess for access to th e lesion by looking at th e direct ion
of ow w ith in each of th e ven ou s st ruct ures.
For CCFs, assess th e presen ce of th e superior op h th alm ic
vein as a possible access p oin t for t reat m en t .
CTA an d MRA are st at ic st u dies. Early ven ou s lling often
is n ot visu alized as th e t im ing of th e con t rast bolu s m ay
a ect t im ing of th e lling of th e vein s.
TCVI are an t ith rom bot ic th erapy (to m in im ize th rom boem bolic com plicat ion s), follow -up im aging, an d select ive use of
en dovascu lar tech n iqu es.
Medica l m a n a gem en t
Anticoagulation w ith intravenous heparin, followed by warfarin, has been com m on practice. However, hem orrhagic
com plication rates range from 8 to 16%19 and a signi cant proportion (3036%) of patients w ith this type of injury are not
candidates for system ic anticoagulation due to concom itant
injuries.
An t iplatelet th erapy o ers a m ore favorable risk pro le an d
m ay be equ ivalen t to or su p erior to an t icoagu lat ion w ith
respect to n eu rologic outcom es.20 Th e au th ors p refer single
agen t an t iplatelet th erapy in th e form of aspirin 325 m g
per day.
Repeat n on invasive im aging, preferably CTA, sh ou ld be
u n der t aken in 6 m on th s.
En dova scu la r m a n a gem en t
Dissect ion
Dissect ion s requ ire t reat m en t (u su ally sten t ing) if th ere
are n ew n eu rologic de cits or oth er sym ptom s desp ite
an t iplatelet th erapy.
Sten t ing requires dual an t iplatelet th erapy for a period of
app roxim ately 1 m on th ; th is m ay p rove p roblem at ic for
p olyt rau m a pat ien ts.
Trau m at ic an eur ysm
En dovascular t reat m en t is in dicated if th e pat ien t is
sym ptom at ic despite an t ip latelet th erapy or if th e
an eu r ysm is fou n d to en large sign i can tly on follow -u p
im aging. Follow -u p im aging sh ould be perform ed after
6 m on th s (see Fig. 9.5).
A covered sten t m ay be appropriate if th e t raum at ic
an eu r ysm occu rs in a port ion of th e vessel devoid of
im port an t bran ch es.
Coil em bolizat ion of t raum at ic an eur ysm s sh ould be
avoided w h en ever possible as th e w all of th e an eu r ysm
m aybe eith er ext rem ely fragile or con sist en t irely of
th rom bo- brous t issue. Coils w ith in t raum at ic an eu r ysm s m ay be pron e to m igrate th rough th e w all of th e
an eu r ysm .
Occlu sion
Vessel occlu sion sh ou ld b e ap p roach e d in a sim ilar
m an n e r to acu t e isch e m ic st roke. Sym p tom at ic ar t e r ial
occlu sion s sh ou ld u n d e rgo re can alizat ion w h e n feasible an d ap p rop r iate. Pat ie n t s w it h asym p tom at ic occlu sion s m ay d o w ell w it h con se r vat ive m an age m e n t
(se e Fig. 9.6).
137
Eviden ce of
vascular inju r y
Dissect ion
Traum at ic
An eu r ysm
An t ip latelet
Agen t
An t ip latelet
Agen t
No evid en ce of
vascu lar inju r y
Un explain ed
n eu rologic
deficit or
h igh susp icion
Occlu sion
Asym ptom at ic
Sym ptom at ic
DSA
Neu rologic
obser vat ion an d
repeat CTA in 6
m on th s
New
n eu rologic
deficit
If stable
con t in u e
an t iplatelet
agen t
Neu rologic
obser vat ion an d
repeat CTA in 6
m on th s
If en larging
or n ew
n eu rologic
deficit
If resolved,
d/c
an t iplatelet
agen t
Con sider
en dovascu lar
t reat m en t
DSA
If un ch anged,
con t in u e
an t iplatelet agen t
An t ip latelet
Agen t
If resolved, d/c
ant ip latelet agen t
New Trau m at ic
An eu r ysm
Neurologic
obser vat ion an d
repeat CTA in 6
m on th s
<8 h ou rs
At tem pt
en d ovascu lar
recan alizat ion
>8 h ou rs
CT
Perfusion
At tem pt
recan alizat ion if CT
Perfusion sh ow s
reversible isch em ia
Su p p ort ive care
n o reversible
isch em ia
Fig. 9.4 Algorithm for the management of blunt, extracranial traumatic cerebrovascular injury. DSA, digital subtraction angiography; CTA,
CT angiography; d/c, discontinue.
138
A few elem ents of m anagem ent are com m on to all such injuries:
Asser t ive m an u al com pression sh ould be used to con t rol
bleeding in it ially.
Th e air w ay m ust be secured, preferably by en dot rach eal
in t ubat ion . If en dot rach eal in t u bat ion is n ot feasible,
cricothyrotom y is th e n ext best opt ion for air w ay con t rol.
Nasot rach eal in t u bat ion sh ou ld be avoided w h en p ossible
because of th e possibilit y of cran ial or n asoph ar yngeal
inju r y due to th e p en et rat ing injur y.
En dova scu la r Tr ea t m en t
En dovascular t reat m en t m ay be preferable for pat ien t s
w ith Zon e I an d III injuries due to th e di cult y of surgical access to th ese areas (see Fig. 9.9).
Covered sten t placem en t m ay be e ect ive for carot id lacerat ion s, p rovided th e lesion can be crossed .
En dovascular ar terial occlu sion m ay be in dicated. Select ive occlusion of extern al carot id bran ch es is u su ally
st raigh tfor w ard . In som e sit u at ion s, occlu sion of th e in tern al carot id or vertebral arter y m ay be n ecessar y to
con t rol bleeding. Angiograph ic assessm en t of collateral
circulat ion to th e a ected brain territor y can h elp determ in e th e risk of resultan t cerebral isch em ia. Sacri ce
of an ar ter y sh ou ld in clu de occlusion of th e vessel both
proxim al an d dist al to th e inju r y, if possible, to m in im ize
th e ch an ce of ret rograde bleeding th rough th e distal segm en t of th e a ected arter y.
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
140
>
<
Fig. 9.8 Zones of the neck. Anatomic zones of the neck. Zone I: clavicle to the cricoid cartilage. Zone II: cricoid cartilage to the angle of the
mandible. Zone III: angle of the mandible to the base of skull.
Fig. 9.9a, b Arterial dissection due to penetrating neck trauma. Patient with a knife wound to the distal cervical ICA (Zone III). The injury was
initially controlled by placement of a Foley balloon catheter in the wound to stop the bleeding. Angiography showed complete transection of the
vessel (a, arrow). The patient was treated with endovascular sacri ce of the ICA (b).
141
Su spected Blu n t
In t racran ial TCVI
CTA eviden ce of
vascu lar inju r y?
Yes
Dissect ion
DSA to assess
collateral
circu lat ion
An t iplatelet
agen t
Poor collateral
circu lat ion
an t iplatelet
agen t
Good collateral
circu lat ion
en dovascular
vessel sacrifice
Repeat CTA in 6
m on th s
New t raum at ic
an eur ysm
If resolved, D/C
an t iplatelet
agen t
No
Trau m at ic
an eur ysm
Treat m en t w ith
en dovascular
or su rgical
in ter ven t ion
Un explain ed
n eu ro deficit?
Occlu sion
Asym ptom at ic
An t ip latelet
Agen t
Repeat CTA in 6
m on th s
If yes, DSA
Sym ptom at ic
< 8 h ou rs,
at tem pt
en dovascu lar
recan alizat ion
If n o, n o furth er
w orku p
> 8 h ou rs,
at tem pt
recan alizat ion
if CTA or MRP
sh ow s pen u m bra
If u n ch anged,
con t in ue
an t ip latelet
agen t
Fig. 9.10 Algorithm for the management of blunt intracranial cerebrovascular injury. MRP, magnetic resonance perfusion.
142
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.
Yes
Dissect ion
An t iplatelet
agen t
Repeat CTA in 6
m on th s
No
Trau m at ic
an eur ysm
Treat m en t
w ith
en d ovascu lar
or su rgical
in ter ven t ion
Fist u la
Con sider
t reat m en t
(en dovascular
or su rgical)
Un explain ed
n eu ro deficit?
If n o, n o fur th er
w orku p
If yes, DSA
New t rau m at ic
an eu r ysm
If resolved, D/C
an t iplatelet
agen t
If u n ch anged,
con t in u e
an t iplatelet agen t
Fig. 9.12 Algorithm for the management of penetrating intracranial cerebrovascular injury.
143
ing tam pon ade for a poten t ial vascular inju r y, th e foreign
body sh ould be rem oved in th e operat ing room un der
direct vision .
Pen et rat ing in t racran ial inju r y (Fig. 9.13).
b
Fig. 9.13a, b Penetrating intracranial injury. (a) Patient with a knife wound to the left temporal area. (b) The blade penetrated the squamous
portion of the temporal bone. The tip was buried in the petrous bone (arrow), adjacent to the carotid canal and temporomandibular joint. Once it
was established by imaging that the injury did not involve any arterial structures, the patient underwent craniotomy and rem oval of the knife blade.
144
Operative Procedure
Surgical Management of Extracranial Penetrating Arterial
Injuries Zone II
Positioning (Fig. 9.14a, b)
Figure
Procedural Steps
Pearls
Fig. 9.14
(a) Place a roll betw een the shoulder blades to extend the
patients neck, and rotate the patients head aw ay from the
side of injury. (b) Prep and drape the entire neck, upper chest,
and low er face.
145
146
Figure
Procedural Steps
Pearls
Fig. 9.15
Figure
Procedural Steps
Fig. 9.16
Use monopolar cautery to divide the platysma muscle. Mobilize and retract the sternocleidomastoid muscle
laterally. Ligate and divide the transverse facial vein.
147
148
Figure
Procedural Steps
Pearls
Fig. 9.17
Avoid the area of injury by working around the hem atom a. All veins (including
the internal jugular vein) m ay be ligated and divided if necessary. If both internal
jugular veins are involved, one should be preserved. Use judicious and selective
compression of bleeding arterial branches and veins as they are encountered.
Figure
Procedural Steps
Pearls
Fig. 9.18
Once the ICA distal to the injury and the CCA or ICA
proximal to the injury have been exposed, place
either a clamp or an aneurysm clip on the artery in
each location.
Large perm anent aneurysm clips are usually su cient for the
ICA, and a Fogart y clamp is usually necessary for the com m on
carotid artery. Large aneurysm clips m ay also be used for
temporary occlusion of external carotid artery (ECA) branches.
149
Figure
Procedural Steps
Pearls
Fig. 9.19
(a) Repair the arterial injury primarily, w hen possible, w ith a running 6-0
nonabsorbable polypropylene mono lament stitch.
(b) When primary repair is not possible, place a tubular polytetra uoroethylene
(PTFE) interposition graft and secure w ith simple interrupted 6-0 polypropylene
mono lament sutures.
Remove the arterial clamps in the follow ing order: ECA, CCA, and ICA.
150
Closing
Leave a drain in place. Close the wound w ith absorbable braided
stitches in the platysm a m uscle and staples or stitches in the skin.
Postoperative Management
Monitoring
All pat ien ts w ith cerebrovascular injuries sh ould be m on i-
Medication
An t ithrom bot ic th erapy w ith aspirin (325 m g daily) is in di
Radiographic Imaging
Follow -u p im aging of t rau m at ic cerebrovascular lesion s w ith
CTA at a 3- to 6-m on th in ter val is u sefu l to m on itor d issect ion s an d to ch eck for th e developm en t or progression of
t raum at ic an eur ysm s.
Further Management
An out patient clinic follow -up evaluation should be com pleted
3 to 6 m onths after discharge.
Special Considerations
Antithrombotic Therapy
Th e u se of an t ith rom bot ic m edicat ion is a reason able op t ion in pat ien t s w ith cerebrovascular injuries as a m easure
to preven t th rom boem bolic isch em ic st roke. How ever, all
References
1. Hugh es KM, Collier B, Green e KA, Ku rek S. Trau m at ic carot id
arter y dissect ion : a signi cant in ciden t al n ding. Am Surg
2000;66(11):10231027
2. Bi W L, Moore EE, Ryu RK, et al. Th e u n recogn ized ep idem ic of
blun t carot id arterial injuries: early diagn osis im proves n eurologic ou tcom e. An n Su rg 1998;228(4):462470
3. Bi W L, Moore EE, O ner PJ, et al. Blunt carotid arterial injuries:
im plications of a n ew grading scale. J Traum a 1999;47(5):845853
4. Bi W L, Moore EE, Elliot t JP, et al. Th e devast at ing p oten t ial of
blun t vertebral arterial injuries. An n Surg 2000;231(5):672681
5. Bi W L, Ray CE Jr, Moore EE, et al. Treat m en t-related ou tcom es
from blu n t cerebrovascu lar inju ries: im p or t an ce of rou t in e follow up ar teriography. An n Surg 2002;235(5):699706; discussion
706707
6. Stein DM, Bosw ell S, Sliker CW, Lu i FY, Scalea TM. Blu n t cerebrovascular injuries: does t reat m en t alw ays m at ter? J Traum a
2009;66(1):132143; discussion 143144
7. Nason RW, Assu ras GN, Gray PR, Lipsch it z J, Bu rn s CM. Pen et rat ing n eck inju ries: an alysis of experience from a Can adian t raum a
cen t re. Can J Surg 2001;44(2):122126
8. Th om a M, Navsaria PH, Edu S, Nicol AJ. An alysis of 203 pat ien t s
w ith penet rat ing n eck injuries. World J Surg 2008;32(12):
27161723
9. Ku eh n e JP, Weaver FA, Papan icolaou G, Yellin AE. Pen et rat ing
t raum a of th e in ternal carot id arter y. Arch Surg 1996;131(9):
942947; discussion 947948
10. Ram adan F, Rutledge R, Oller D, How ell P, Baker C, Keagy B.
Carot id ar ter y t rau m a: a review of con tem p orar y t rau m a cen ter
experien ces. J Vasc Su rg 1995;21(1):4655; d iscu ssion 5556
11. Sekh aran J, Den n is JW, Velden z HC, Miran da F, Fr ykberg ER.
Con t in u ed exp erien ce w ith p hysical exam in at ion alon e for
evalu at ion an d m an agem en t of p en et rat ing zon e 2 n eck inju ries:
result s of 145 cases. J Vasc Surg 2000;32(3):483489
12. McKevit t EC, Kirkpat rick AW, Vertesi L, Granger R, Sim on s RK.
Iden t ifying p at ien t s at risk for in t racran ial an d ext racran ial blu n t
carot id inju ries. Am J Su rg 2002;183(5):566570
13. Ven t ureyra EC, Higgin s MJ. Traum at ic in t racran ial an eur ysm s in
ch ildh ood and adolescen ce. Case repor t s and review of th e literat ure. Ch ilds Ner v Syst 1994;10(6):361379
14. Holm es B, Harbaugh RE. Traum at ic in t racran ial an eur ysm s: a
con tem porar y review. J Traum a 1993;35(6):855860
15. Dusick JR, Esposito F, Malkasian D, Kelly DF. Avoidan ce of
carot id ar ter y injuries in t ran ssph enoidal surger y w ith th e
Dop p ler p robe an d m icro-h ook blad es. Neu rosu rger y 2007;
60(4 Su ppl 2):322328
151
152
pen et rat ing h ead inju ries occu rring d u ring w ar: p rin ciples an d
pitfalls in diagn osis an d m an agem en t . A su r vey of 31 cases an d
review of th e literat ure. J Neurosurg 1996;(5):769780
19. Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt
cerebrovascular injuries: analysis of diagnostic m odalities and outcom es. Ann Surg 2002;236(3):386393; discussion 393395
20. Beletsky V, Nadareishvili Z, Lynch J, et al. Cervical arterial dissection:
tim e for a therapeutic trial? Stroke 2003;34(12):28562860
10
Introduction
Major du ral ven ou s sin u ses form at th e d u ral re ect ion s w h ere
th e super cial an d deep layers of th e dura split an d th e deep
layer fu ses to form th e falx cerebri an d th e ten torium cerebelli.
Inju r y to th e du ral ven ou s sin u ses m ay be en cou n tered in p en et rat ing an d n onpen et rat ing h ead t rau m a or can resu lt from
plan n ed or acciden tal disrupt ion during a cran iotom y.13 Th e
dural ven ous sin us h as a th ree-sided lum en th at is teth ered lat erally by th e adjacen t du ra m ater an d deep ly by th e falx cerebri
or ten torium cerebelli. Hem orrh age can arise from th e sin us
roof, lateral w alls, ven ou s lakes, arach n oid gran u lat ion s, em issar y vein s, or cort ical vein t ribu taries.
Th e decision to repair versu s sacri ce th e sin us is dependen t
on th e locat ion of injur y. W h en repair is in dicated, th e t ype an d
exten t of inju r y w ill largely dict ate th e opt im al repair tech n iqu e,
w h ich ranges from direct repair to segm en t al replacem en t .
Cerebral angiography
Alth ough angiography rem ain s th e gold stan dard for im ag-
Medication
An t im icrobial prophylaxis is in it iated.
An t iseizure prophylaxis is in it iated.
Indications
Trau m at ic injur y resu lt ing in sign i can t h em orrh age or
th rom bosis
Resect ion of an in lt rat ing n eoplasm
Th ree areas require repair to m ain tain paten cy 1,4
Posterior t w o-th irds of th e su p erior sagit t al sin u s
Torcu lar h eroph ili
Dom in an t t ran sverse sin u s
All oth er areas m ay be ligated w ith m in im al risk 1,4
Preprocedure Considerations
Radiographic Imaging
Com puted tom ography (CT)
Du ral ven ou s sin u s inju r y sh ou ld be su sp ected if im aging
sh ow s an ep id u ral h em atom a in th e region of a m ajor ven ou s sin us.5 In on e st u dy, 89% of ep id u ral h em atom as arising from a du ral ven ou s sin us h ad an associated fract ure
th at crossed th e sin us.1 Posterior fossa ep id u ral h em atom as involve th e du ral ven ou s sin u ses in 42.5% of cases.6
CT ven ography (CTV), w hich requires the adm inistration of
intravenous contrast and is taken during the venous phase,
can be diagnostic of sinus throm bosis. The em pt y delta sign
m ay be seen in the area of sinus th rom bosis.7 CTV is indicated
w hen there is a depressed skull fracture over a dural venous
sinus, w hich can cause sinus stenosis and throm bosis.8,9
ing th e du ral ven ous sin uses, it is invasive an d t im e con su m ing, w h ich ren ders it im pract ical in th e set t ing of acu te
t raum a.
Pre o pe rative im aging (Fig. 10.1).
verse Tren delen bu rg m ay be n eeded to m in im ize in t racran ial ven ou s p ressu re if bleeding is p rofu se.
Th e inju red du ral ven ou s sin u s segm en t sh ou ld be at th e
h igh est poin t of th e op erat ive eld.
Avoid excessive n eck rotat ion or exion .
A bilateral craniotom y exposure is indicated to address injury
to the superior sagittal sinus. A supra- and infratentorial ap proach is necessary to address injury to the transverse sinus.
Measu res to m axim ize cran ial ven ou s ou t ow
Avoid com pressive air w ay t ap e.
Min im ize jugu lar com p ression from a rigid cer vical collar.
Avoid excessive n eck rotat ion or exion .
In tern al jugu lar cen t ral ven ou s lin es are con t rain dicated
due to th e possibilit y of iat rogen ic th rom bosis an d im pairm en t of cran ial ven ou s ou t ow.
Blood loss
Large volu m e h em orrh age m ay occu r from th e inju red ven ou s sin u s. Sign i can t losses m ay also occu rboth preop erat ively an d in t raop erat ivelyfrom scalp , bon e, an d brain .
Packed red blood cells, platelet s, an d fresh frozen p lasm a
m u st be available in th e op erat ing room .
Ven ou s air em bolism
Ven ou s air em bolism m ay occu r w h en th e h ead is elevated
above th e h eart , resu lt ing in n egat ive p ressu re in th e du ral
ven ou s sin u sallow ing air to en ter an d becom e t rap ped in
th e righ t at rium .
A fall in th e en d t idal p CO2 an d hypoten sion m ay en sue.
St rong con siderat ion sh ould be given to th e use of cap n ography, a precordial Dop pler probe, an d an ar terial lin e. Air
em bolism p rodu ces w ash ing m ach in e sou n ds by Dop pler.
Rem oval of air from th e righ t at riu m is p ossible if a righ t
at rial cath eterplaced via th e brach ial or subclavian
rou teis in place.
153
Fig. 10.1 CT sagit tal reconstruction demonstrating extensive, supra- and infratentorial epidural hematoma suggestive of a transverse sinus injury.
Operative Management
Treat m en t is discu ssed sep arately for th e follow ing p ar ts of th e
ven ou s sin u s system : an terior on e-th ird of th e su p erior sagit t al
sin u s, p osterior t w o-th irds of th e su p erior sagit t al sin u s, torcular h eroph ili, an d d om in an t t ran sverse sin us.
154
tam pon ade tech n iques or direct sut ure repair if th e lacerat ion is sm all.
Lacerat ion s th at are too large to su t u re directly often can be
t reated w ith a sut ured, bolstered patch .
Lesion s th at can n ot be repaired can be t reated relat ively
safely w ith sin u s ligat ion via an en circling su t u re or
vascu lar clips.
Su p erior sagit t al sin u sp osterior t w o-th irds
Th is p or t ion of th e sin u s sh ou ld be rep aired or rep laced in
vir t u ally all cases, bu t especially w h en m ajor cor t ical ven ou s drain age is involved.
Avoid p rim ar y su t u re closu re th at com p rom ises greater
th an 50% of th e sin us lu m en , as th is m ay be m ore likely to
resu lt in com prom ised ow an d even t ual sin us occlusion .
10
Operative Procedure
Surgical Approach to Injuries of the Anterior Third of the Superior
Sagittal Sinus
Positioning (Fig. 10.2)
Figure
Procedural Steps
Pearls
Fig. 10.2
155
156
Figure
Procedural Steps
Pearls
Fig. 10.3
10
Figure
Procedural Steps
Pearls
Fig. 10.4
The position of bur holes depends upon the anatomy of the speci c fracture.
(a) If a nondepressed, linear fracture w ith suspected dural sinus laceration is present,
consider leaving a bony shelf adjacent to the sinus in order to permit the use of
epidural tacking stitches that might tamponade the lacerated sinus.
should be elevated in
stages; defer rem oval of
any fragm ent directly
over the sinus until last.
(b) If fracture fragments appear depressed into the sinus, bur holes should be placed
at the outer rim of the depressed segmentallow ing access to normal structures at
the periphery.
If the sinus is transected, bilateral bony exposureboth proximal and distal to the
sinus injuryis necessary.
157
158
Figure
Procedural Steps
Pearls
Fig. 10.5
10
Figure
Procedural Steps
Pearls
Fig. 10.6
159
Figure
Procedural Steps
Pearls
Fig. 10.7
160
10
Figure
Procedural Steps
Pearls
Fig. 10.8
161
Figure
Procedural Steps
Pearls
Fig. 10.9
162
10
Figure
Procedural Steps
Fig. 10.10
An inverted U-shaped incision permits access to the supratentorial and infratentorial compartments.
A transverse, linear incision providing access to the bilateral hemispheres may be used to approach injuries to the
middle third segment of the sagittal sinus.
163
164
Figure
Procedural Steps
Pearls
Fig. 10.11
10
Figure
Procedural Steps
Pearls
Fig. 10.12
165
Figure
Procedural Steps
Pearls
Fig. 10.13
Lacerations that are too large to suture directly may be treated w ith a
sutured, bolstered patch.
166
10
Closing
Du ral closu re is perform ed w ith 4-0 braid ed nylon su t u re.
Th e bon e ap is reapproxim atedif feasiblew ith an in t ra
Medication
An t im icrobial prophylaxis is con t in u ed for 24 h ours.
An t iepilept ic prophylaxis is con t in ued for 7 days.
Radiographic Imaging
A CT scan is perform ed early in th e postoperat ive period to
Postoperative Management
Monitoring
Special Considerations
Late Complications
Post-repair ven ous sin us sten osis or sin us com pression (e.g.,
from a dep ressed sku ll fract u re) in creases th e risk of delayed
sin u s th rom bosis. Ven ou s sin u s th rom bosis m ay lead to p rogressive bilateral en ceph alopathy, in creased in t racran ial
p ressure, cerebral edem a, in t raparen chym al h em orrh age, an d
ven ou s in farct ion . Deep ven ou s h em orrh age an d in farct ion
involving th e th alam us can occur w ith injur y to th e st raigh t
sin u s at th e level of th e ten toriu m .
Fig. 10.14 Sagit tal CT reconstruction demonstrating resolution of extra-axial hematoma following repair of a
transverse sinus injury.
167
References
1. Pricola KL, Zou H, Chang SD. Successful repair of a gunshot wound
to the head w ith retained bullet in the torcular herophili. World
Neurosurg 2011;76(34):e361364
2. Sin dou MP, Alvern ia JE. Resu lt s of at tem pted radical t u m or
rem oval an d ven ous repair in 100 con secut ive m en ingiom as
involving th e m ajor dural sin uses. J Neurosurg 2006;105(4):
514525
3. Kap p JP, Gielch in sky I. Man agem en t of com bat w ou n ds of th e
du ral ven ou s sin u ses. Su rger y 1972;71(6):913917
168
II
11
Introduction
Preprocedure Considerations
Radiographic Imaging
X-ray an d/or com p u ted tom ograp hy (CT) eviden ce of fract u re,
Indications
Cer vical spin al m isalign m en t due to t raum at ic fract ure/
170
dislocat ion
Sp in al cord/n er ve root com p ression du e to m isalign m en t
Cer vical spin al in st abilit y du e to t rau m at ic fract u re or ligam en tou s in stabilit y requ iring im m obilizat ion th at can n ot be
adequ ately ach ieved w ith extern al orth oses alon e
Aw ake, coop erat ive p at ien t
Availabilit y of radiographic/clinical m onitoring during reduction
Absen ce of skull fract ure or prior bur hole at proposed pin sites
Absen ce of occipitoatlan tal or atlan toaxial dissociat ion or
com plete ligam en tous injur y at any level
Absen ce of fract ure/in st abilit y at level rost ral to in ten ded
level of t reat m en t
Absen ce of kn ow n sign i can t associate t raum at ic cer vical
disk h ern iat ion , w h ich can w orsen n eurologic de cit un der
t ract ion
Medication
System ic: Non sedat ing pain m edicat ion (m orph in e, fen t anyl)
11
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
Operative Procedure
Positioning (Fig. 11.2)
172
Figure
Procedural Steps
Pearls
Fig. 11.2
It is easier to place an open halo ring than a closed ring while supine. Check lateral
X-ray in position prior to proceeding. If one needs to reduce kyphosis, a shoulder roll can
be placed. If the plan is to eventually place in halo vest, one can preplace the back of
the halo vest for the patient to lie on.3
11
Figure
Procedural Steps
Pearls
Fig. 11.3
173
Figure
Procedural Steps
Pearls
Fig. 11.4
174
11
Figure
Procedural Steps
Pearls
Fig. 11.5
If stabilizing an unstable fracture bet ween occiput and C2, begin with 5 lb, and advance to
175
Figure
Procedural Steps
Pearls
Fig. 11.6
176
11
Figure
Procedural Steps
Fig. 11.7
Lateral radiograph of cervical spine after tongs traction in patient depicted in Fig. 11.1. Spinal alignment at C4-5 has
improved after serial w eights w ere applied, but the patient required open reduction and xation.
It is important to obtain imaging after halo or traction placement to verify alignment of the injured segment.
177
Postoperative Management
Monitoring
Mon itor n eu rologic st at u s an d vital sign s ever y 2 h ou rs.
Mon itor for skin breakdow n /decu bit is u lcers.
Medication
Pain m an agem en t an d m u scle relaxat ion can be adm in istered.
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.
Further Management
After su ccessfu l realign m en t , decide to brace, p lace in h alo
Special Considerations
Pediat ric pat ien t s h ave special con cern s regarding n u m ber of
pin s an d pin torque pressures (see above). In pat ien t s w ith an kylosing spon dylit is,7,8 ligh t cer vical t ract ion (, 5 or 10 lb) is ad vised. Prolonged t ract ion w ith ligh t w eigh ts m ay lead to desired
178
References
1. Lu K, Lee T, Ch en H. Closed redu ct ion of bilateral locked facet s
of th e cer vical spin e un der gen eral an esth esia. Act a Neuroch ir
(Wein ) 1998;40:10551061
2. Sect ion on Disord ers of th e Sp in e an d Perip h eral Ner ves of
th e Am erican Associat ion of Neu rological Su rgeon s an d Th e
Congress of Neu rological Su rgeon s: In it ial closed redu ct ion
of cer vical spin e fract u re-dislocat ion injuries. Neurosurger y
2002;50(suppl 3):s4450
3. Goldstein R, Deen HG, Zim m erm an RS, Lyon s MK. Preplacem en t
of th e back of th e h alo vest in pat ien t s un dergoing cer vical
t ract ion for cer vical spin e injuries: a tech n ical n ote. Surg Neurol
1995;44:476478
4. Cop ley LA, Pep e MD, Tan V, Sh eth N, Dorm an s JP. A com p arison of
variou s angles of h alo p in in ser t ion in an im m at u re sku ll m od el.
Spin e 1999;24:17771780
5. Arkader A, Hosalkar HS, Dru m m on d DS, Dorm an s JP. An alysis of
h alo-or th osis applicat ion in children less th an th ree years old.
J Ch ild Or th op 2007;1:337344
6. Cop ley LA, Pep e MD, Tan V, Dorm an s JP, Gabriel JP, Sh eth NP,
Asada N. A com p arat ive evalu at ion of h alo p in d esign s in an
im m at ure skull m odel. Clin Orth op 1998;357:212218
7. Kan ter AS, Wang MY, Mu m m an en i PV. A t reat m en t algorith m
for th e m anagem en t of cer vical spin e fract ures an d deform it y
in pat ien t s w ith ankylosing spon dylit is. Neurosurg Focus
2008;24(1):E1117
8. Th u m bikat P, Harih aran RP, Ravich an d ran G, McClellan d MR,
Math ew KM. Sp in al cord inju r y in pat ien t s w ith an kylosis
spon dylit is: a 10-year review. Spin e 2007;32(26):29892995
12
Emergency Management of
Odontoid Fractures
Sanjay Yadla, Benjam in M. Zussm an, and Jam es S. Harrop
Introduction
Indications
Disru pt ion of th e t ran sverse ligam en t cau sing atlan toa xial
in st abilit y.
Type II odon toid fract ures w ith eviden ce of in st abilit y
(i.e., greater th an 6 m m of displacem en t).
Movem en t at th e fract u re site in h alo vest dem on st rated on
su p in e an d u prigh t X-rays.
Preprocedure Considerations
Radiographic Imaging
Radiological st u diesin it ial lm s sh ou ld in clu de an terop os
Medication
Periop erat ive an t ibiot ics are in it iated an d m ain t ain ed for
24 h ours after in cision .
179
Management
Type 1
Conservative
External im m obilization
100%
Type II
Conservative
External im m obilization
55-65%
Surgical
Type III
90%
74-87%
Conservative
External im m obilization
50-84%
Surgical
100%
b
Fig. 12.2a, b (a) Sagit tal and (b) coronal preoperative CT images demonstrating a t ype II odontoid fracture.
180
12
Operative Procedure
Odontoid Screw
Positioning (Fig. 12.3)
Figure
Procedural Steps
Pearls
Fig. 12.3
The anteroposterior (AP) view is obtained transorally using a C-arm uoroscope, and
a radiolucent prop m ay be used to open the m outh to improve AP visualization. The
lateral view is obtained by a second C-arm uoroscope, oriented horizontally. Using
uoroscopy as a guide, the head and neck are positioned to align the fracture edges.
Finally, because blockage of screw insertion due to body obstruction (e.g., barrel chest)
or body positioning (e.g., xed cervical kyphosis) m ay lim it this procedure, a Kirschner
wire (K-wire) m ay be used to estim ate screw/instrum ent trajectory and ensure that the
patients body will perm it clearance during screw placem ent prior to incision.
181
182
12
Figure
Procedural Steps
Pearls
Fig. 12.4
183
184
Figure
Procedural Steps
Pearls
Fig. 12.5
12
Figure
Procedural Steps
Fig. 12.6
(a) AP and (b) lateral X-ray images of nal odontoid screw construct.
185
186
Figure
Procedural Steps
Pearls
Fig. 12.7
The operating table and room should be arranged to accom m odate lateral uoroscopy
with a com fortable viewing angle for the operating surgeon. A three-pinion head holder
is used to secure the head in the m ilitary tuck position, which will allow access to the
atlantoaxial joint at the appropriate angle with surgical instruments. Lateral uoroscopy
can be used to con rm that no displacem ent has occurred and that the neck rem ains
neutral after positioning. Screw entry sites and trajectories can be estim ated using
uoroscopy at this point. In older patients with a pronounced thoracic kyphosis, an
adequate trajectory may not be at tainable.
12
Figure
Procedural Steps
Pearls
Fig. 12.8
187
188
Figure
Procedural Steps
Pearls
Fig. 12.9
(a) Tissue dissection is carried dow n through the midline along the
relatively avascular midline raphe betw een the paraspinal muscles. The
dissection is taken dow n to the spinous processes and articulating pro cesses of C1 and C2. (b) Brisk venous bleeding may be encountered upon
exposure of the C1 facet. This should be anticipated and can be controlled
w ith a thrombin-soaked gelatin sponge. The exiting C2 nerve root is
encountered betw een the posterior arch of C1 and lamina of C2. It can be
protected by dow nw ard retraction using a Pen eld no. 4.
12
Figure
Procedural Steps
Pearls
Fig. 12.10
189
190
Figure
Procedural Steps
Fig. 12.11
12
Figure
Procedural Steps
Pearls
Fig. 12.12
The patient is positioned prone under general anesthesia under cervical traction w ith skull tongs. The incision is marked from occiput to C4.
After prepping, a midline incision is made. Soft tissue dissection is conducted w ith monopolar cautery along the midline. A relatively avascular
plane can be found in the midline raphe betw een the paraspinal muscles
(see Fig. 12.9a).
191
192
Figure
Procedural Steps
Pearls
Fig. 12.13
12
Figure
Procedural Steps
Pearls
Fig. 12.14
193
194
Figure
Procedural Steps
Pearls
Fig. 12.15
12
Figure
Procedural Steps
Fig. 12.16
195
Closing
Th e w oun d is h eavily irrigated.
An opt ion al su bcu t an eou s d rain m ay be placed.
For an terior procedures, th e plat ysm a is reapproxim ated us
Postoperative Management
Monitoring
It is th e sen ior au th ors (JSH) p ract ice to p lace th e p at ien t in a
m on itored set t ing overn igh t .
Medication
Periop erat ive an t ibiot ics are m ain t ain ed for 24 h ou rs after
in cision .
Further Management
Drain s are rem oved on p ostoperat ive day 1 or 2.
Skin su t u res are rem oved after 2 w eeks.
For posterior procedures, pat ien ts are t ypically kept in a rigid
Special Considerations
The senior author (JSH) prefers not to use additional bone w iring techniques though several have been described. A posterior
bone w iring technique is often perform ed to provide three-point
xation. The C1-C2 transarticular screw, as initially described by
Magerl in 1987, was the rst m ajor advance from bone w iring
techniques.8 Using this technique, im m ediate three-dim ensional
unisegm ental fusion can be achieved and, w hen perform ed in
com bination w ith bone w iring techniques, the use of external
im m obilization (e.g., halo vest) is not necessary. One advantage
of this technique is that it elim inates rotational m otion at C1-C2,
w hich increases the chance of bony fusion. However, its popularit y
has been lim ited by its relative technical com plexit y and associated risks such as hypoglossal nerve and vertebral artery injuries.5
Th e basic prin ciples of m ult isystem t rau m a m an agem en t
sh ou ld n ot be foregon e in th e set t ing of sp in al cord inju r y (SCI).
The ABCs (air w ay, breath ing, circulat ion ) sh ould be m on itored
an d t reated app ropriately. SCI p at ien t s m ay p resen t w ith oth er
life th reaten ing inju ries th at m ake op erat ive in ter ven t ion for
196
atlan toaxial in st abilit y u n safe in th e acute set t ing. If th e fract ure can be reduced an d th e pat ien t does n ot h ave a progressive
n eu rologic de cit th en th e p at ien t can be im m obilized in a rigid
cer vical collar, h alo vest , or t ract ion un t il con curren t injuries
are st abilized. In th e au th ors exp erien ce, p at ien ts w ith h igh
cer vical injuries are best m on itored in th e in ten sive care un it
un t il de n it ive t reat m en t .
Th ere are no stan dards regarding th e ideal t im ing of surgical in ter ven t ion . In the on ly publish ed ran dom ized t rial on this
top ic (for spin al cord inju r y pat ien ts), Vaccaro et al fou n d n o
di eren ce in length of in ten sive care un it stay, length of inpat ien t
reh abilit at ion , or Am erican Spin al Injur y Associat ion (ASIA)
score im provem en t bet w een early (, 72 h ours from inju r y) an d
late (. 5 days from inju r y) surgical in ter ven t ion in 123 pat ien t s
w ith C3 to T1 injuries.9 In a recen t Coch ran e Database system at ic review, Bagnall et al foun d in su cien t eviden ce to establish
recom m en dat ion s on t im ing of surger y.10 Early eviden ce from
th e Surgical Treat m en t for Acute Spin al Cord Injur y St udy (STASCIS), a m ult i-inst it ut ion al ran dom ized t rial of early (, 24 h ours)
versus late su rger y for isolated cer vical SCI, suggests th at early
decom pression m ay be associated w ith im proved neurologic recover y at 1-year follow -up.11 Subsequen t result s dem on st rated
safet y in early su rger y w ith im provem en t in at least t w o grades
of the ASIA im pairm en t scale at 6 m onths follow -up.12
References
1. Sm ith HE, Malten fort M, Harrop JS, et al. Od on toid fract u res an d
th eir m an agem en t . Top ics in Sp in al Cord Inju r y Reh abilit at ion
2010;15(3):6572
2. An derson LD, DAlon zo RT. Fract u res of th e odon toid process of
th e axis. J Bon e Join t Su rg Am 1974;56(8):16631674
3. Su bach BR, Moron e MA, Haid RW Jr., McLaugh lin MR, Rodt s
GR, Com ey CH. Man agem en t of acute odontoid fract ures w ith
single-screw an terior
xat ion . Neurosurger y 1999;45(4):
812819; discu ssion 819820
4. Apfelbau m RI, Lon ser RR, Veres R, Casey A. Direct an terior screw
xat ion for recen t an d rem ote odontoid fract ures. J Neurosurg
2000;93(2 Su ppl):227236
5. Haid RW Jr., Su bach BR, McLaugh lin MR, Rodt s GE Jr., Wah lig
JB, Jr. C1- C2 t ran sar t icu lar screw xat ion for atlan toaxial in st abilit y: a 6-year experien ce. Neurosu rger y 2001;49(1):6568;
discu ssion 6970
6. Harm s J, Melch er RP. Posterior C1- C2 fu sion w ith polyaxial screw
an d rod xat ion . Sp in e (Ph ila Pa 1976) 2001;26(22):24672471
7. Sm ith HE, Vaccaro AR, Malten for t M, et al. Tren ds in su rgical m an agem en t for t ype II odon toid fract u re: 20 years of exp erien ce at a
region al spin al cord injur y cen ter. Or th opedics 2008;31(7):650
8. Grob D, Magerl F. [Su rgical st abilizat ion of C1 an d C2 fract u res].
Or th op ad e 1987;16(1):4654
9. Vaccaro AR, Daugh er t y RJ, Sh eeh an TP, et al. Neu rologic ou tcom e
of early versu s late surger y for cer vical spin al cord injur y. Spin e
(Ph ila Pa 1976) 1997;22(22):26092613
10. Bagn all AM, Jon es L, Du y S, Riem sm a RP. Sp in al xat ion su rger y
for acute t raum at ic spin al cord injur y. Coch ran e Dat abase Syst
Rev 2008(1):CD004725
11. Feh lings MG, Ar vin B. Th e t im ing of su rger y in pat ien t s w ith cen t ral spin al cord injur y. J Neurosurg Spin e 2009;10(1):12
12. Feh lings MG, Vaccaro A, Wilson JR, et al. Early versu s delayed decom pression for t raum at ic cer vical spin al cord injur y: result s of
th e su rgical t im ing in acu te sp in al cord inju r y st u dy (STASCIS).
PLoS On e 2012;7:e32037
13
Introduction
Cer vical burst fract ures are th e result of exion com pression
inju ries an d are ch aracterized by loss in vertebral body (VB)
h eigh t , cor t ical fract ure of th e posterior VB w all, ret ropulsion of
fragm en t s in to th e can al, an d an in crease in in t rap edicu lar distan ce (IPD). Burst fract ures th at presen t w ith n eurologic de cit
h ave p ersisten t can al com pression or th at involve th e posterior
elem en t s usually require surgical in ter ven t ion t ypically in
th e form of corpectom y an d an terior recon st ruct ion . How ever,
burst fract ures th at do n ot a ect th e posterior elem en t s an d
presen t n eurologically in tact can be m an aged w ith extern al
or th osis. In th e follow ing ch apter w e discuss the su rgical in dicat ion s, m edical m an agem en t , radiograph ic n dings, surgical
ap proach , an d p ostop erat ive care of pat ien t s w ith su baxial cervical sp in e bu rst fract u res.
Indications
Th ere are a variet y of classi cat ion system s for su baxial cervical bu rst fract u res. Th e Allen classi cat ion 1 categorized
su baxial spin e inju ries in to six m ajor grou p s of inju r y: th ree
com pressive injuries ( exion com pression [20%], exten sion
com pression [25%], an d vert ical com pression ); t w o dist ract ion
inju ries ( exion dist ract ion [40%], exten sion -dist ract ion ); an d
n ally on e lateral exion inju r y. Bu rst fract u res belong to both
exion com p ression an d vert ical com p ression categories.
Perh aps th e m ost clin ically useful classi cat ion system w as
put for w ard in 2007 by Vaccarro et al w h o developed th e sub axial cer vical spin e classi cat ion system (SLIC) gu idelin es
(Table 13.1).2 Th ese guidelin es are u n iqu e in th eir con siderat ion
of bony m orph ology, involvem en t of th e discoligam en tous
com plex (DLC), an d n eurologic presen t at ion . Num erical values are given u n der each categor y dep en d ing on th e severit y
of involvem ent . W h en th e sum of all th ree categories am oun ts
to less th an 4 p oin t s, th en con ser vat ive m an agem en t sh ou ld
be con sidered. Greater th an 4 poin t s is suggest ive of surgical
m an agem en t . Based on th e SLIC scale, bu rst fract u res w ith ou t
disrupt ion of th e DLC or ch ange in n eurologic st at us w ould be
given 3 to 4 poin t s an d be t reated w ith extern al orth osis w h ile
th ose w ith deteriorat ion in n eurologic stat us an d disrupt ion of
th e DLC w ould h ave . 4 p oin ts an d th erefore requ ire su rgical
stabilizat ion . Th e p roposed algorith m in clu ded in th is ch apter
is also dependen t on n eu rologic stat u s an d th e st at us of th e
posterior ligam en tous com plex (Fig. 13.1). Isolated burst fract ures w ith out n eurologic de cit are m an aged w ith extern al orth osis w h ile th ose presen t ing w ith n eurologic sym ptom s an d
disrupt ion of th e posterior elem en ts require both an terior decom pression an d posterior recon st ru ct ion .
Panjabi an d W h ite p roposed an altern at ive p oin t-based classi cat ion system t argeted tow ard th e su baxial cer vical sp in e as
w ell as th oracic an d lu m bar inju ries. Th ey con sidered angu lat ion . 11% or . 3.5 m m of sublu xat ion as un stable.3 Cooper
et al based th eir decision on th e p resen ce of irred u cible facet
fract u res, ret ropu lsed fragm en t s cau sing p ersisten t can al com prom ise in an in com plete SCI, progressive n eurologic de cit
from sp in al in st abilit y, root decom pression , or ch ron ic progressive deform it y w ith in com p lete sp in al cord inju r y or n er ve root
de cit .4 Hadley et al recom m en ded th e follow ing in dicat ion s
for su rger y: irredu cible bon e align m en t , irredu cible sp in al cord
com pression , in st abilit y post reduct ion , ligam en tous injur y
w ith facet in st abilit y, . 15% kyph osis, or . 20% su blu xat ion .5
To bet ter determ in e th e correlat ion of radiograph ic n dings
of can al com prom ise an d n eurologic outcom e, Feh lings et al
perform ed an eviden ce-based an alysis of publish ed criteria in
pat ien t s w ith acute cer vical SCI.6,7 Th ey w en t on to develop a
prospect ive st udy invest igat ing m agn et ic reson an ce im aging
Points
Morphology
No abnorm alit y
Compression
Burst
Distraction
Rotation/translation
0
1
2
3
4
Discoligamentous complex
Intact
Indeterm inate
Disrupted
0
1
2
Neurologic status
Intact
Root injury
Complete cord injury
Incomplete cord injury
Continuous compression
0
1
2
3
11
197
198
13
Cervical Burst Fractures
199
200
Preprocedure Considerations
Radiographic Imaging
Th e ch oice of im aging in su spected cer vical burst fract ures
h as ch anged over th e past few decades. Tradit ion ally, an teroposterior (AP), lateral, an d odon toid plain lm s of th e
C-spin e w ere th e rst-lin e im aging of choice. Th ere are several radiograp h ic feat u res suggest ive of bu rst fract u resm ost
im port an tly, loss of ver tebral body h eigh t , cort ical fract ure
of th e posterior VB w all, ret ropu lsion of fragm en t s in to th e
can al result ing in loss of th e dorsal ver tebral body lin e, an d
an in crease in in t rapedicu lar distan ces or sp laying of th e facet
join t s. Th is is occasion ally accom pan ied by VB kyph ot ic or
t ran slat ion al deform it y.
In m any cen ters, com p u ted tom ography (CT) scan is n ow th e
rst-lin e im aging m odalit y of ch oice in cases su sp iciou s of
n eck t rau m a. Typ ically, bu rst fract u res w ill h ave d isru pt ion of
th e posterior VB w all w ith or w ith ou t ret ropulsed fragm en t s.
As in plain lm s, th ey w ill dem on st rate an in creased IPD w ith
splaying of th e vertebral arch . CT angiograp hy (CTA) sh ou ld
also be con sidered w h en th ere is con cern of com p rom ise of
th e ver tebral can al an d, in m any in st it ut ion s, it h as becom e
part of th e st an dard im aging protocol for con rm ed C-spin e
inju ries.
MRI can often be h elp fu l in bet ter visu alizing soft t issu e
st ru ct u res, disk, can al sten osis as w ell as cerebrospin al u id
(CSF) e acem en t , cord im pingem en t , or sign al ch anges23%
of all blu n t t raum a pat ien t s presen t ing w ith a cer vical in jur y h ave eviden ce of disk injur y on MRI. Th is in creases to
as h igh as 36% of th ose p at ien ts w ith com p lete SCI, 54% of
13
Approach
On ce th e decision to operate h as been m ade, th e role of an terior,
posterior, or com bined approaches m ust be con sidered. There
are risks an d ben e ts to both an d approach is ult im ately determ in ed by th e areas of com pression , n eurologic stat u s, stat us of
the posterior elem en ts, an d com fort of th e surgeon. In cer vical
burst fract ures the approach of choice is predom inantly ventral.
Neurologic com pression is a result of retropu lsed an terior elem en ts w h ich can be rem oved un der direct vision w ith an an terior approach and therefore on e can provide opt im al decom pression . Fu rth erm ore, corpectom y w ith an terior recon st ruction
provides excellent biom echanical stabilit y and correction of kyphotic deform it ies. The resected vertebral body provides large
am oun ts of excellen t m aterial for autologous bon e graft ing.
An terior approach es also h ave less blood loss an d postoperat ive pain. Indeed, w hen directly com pared, Toh et al found an terior fusion preferred to posterior fusion in cer vical burst and
teardrop fract ures.14 This w as echoed by several biom echanical
201
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
Operative Procedure
Positioning (Fig. 13.3)
Figure
Procedural Steps
Pearls
Fig. 13.3
203
Figure
Procedural Steps
Fig. 13.4
A right longitudinal paracervical incision is made w ith a no. 20 blade along the anterior border of the
sternocleidomastoid muscle. The incision is extended dow n through skin, subcutaneous tissue, and platysma.
Subplatysmal aps are elevated and the omohyoid muscle is isolated and divided w ith diathermy cautery.
204
13
Figure
Procedural Steps
Pearls
Fig. 13.5
Through the superior end of incision, the superior thyroid artery and
superior laryngeal nerve can be identi ed and protected. At the lower end
of the incision the inferior thyroid vein can occasionally be visualized. At
all points it is important to identify and protect the pharynx/esophagus.
205
206
Figure
Procedural Steps
Fig. 13.6
Blunt dissection is used to identify the prevertebral fascia w hich is then opened w ith sharp dissection. Superior
osteal dissection ensues under the longus colli muscle bilaterally.
13
Figure
Procedural Steps
Pearls
Fig. 13.7
207
208
Figure
Procedural Steps
Fig. 13.8
Disk spaces above and below the injured vertebra are evacuated using a combination of high speed bur, pituitary
rongeurs, Kerrison punches, and microsurgical curettes. A longitudinal trough is then fashioned longitudinally in
line w ith the uncovertebral joints. The endplates are thoroughly burred dow n to posterior longitudinal ligament.
13
Figure
Procedural Steps
Fig. 13.9
The injured vertebral body is resected w ith Leksell rongeurs and high-speed burs. The posterior longitudinal
ligament is then opened and all retropulsed fragments are carefully removed via microsurgical dissection under
microscopic magni cation.
209
210
Figure
Procedural Steps
Fig. 13.10
Distraction pins are placed in the vertebral body above and below the level of injury. Fibular allograft is cut to the
appropriate length and packed w ith local corpectomy bone graft. These are gently tapped in to position. Distraction
pins are removed and the security of t is assessed. Bleeding from the pin sites is controlled w ith bone w ax.
13
Figure
Procedural Steps
Pearls
Fig. 13.11
The literature supporting dynamic or static locking plates is divergent 17 and the
decision to use one over the other is typically related to the preference of the
surgeon. While locking screws do have bene t over nonlocking screws,18,19 unicortical
and bicortical screws have both shown immediate stability so either is a reasonable
choices depending on the experience of the surgeon and risk of protrusion through
the posterior vertebral bodies.20 Approximately 4 mm should be left at both the
rostral and caudal end to diminish the risk of future adjacent level disease.
211
Closing
Ret ractors are rem oved an d soft t issues are carefu lly in spect -
Postoperative Management
Monitoring
Pat ien t s sh ou ld be m on itored for blood pressu re an d n eurologic fu n ct ion postoperat ively w ith a t arget of MAP . 80.
A p lain CT of th e cer vical sp in e w ill h elp con rm p lacem en t
of in st rum en t at ion .
Medication
Th e u se of postoperat ive an t ibiot ics is con t roversial. Th ere is
n o good evid en ce th at rou t ing postoperat ive an t ibiot ics provides any advan t age to p ostop w ou n d in fect ion s.
The use of steroids in acute SCI is also controversial and its poten tial ben e t m ust be w eigh ed again st th e risk of pn eu m on ia,
poor w ound healing, and recover y from associated injuries.
Fig. 13.12 The patient was treated with a C4 corpectomy and C3-5
anterior reconstruction with a bular allograft (packed with local
corticocancellous autograft), and anterior screw-plate xation. Under
the same anesthetic, the patient was turned (using May eld cranial
xation and a Jackson table) in the supine position and a C3-5 posterior
lateral mass reconstruction was undertaken.
212
Further Management
Dep en ding on th e degree of inju r y, u se of an extern al or th osis
postoperat ively m ay ben e t th e pat ien t in term s of both stabilit y an d pain con t rol.
Special Considerations
Th e term cer vical burst fract ure is used in a variet y of con text s. Th e im port an t factors in determ in ing th e role of su rgical xat ion are th e involvem en t of th e posterior com plex an d
ongoing n eurologic de cit secon dar y to ongoing cord com pression . Th ey are often con sidered in th e con text of su baxial
cer vical spin e classi cat ion system s, m ost n ot ably th e SLIC
classi cat ion . W h ile th ese can aid in determ in ing th e st abilit y
of th e injur y, ult im ately each pat ien t an d th eir inju r y is un iqu e
an d requ ire in dividu al con sid erat ion .
References
1. Allen BL, Jr., Fergu son RL, Leh m an n TR, OBrien RP. A m ech an ist ic
classi cat ion of closed, in direct fract ures an d dislocat ions of th e
low er cer vical spin e. Spin e (Ph ila Pa 1976 ) 1982;7(1):127
2. Vaccaro AR, Hu lber t RJ, Patel AA, et al. Th e su baxial cer vical
spin e injur y classi cat ion system : a n ovel approach to recogn ize
th e im por t an ce of m orph ology, n eurology, an d integrit y of th e
disco-ligam en tou s com p lex. Sp in e (Ph ila Pa 1976 ) 2007;32(21):
23652374
3. W h ite AA, III, Panjabi MM. Update on th e evalu at ion of in st abilit y of th e low er cer vical spine. In st r Cou rse Lect 1987;36:
513520
4. Coop er PR, Maravilla KR, Sklar FH, Moody SF, Clark W K. Halo im m obilizat ion of cer vical spin e fract u res. In dicat ions an d result s.
J Neu rosu rg 1979;50(5):603610
5. Hadley MN, Walters BC, Grabb PA, et al. Gu idelin es for th e m an agem en t of acu te cer vical sp in e an d sp in al cord inju ries. Clin
Neurosu rg 2002;49:407498
6. Feh lings MG, Rao SC, Tator CH, et al. Th e opt im al rad iologic m et h od for assessing sp in al can al com p rom ise an d cord
com p ression in p at ien t s w it h cer vical sp in al cord inju r y.
Par t II: Resu lt s of a m u lt icen ter st u dy. Sp in e (Ph ila Pa 1976)
1999;24(6):605613
7. Rao SC, Feh lings MG. Th e opt im al radiologic m eth od for assessing spin al can al com prom ise an d cord com pression in pat ien t s
w ith cer vical spin al cord injur y. Par t I: An eviden ce-based analysis of th e publish ed literat ure. Spin e (Ph ila Pa 1976 ) 1999;24(6):
598604
8. Miyanji F, Fu rlan JC, Aarabi B, Arn old PM, Feh lings MG. Acu te
cer vical t raum at ic spin al cord injur y: MR im aging n dings
correlated w ith n eurologic outcom eprospect ive st udy w ith
100 con secut ive pat ien t s. Radiology 2007;243(3):820827
9. Marin o RJ, Barros T, Biering-Soren sen F, et al. In tern at ion al st an dards for n eurological classi cat ion of spin al cord injur y. J Spin al
Cord Med 2003;26 Su p pl 1:S50S56
10. Feh lings MG, Vaccaro A, Wilson JR, et al. Early versu s delayed decom pression for t rau m at ic cer vical spin al cord injur y: result s of
th e Su rgical Tim ing in Acu te Spin al Cord Inju r y St u dy (STASCIS).
PLoS On e 2012;7(2):e32037
13
11. Koivikko MP, Myllyn en P, Karjalain en M, Vorn an en M, San t avir t a
S. Con ser vat ive an d operat ive t reat m en t in cer vical burst fract ures. Arch Or th op Traum a Surg 2000;120(7-8):448451
12. Rizzolo SJ, Vaccaro AR, Cotler JM. Cer vical sp in e t rau m a. Sp in e
(Ph ila Pa 1976 ) 1994;19(20):22882298
13. Benzel EC, Hart BL, Ball PA, Baldw in NG, Orrison W W, Espinosa
MC. Magnetic resonance im aging for the evaluation of patients
w ith occult cervical spine injur y. J Neurosurg 1996;85(5):824829
14. Toh E, Nom u ra T, Wat an abe M, Moch ida J. Su rgical t reat m en t
for inju ries of th e m iddle and low er cer vical spin e. Int Or th op
2006;30(1):5458
15. Zigler J, Eism on t F, Gar n S, Vaccaro A. Sp in e Trau m a. Rosem on t ,
IL: Am erican Academ y of Or th opaedic Su rgeon s; 2011
16. Dvorak MF, Pit zen T, Zh u Q, Gordon JD, Fish er CG, Oxlan d TR. An terior cer vical plate xat ion : a biom echan ical st u dy to evaluate
17.
18.
19.
20.
213
14
Introduction
Dislocat ion of th e facets join t s of th e spin e can occu r at all levels,
but it is m ost com m on ly an injur y fou n d in th e cer vical spin e.
First , th e coron al orien t at ion of th e join t s th em selves leaves
th em suscept ible to dislocat ion w ith hyper exion . Secon d, un like th e su bstan t ial size of th e lum bar ar t icu lat ing processes,
th ose in th e cer vical spin e are m uch less robust .1 Th erefore,
th e ar t iculat ing processes in th e cer vical spin e are m uch m ore
p ron e to fract u re an d dislocat ion . Th ird , th e cer vical spin e is
n at u rally h igh ly m obile in com p arison to th e th oracic an d lu m bar spin e w ith th e h eads w eigh t ser ving as a con t ribut ing factor. Th is ch aracterist ic leaves th e cer vical spin e vuln erable to
su dden ch anges in m ovem en t su ch as th at w h ich occu rs in a
h ead-on collision .
Dislocat ion of th e cer vical facet join ts can be both u n ilateral
an d bilateral. In th e case of u n ilateral facet dislocat ion , th ere
is often a rotator y force experien ced along w ith th e hyper exion . Th e hyp er exion force vector is en ough to raise th e in ferior
ar t icu lat ing processes of both facet join ts at th e a ected level
w ith respect to th e superior ar t iculat ing process. The rotat ion
exp erien ced at th e sam e t im e cau ses on ly on e of th e t w o elevated in ferior art icu lat ing p rocesses to t ran slate for w ard, locking an terior to th e su perior art icu lat ing p rocess of th e ver tebra
below it .2 A pu rely hyp er exion m om en t w ith ou t rot at ion is
m u ch m ore likely to cau se bilateral facet dislocat ion as th e force
vectors exp erien ced by each facet are th eoret ically sim ilar. In
eith er scen ario, th e dislocat ion is visu alized as eith er a p erch ed
facet (on e in w h ich th e in ferior p roject ion of th e in ferior ar t icu lat ing p rocess of th e p roxim al ver tebral body ar t iculates w ith
th e superior project ion of th e superior ar t icu lat ing process of
th e dist al ver tebral body) or a locked facet (in w h ich th e in ferior
art icu lat ing process of th e p roxim al ver tebral body is an terior
to th e su perior art iculat ing process of th e dist al ver tebral body).
All region s of th e cer vical spin e are n ot created equ al. Un like
th e su baxial cer vical spin e, th e C1-C2 facet join t s are orien ted
in an axial plan e m aking th em less vuln erable to dislocat ion
from hyper exion . Th e occip itocer vical ju n ct ion is su bject to
a n u m ber of part icu lar inju r y pat tern s th at are discu ssed elsew h ere. It is th e su baxial cer vical spin e, speci cally C4- C7, th at is
m ost p ron e to hyper exion inju ries.3 In large p art , th is is du e to
th e dyn am ic forces th e cer vical spin e experien ces as a collision
evolves. At th e on set of a h ead -on collision , th e low er cer vicoth oracic jun ct ion of th e spin e com presses an d extends w h ile
th e subaxial cer vical spin e exes w ith great force. As th e forces
evolve, th e cer vical sp in e is even t u ally th row n in to exten sion .
Th is evolut ion of forces, com m on ly referred to as w h iplash ,
causes th e spin e to assum e an S-shape, a ph en om en on referred
to as sn aking. Th e hyper exion , if severe en ough , can lead to
facet dislocat ion by it self.
214
Indications
Hyp er exion inju r y resu lt ing in u n ilateral or bilateral facet
Examination
Any pat ien t th at su ers a cer vical facet dislocat ion h as su s-
t ain ed forces su cien t to cause a m yriad of oth er life-th reat en ing inju ries; th erefore, a fu ll t rau m a w orku p sh ou ld be
com pleted w ith priorit y given to th e ABCs (air w ay, breath ing,
circulat ion ). Im m obilizat ion of th e cer vical spin e du ring th is
evalu at ion m u st be a priorit y.
A full n eurologic exam in at ion sh ould be perform ed as th is
h as im plicat ion s regarding th e t im ing of in ter ven t ion .
Ad dit ion ally, evalu at ion of n eu rologic st at u s m ay allow localizat ion of th e injur y prior to im aging.
14
ReductionClosed or Open
Class III eviden ce suggest s early redu ct ion of cer vical facet
Operative Management 11
Approach
If closed redu ct ion h as been ach ieved, an terior xat ion an d
Techniques
Preprocedure Considerations
Radiographic Imaging
cal spine traum a evaluation. Identi cation of osseus abnorm alit y is straightforward w hile ligam entous injury is not always
detectable. Ligam entous injury m ay be detected due to enlarged
spaces bet ween otherw ise norm al appearing osseus structures.
MRI: Th is test h as, in th e past , been advocated as a n ecessar y
p ar t of any pre-reduct ion w orkup, w h eth er th at reduct ion be
in th e in ten sive care un it (ICU) or operat ing room set t ing. Th e
rat ion ale for th is w as to iden t ify any ven t ral in ter vertebral
disk h ern iat ion s th at m ay cause n eurologic injur y du ring reduct ion . According to an eviden ce-based review, th ere w as
n o relat ion sh ip bet w een th e p resen ce of h ern iated disks an d
risk of n eu rologic inju r y du ring closed redu ct ion of facet dislocat ion s in th e presen ce of a ven t rally h ern iated disk.4 W h ile
p re-redu ct ion or preop erat ive MRI m ay be useful in term s of
de n ing associated injuries an d in som e cases dict at ing surgical approach , as in th e obt un ded pat ien t , in th e absence of a
clear in dicat ion for MRI, reduct ion of th e dislocat ion sh ould
n ot be delayed in a p at ien t w ith a severe n eu rologic inju r y.
Cervical X-ray: The role of plain radiographs in the initial assessm ent of severe traum a has been lim ited by the advent of aggressive use of CT im aging. Plain lm s are quite helpful for diagnosing
cervical facet dislocations and are em ployed serially (or w ith uoroscopy) during the process of either open or closed reduction.
Medication
great con troversy. Draw ing from the 2002 an d 2013 AANS/CNS
215
Operative Procedure
Posterior Approach (Fig. 14.1a, b)
216
14
Figure
Procedural Steps
Pearls
Fig.14.2
Fiberopticintubationisanecessit yinthese
patients.May eldpinsmayalsobeusedto
stabilizethespine.
217
218
Figure
Procedural Steps
Pearls
Fig.14.3
Maintainingm idlineiscrucialnotonlyfor
localizationbutalsoform aintenanceof
hem ostasis.
14
Figure
Procedural Steps
Pearls
Fig.14.4
219
220
Figure
Procedural Steps
Pearls
Fig.14.5
Once the injured level has been identi ed (visually and via
intraoperative X-ray), removal of compressive bony elements and
reduction of the dislocated segment can begin using a series of
rongeurs, punches, and curettes. Reduction may require drilling of the
superior facet. Care is taken to save all bony elements for the fusion.
14
Figure
Procedural Steps
Fig.14.6
Follow ing decompression, decortication of the lateral elements and usually the facet joint itself should be carried
out to provide an adequate fusion substrate.
221
222
Figure
Procedural Steps
Pearls
Fig.14.7
Screwlengthisindividualandshouldbedeterm ined
preoperativelyonCT.Eitherunicorticalorbicorticalpurchase
isassociatedwithexcellentoutcom esandclinicallyadequate
purchaseinboththeanteriorandposteriorapproaches.17,18
Iftheconstructcrossesthecervicothoracicjunction,polyaxial
screwsa ordthegreatest exibilit yinrodplacem ent.In
thesubaxialcervicalspine,eitherrod-basedorplate-based
system sm aybeusedwithhighsuccessrates.
14
Figure
Procedural Steps
Fig.14.8
A rod is fashioned to recreate the natural cervical lordosis and is placed in the screw heads. The caps are tightened
in place.
223
224
Figure
Procedural Steps
Fig.14.9
The bone fragments removed during the decompression, having been cleaned of all soft tissue and morselized, are
placed in the decorticated facet joints and over the available lateral mass to complete the fusion.
14
Closing
Posterior
Follow ing ach ievem en t of h em ost asis, drain p lacem en t is
225
226
Figure
Procedural Steps
Pearls
Fig.14.11
GardnerWellstongsm aybeplacedifdesiredforintraoperativeaxialtraction.
Removalofim mobilizationdevicesshouldbeperform edbyatrainedm em berof
thesurgicalteamwhoisresponsibleform aintaininganeutralalignment.
14
Figure
Procedural Steps
Pearls
Fig.14.12
227
228
Figure
Procedural Steps
Pearls
Fig.14.13
With the carotid sheath and its contents retracted laterally and
the trachea and esophagus medially, the prevertebral fascia and
longus colli muscles can be seen overlying the bony elements of
the cervical spine.
Thespacebet weenthecarotidsheathisa
potentialspacethatcanbecreatedusing
blunt ngerdissection.
14
Figure
Procedural Steps
Pearls
Fig.14.14
Thetransverseprocessesliealongthesuperiorborderof
eachvertebralcolum nsothatinjurytothevertebralartery
ispreventedhere.Theoppositeistrueattheinferior
aspectsofthevertebralbodiesandcareshouldbetakento
avoidindiscrim inateuseofm onopolarelectrocautery.
229
230
Figure
Procedural Steps
Fig.14.15
The intervertebral disk and the posterior longitudinal ligament are removed using Kerrison punches and pituitary
instruments, resulting in exposure of the spinal cord dura.
14
Figure
Procedural Steps
Fig.14.16
Caspar pins are placed into the vertebral bodies and distraction and hyper exion is applied using either the Caspar
pin appliers or pliers. Usually, the facet reduction is palpable and the vertebral bodies are then allow ed to return
to an anatomic position. Fluoroscopy or a lateral radiograph is used to check alignment prior to graft placement.
231
232
Figure
Procedural Steps
Pearls
Fig.14.17
Carem ustbetakentoavoidoverdistraction
duetoanoversizedgraft.
14
Figure
Procedural Steps
Pearls
Fig.14.18
Thescrewsaredirectedm ediallyandeithersuperiorly
orinferiorlyintothesuperiorandinferiorvertebralbody,
respectively.
233
Closing
Radiographic
Anterior
Ret ract ion is rem oved slow ly w ith all poin t s of bleeding
Postoperative Management
Monitoring
Pat ien t s w ith severe n eu rologic inju ries are adm it ted to th e
Medication
Pain Management
Acetam in oph en 1000 m g by m ou th (PO) th ree t im es a day
Oxycodon e 5 to 15m g (u p to 20 m g) PO ever y 3 to 4 h ou rs as
n eeded
Gabapen t in 300 m g (up to 900 m g) PO th ree t im es a day
Diazepam 5 to 10 m g PO ever y 6 h ou rs as n eeded for m u scle
spasm s (opt ion al)
Longer act ing oxycod on e 10 m g PO t w ice a day (in crease as
n eeded)
Narcot ics an d gabap en t in are w ean ed as rapidly as p ossible.
Other
All n on steroidal an t i-in am m ator y drugs are avoided for at
234
least 3 m on th s.
Proch lorperazin e an d droperidol are avoided if possible due
to th eir sedat ing e ects w h ile th e p at ien ts are requ iring sign i can t doses of pain m edicat ion s.
Further Management
It is ou r pract ice to rem ove drain s w h en th e ou t pu t drops be
Special Considerations
It is im portant to consider th e exten t of the injur y in ch oosing an
operat ion. W hile closed reduct ion follow ed by extern al im m obilizat ion is overall a safe m odalit y that can be perform ed at the
bedside,4,20,21 it is gen erally m ost su ccessfu l in inju ries lim ited to
the osseous com ponen ts of th e spine.20,21 In gen eral, facet dislocation involves the ligam entous st ruct ures of the spine in addition to the osseous elem en ts. Therefore, internal xation is usually felt to be m ore appropriate. Th e ch oice of approach is m ore
debatable. Posterior fusion has been thoroughly st udied an d
foun d to be appropriate for cer vical facet dislocat ions.22,23 Both
an terior an d posterior approach es h ave been su ccessful, but th e
gu idelin es adopted by th e Am erican Associat ion of Neurological Surger y and the Congress of Neurological Surgeon s favor the
posterior approach w ith som e t ype of lateral m ass xation.12
Th e quest ion of im aging for evaluat ion of vertebral arter y in jur y is on e of sign i can t con t roversy. A 2006 m et a-an alysis 24
fou n d th e in ciden ce of vertebral arter y inju r y (VAI) in facet
dislocat ion w ith or w ith out associated fract ure to be 21 to 75%
(m ean , 35%). VAI w as m ore likely to occur in un ilateral rath er
th an bilateral facet dislocat ion s. Due to sign i can t collateral
ow, on ly 12 to 20% of th e VAIs iden t i ed w ere sym ptom at ic.
Th e 2002 guidelin es,25 in a st atem en t regarding VAI, recom m en d ed again st an t icoagu lat ion for asym ptom at ic p at ien ts as
th e in h eren t risk of an ticoagulat ion itself w as rough ly equivalen t to th e risk of st roke in h eren t to a VAI. Th e 2013 guidelin es 26
su p p or ts CT angiography in select p at ien ts m eet ing clin ical
(sym ptom s an d sign s) an d radiograph ic criteria. In addit ion ,
t reat m en t decision for VAI (an t icoagulat ion , an t iplatelet th erapy, obser vat ion ) sh ou ld be based u pon clin ical circu m st an ces.
Th e qu est ion th en is w h eth er to im age th e pat ien t in order to
detect th ese injuries. In follow ing th e gu idelin es, if th e pat ien t
is asym ptom at ic, vascular st udies to iden t ify asym ptom at ic in juries are n ot n ecessar y as th ey w ou ld n ot ch ange m an agem en t .
If th ere are im aging st u dies p lan n ed for oth er reason s, con siderat ion can be given to im aging of th e ver tebral arteries.
14
References
a
Fig. 14.19a, bPostoperativeimagesofpatientdepictedinFig. 14.1.
(a)Oncestabilized,hewasbroughttotheoperatingroomforanopen
posteriorreductionand(b)stabilizationusinglateralmassscrewsinthe
midcervicalspineandpediclescrewsinC7andT1.
1. Da n er RH. Evalu at ion of cer vical ver tebral inju ries. Sem in
Roen tgen ol 1992;27:239253
2. Ben zel EC. Trau m a, t u m or, an d in fect ion . In : Biom ech an ics of
Spin e St abilizat ion . New York: Th iem e; 2001:79
3. Wickst rom JK, Mar t in ez JL, Rodrigu ez R Jr. Hyperexten sion
an d hyper exion injuries to th e h ead an d n eck of prim ates.
In : Gu rdjian ES, Th om as LM, eds. Neckach e an d Backach e:
Proceedings Worksh op of th e Am erican Associat ion of Neurological Su rger y an d th e Nat ion al In st it u te of Health . Spring eld,
IL: Th om as; 1970
4. Gelb DE, Hadley MN, Aarabi B, et al. In it ial closed redu ct ion
of cer vical spin e fract ure-dislocat ion injuries. Neurosurger y
2013;72(suppl):7383
235
236
15. De Iu re F, Scim eca GB, Palm isan i M, et al. Fract u res an d dislocat ion s of th e low er cer vical spin e: surgical t reat m ent . A review of
83 cases. Ch ir Organ i Mov 2003;88:397410
16. Ordon ez BJ, Ben zel EC, Naderi S, et al. Cer vical facet d islocat ion :
tech n iques for ven t ral reduct ion an d st abilizat ion . J Neurosurg
2006;92:1823
17. Leh m an n W, Blauth M, Briem D, Sch m idt U. Biom ech an ical analysis of anterior cer vical spin e plate xat ion system s w ith un icort ical and bicor t ical screw purchase. Eur Spine J 2004;13(1):6975
18. Seybold EA, Baker JA, Criscit iello AA, Ordw ay NR, Park CK, Con n olly PJ. Ch aracterist ics of un icor t ical an d bicor t ical lateral m ass
screw s in th e cer vical spin e. Spin e 1999;24(22):23972403
19. Ryken TC, Hu rlber t RJ, Had ley MN, et al. Th e acu te cardiop u lm on ar y m an agem en t of pat ien t s w ith cer vical spin al cord injuries.
Neurosu rger y 2013;72[suppl 2]:8492
20. Bucholz RD, Chang KC. Halo vest versus spinal fusion for cervical injury: Evidence from an outcom e study. J Neurosurg 1989;71(6):955
21. Son t ag VK, Hadley MN. Non operat ive m an agem en t of cer vical
spin e injuries. Clin Neurosurg 1988;34:630649
22. Hadley MN, Fit zp at rick BC, Son n t ag VK. Facet fract u re- dislocat ion
injuries of the cer vical sp in e. Neu rosurger y 1992;30:661666
23. Mon roe MA, Ball PA. Spin al t ract ion . In : Ben zel EC, ed. Sp in e
Surger y: Tech n ique, Com plicat ion , Avoidan ce, an d Man agem en t .
Ph iladelph ia: Saun ders; 1999:13531362
24. In am asa J. Gu iot BH. Ver tebral ar ter y inju r y after blu n t cer vical
t raum a: an update. Surg Neurol 2006;65:238246
25. Hadley MN, Beverly CW, Grabb PA, et al. Man agem en t of vertebral arter y injuries after n onpen et rat ing cer vical t raum a. In :
Neurosu rger y Sect ion on Disorders of th e Spin e an d Periph eral
Ner ves of th e Am erican Associat ion of Neurological Surgeons
an d th e Congress of Neu rological Su rgeon s Gu idelin es for th e
m an agem en t of acute cer vical spin e an d spin al cord injuries.
Neurosu rger y 2002;50(3):S173S178
26. Harrigan MR, Hadley MN, Dh all SS, et al. Man agem en t of ver tebral arter y injuries follow ing n on -pen et rat ing cer vical t raum a.
Neurosu rger y 2013;72[suppl 2]:234243
15
Introduction
Th oracic fract ures in h ealthy in dividuals are un com m on due
to th e st abilizing e ect of th e rib cage. How ever, h igh en ergy
t raum a an d predisposing con dit ion s can in crease th e likelih ood of fract u re.1 Alth ough th ere is n o id eal st an dard for classi cat ion of th oracolu m bar (TL) inju ries, th e evolu t ion of th e
th ree- colu m n m odel of Den n is, th e AO/Magerl com p reh en sive
classi cat ion , an d th oracolu m bar injur y severit y scale an d
score (TLISS)/th oracolu m bar inju r y classi cat ion an d severit y
score (TLICS) poin t system h ave provided sign i can t in sigh t
in to an atom y, m ech an ism of injur y, an d th e im plicat ion s an d
th erapies for in st abilit y.24 Mu lt iple su rgical tech n iqu es add ress
spin al in st abilit y, bu t th e ch oice of su rger y d ep en ds on th e level
of injur y an d an atom y.
Facets
Th e art icular processes arise from th e su perior an d in ferior
Ribs
Th e m ost dist inguish ing feat ures of th e th oracic spin e are th e
Indications
Th e goal of th oracic spin e fract ure t reat m en t is preven t ing deform it y, p roviding st abilit y, an d p rotect ing th e n eu ral elem en t s.
If con ser vat ive m an agem en t is deem ed in su cien t to p rovide
th ese goals, th en surgical m an agem en t sh ould be con sidered.
Su rger y sh ou ld be also con sidered as an adju n ct to h asten reh abilitat ion , sh or ten h ospit al st ays, an d par t icu larly in cases of
m u lt iple inju r y.
Anatomy
Th e th oracic spin e is th e longest spin e segm en t an d a com m on
site for t rau m a, esp ecially at it s low er segm en t s (T10-T12).5 Th e
th oracic spin e con sist s of 12 vertebrae w ith a physiologic kyph ot ic cur ve due to w edging of th e th oracic ver tebrae (a 2- to
3-m m di eren ce in an terior an d posterior h eigh t).6
Bony Structure
Spinal Cord
lam in ar surfaces.
From T1 to T10, the thoracic facets are oriented coronally. This
m inim izes an terior translation during exion. From T11 to T12,
the facets have an oblique sagittal orientation to lim it rotation.
Th e coron al facet orien t at ion of th e upper th oracic spin e allow s for rotat ion aroun d th e cran iocaudal axis (75 degrees of
rot at ion to each side) w ith th e greatest rot at ion at T8-T9.8 In
con t rast , lu m bar spin e rot at ion is lim ited by th e orien tat ion
of th e facet s an d an terior an n ulus to on ly 10 degrees.
237
Neurologic Examination
Neu rologic exam sh ou ld in clu de m otor st rength , sen sor y
fu n ct ion , an d re exes.
If sp in al cord inju r y is su sp ected, serial exam s are n ecessar y
as th e n eu rologic exam m ay ch ange, esp ecially in set t ings of
in st abilit y.
Grading by th e Am erican Spin al Inju r y Associat ion (ASIA) Im pairm en t Scale docum en t s th e level an d severit y of th e spin al
cord injur y.
A rep eat evalu at ion sh ou ld be perform ed if in it ial evalu at ion
is in adequ ate.
Pat ien t s w ith sp in al cord inju r y sh ou ld be tested for perian al
sen sat ion , rect al ton e, an d bu lbocavern osu s re ex. Any su sp icious n dings w arran t im aging.
Sp in e precau t ion s sh ou ld rem ain in place u n t il sp in al t rau m a
is exclu ded.
Sp in al fract u res are m issed frequ en tly in set t ings of m u lt ip le
inju ries.1215
Orthoses
If su pport is n eeded, com pression fract ures are rout in ely
238
Preprocedure Consideration
Radiographic Imaging
Correct diagnosis w ith physical exam m ay be di cult, particularly
in patients w ith altered m ental status, patients w ho are intubated
or sedated, and patients w ith m ultiple pelvis or lim b fractures.
Initial im aging (plain radiography or CT) is crucial in these cases.
Plain Radiography
AP an d lateral plain X-rays of th e th oracic an d lu m bar spin e
allow th e p hysician to cou n t th e n u m ber of rib - bearing vertebrae an d th e n um ber of lum bar vertebrae to en sure accu racy
Computed Tomography
Modern com puted tom ography (CT) allow s rapid characteriza-
Medication
Operative Management
as n eeded.
Pressu re poin t s are padded.
239
Localization
Im aging an d p hysical exam review is crit ical to d eterm in e
th e su rgical levels. Preoperat ive im aging m ay in clu de localizat ion u sing cross t able lateral p lain lm s w ith a radiopaqu e
m arker.
Prior to Incision
Th e skin is prepped in sterile fash ion an d th e in cision is in lt rated w ith lidocain e 1% w ith epin eph rin e 1:100,000
Approaches
Su rgical ap proach es to th e th oracic sp in e can be divided in to
posterior, posterolateral, an d an terior. These approach es can
also be com bin ed in th e sam e p roced u re or staged . Ult im ately,
th e approach w ill depen d on th e path ology, locat ion , spin al
cord com pression , in st abilit y, an d m edical con dit ion .
Posterior Approach
Poster ior ap p roach es to t h e t h oracic sp in e are t h e m ain st ay of sp in e p roced u res. Th e id eal p at h ology for t h ese ap p roach es is gen erally p oster ior to t h e sp in al cord . Th e m ost
com m on p oster ior ap p roach (lam in ectom y w it h or w it h ou t
in st r u m en t at ion ) is u sed com m on ly for rad icu lom yelop at hy
from t h oracic d isk h er n iat ion , sp on dylosis, an d t rau m a w it h
st able sp in e alon g w it h som e t u m ors an d in fect ion . How ever,
it is d i cu lt to access ven t ral p at h ology w it h ou t r isk of sp in al
cord inju r y.
Th ese approach es can be tailored for access to a region of in terest from directly m idlin e to th e spin al can al (e.g., lam in ectom y) to fu rth er p osterolateral in at tem pt s to reach an terior
to th e can al (e.g., t ran sp ed icu lar, costot ran sversectom y, lateral
ext racavit ar y ap proach es).
240
Operative Procedure
Posterior Approach (Fig. 15.1ac and Fig. 15.2)
241
Fig. 15.2 MRI in same patient showed narrowing of the spinal canal with cord compression at that level. Fortunately,
the patient was moving his lower extremities.
242
Figure
Procedural Steps
Pearls
Fig. 15.3
243
244
Figure
Procedural Steps
Pearls
Fig. 15.4
The skin is in ltrated w ith lidocaine and the incision is opened w ith a no. 10 blade
to the subcutaneous tissue. Hemostasis is obtained w ith monopolar cautery.
The subcutaneous tissue is dissected dow n to the fascia w ith monopolar cautery.
Cerebellar retractors are used at this point to re ect the tissue. The bone of the
spinous process is palpated and a subperiosteal dissection is made by cutting
the muscular and tendinous attachments directly o the bone. Dissection should
continue dow n, follow ing the lamina, and out laterally to the beginning of the facet
complex. If there is signi cant bleeding then it may be more e ective to sw itch to
bipolar cautery to achieve hemostasis. The levels are veri ed by placing tw o metal
instruments in the incision such that the tips mark the rostral and caudal extent of
the anticipated bony dissection. A cross-table plain X-ray or uoroscopic image is
taken to verify the correct level of surgery.
Figure
Procedural Steps
Fig. 15.5
The interspinous ligament can be cut using monopolar cautery or scissors allow ing removal of the spinous process
w ith a Horsley.
245
246
Figure
Procedural Steps
Pearls
Fig. 15.6
Using a high speed drill, the lamina is thinned to a layer of cortical bone
over the ligamentum avum. The bone can then easily be removed
w ith a 2-mm Kerrison punch. Hemostasis should be achieved by
application of bone w ax to the bleeding cut surface of the bone.
Figure
Procedural Steps
Pearls
Fig. 15.7
247
248
Figure
Procedural Steps
Pearls
Fig. 15.8
Figure
Procedural Steps
Fig. 15.9
Tap the hole w ith the appropriate sized tap (1). Insert the screw into the hole (2). Use uoroscopy to verify position.
249
250
Figure
Procedural Steps
Fig. 15.10
When all pedicle screw s have been placed, insert a malleable temporary rod through the polyaxial screw heads to
determine the shape and length of the rod. Cut the rod to the appropriate size, and bend it to t. Fit the rod though
the screw heads and a x screw caps. When the rod ts and all screw caps are in place, use the nal tightener to
lock the screw caps dow n.
b
Fig. 15.11 Sagit tal CT reconstructions of an 18-year-old woman who was involved in a motorcycle accident, sustaining thoracic fracture
dem onstrating (a) T6 and (b) T10 burst fractures with kyphotic angulation. (a) In addition, at the T5-6 level she had a fracture-dislocation with T5
laminar and spinous process fractures. The patient was able to move her lower extremities with some sensation. However, due to the fact that she
had grossly unstable spine, she was kept on bedrest until surgical stabilization could be performed.
251
252
Figure
Procedural Steps
Pearls
Fig. 15.12
Figure
Procedural Steps
Fig. 15.13
Using a high speed drill, remove the facet complex, lamina, pars interarticularis, and pedicle on the side of the
chosen approach. The neurovascular complex is ligated. The exposure should be from the pedicle of the level above
to the pedicle of the level below.
253
254
Figure
Procedural Steps
Pearls
Fig. 15.14
The corpectomy is done w ith a combination of drilling and using the Kerrison
rongeur (1). Use curette to scrape disk material o the endplate (2). Remove
the disk w ith a pituitary.
Figure
Procedural Steps
Pearls
Fig. 15.15
Partially cut through the rib head until the deep surface
becomes thin enough to bend. When this is achieved,
the spacer can be slid past the rib head for placement.
Size the distance from the rostral to caudal endplates of
the levels above and below. Then insert the spacer lateral
to the thecal sac taking care not to put any pressure on
the cord.
255
256
Figure
Procedural Steps
Fig. 15.16
Insert the remaining pedicle screw s on the operative side then t and lock in a second rod.
b
Fig. 15.17 (a) Sagit tal CT and (b) MRI images of a 38-year-old man who was riding on a monster truck at a rally when he crashed, sustaining a T12
burst fracture with spinal cord injury. The imaging shows retropulsion of the T12 vertebral body with approximately 50% canal compromise with a
conus injury and cord signal changes. There was also associated kyphotic deformit y.
257
Transthoracic Vertebrectomy
Positioning and Approach Planning (Fig. 15.18)
258
Figure
Procedural Steps
Pearls
Fig. 15.18
Often the lesion will determ ine the lateralit y but in cases of m idline
lesions or lesions that span the entire vertebral body, the vascular
anatomy m ay dictate the approach. The position of the aorta needs to
be reviewed on CT to determ ine if it will be in the way. The vena cava
is t ypically m idline and rarely a ects the choice of left versus right.
The aorta has a m ore variable position, but often surgery above T9
is best approached from the right. Below T9 the left side is an easier
approach as the liver pushes up on the diaphragm on the right.
Figure
Procedural Steps
Fig. 15.19
The muscular layers are divided using electrocautery. The muscles transected are the trapezius, latissimus dorsi,
then the rhomboids, and nally serratus. The rib is identi ed, dissected free, and resected. The neurovascular
bundle is identi ed, ligated, and cut.
259
260
Figure
Procedural Steps
Pearls
Fig. 15.20
Figure
Procedural Steps
Fig. 15.21
(a) An appropriately sized spacer, either rib autograft, femoral allograft, or cage is inserted. (b) A plate and
screw s are placed to provide rigid xation.
261
Closing
Su rgical w ou n ds are closed in layers.
A drain is placed above the fascia to prevent hem atom a form ation.
Th e skin is closed w ith inverted 3-0 absorbable sut ures fol
Postoperative Management
Pat ien t s sh ou ld be follow ed closely p ostop erat ively w ith n eurologic ch ecks. Th e acu it y of care w ill dep en d on th e exten t
of th e surger y an d th e exten t of n eurologic com prom ise.
Pat ien t s w ith m ore exten sive procedu res th at are at risk for
m ore exten sive blood loss sh ou ld be obser ved overn igh t in
th e in ten sive care un it .
Medication
Postop erat ive an t ibiot ics sh ou ld be adm in istered for 24 h ou rs
or as long as th e drain is in place.
Radiographic Imaging
Postop erat ive
Further Management
Th e pat ien t sh ould h ave lim ited physical act ivit y w ith n o
b
Fig. 15.22a, b Postoperative (a) AP and (b) lateral radiographs of the patient depicted in Figs. 15.1 and 15.2 underwent open
reduction and T9 to T12 arthrodesis instrumentation using pedicle screws, rods, and a cross connector with in situ autograft,
cancellous allograft 90 mL, and demineralized bone matrix 20 mL. He was fully recovered at his 1-year postoperative visit.
262
b
Fig. 15.23a, b (a) Lateral and (b) AP radiographs of open reduction procedure in patient depicted in Fig. 15.11. This procedure included
anterior T6 and T10 corpectomies using t wo titanium cages packed with in situ autograft. Also performed were T5 laminectomy,
T6-7 decompression laminotomies, and T3-T11 arthrodesisinstrumentation using sublaminar hooks, pedicle screws, rods, and
cross links, supplemented with in situ autograft, demineralized bone matrix, and cancellous allografts.
a
Fig. 15.24a, b Postoperative (a) sagit tal and (b) coronal images of the same patient depicted in Fig. 15.17. He underwent a minimally
invasive transthoracic transdiaphragmatic exposure from T11 to L1 and T12 corpectomy and decompression on spinal cord. T11 to
L1 arthrodesis instrumentation was performed using an expandable titanium cage packed with in situ autograft, rib strut autograft,
and thoracolumbar plate with screws.
263
Special Considerations
Posterolateral app roach es su ch as th e costot ran sversectom y
an d lateral ext racavit ar y ap proach es p rovide greater exposu re
to th e lateral p or t ion of th e ver tebral can al an d th e an terolateral port ion of th e th oracic vertebral bodies. Costot ran sversectom y m ay be u sed in th e rem oval of t rau m at ic bon e fragm en t s
or oth er foreign bodies in t raum a an d is u seful in cases w h ere
a pat ien t m ay n ot tolerate a form al th oracotom y eith er du e to
age or p u lm on ar y p ath ology. It is less u seful in cases w h ere th e
an terior can al n eeds to be fu lly visu alized or for oth er m idlin e
path ology.
In costot ran sversectom y, th e pat ien t m ay be placed pron e,
sem ip ron e, or in m odi ed lateral decu bit u s p osit ion . In t u bat ion
w ith a double lum en cu ed en dot rach eal t ube is again recom m en ded as p n eu m oth orax is a possibilit y. Th e ap proach sh ou ld
be on th e side of th e inju r y, or if m idlin e, on th e righ t to avoid
th e arter y of Adam kiew icz w h ich usually origin ates on th e left
side bet w een T8 to L2. Th e in cision is m idlin e (som et im es w ith
a T) or p aram ed ian w ith or w ith ou t a h ockey st ick rela xing
in cision . If th e in cision is param edian , th e m uscles (t rapezius
an d lat issim u s dorsi) are re ected m edially. Midlin e in cision s
requ ire subperiosteal dissect ion s. Th e ribs to be rem oved are
skeleton ized su bperiosteally. En t ran ce to a d isk sp ace requ ires
exp osu re of th e in ferior rib (e.g., T9-T10 disk sp ace requ ires exposure of th e 10th rib). Th e art icu lat ion s th at m ust be addressed
in clu de th e su perior an d in ferior costal facet an d t ran sverse
cost al facet . Th e pleura is m obilized an d re ected from th e un derside th e rib an d an terolateral posit ion of th e spin e. Th e rib
of in terest is th en t ran sected approxim ately 5 cm from th e rib
h ead. Th e foram en can then be iden t i ed by follow ing th e n eu rovascular bu n dle t ravelling on th e in ferior surface of th e rib.
Th e pedicles can th en be iden t i ed above an d below th e foram en w h ich can be resected to visu alize th e lateral th ecal sac.
Th e pleu ral an d in tercost al m uscles are blun tly dissected aw ay
from th e vertebral body. Bon e from th e lateral ver tebral body
or disk m ay be rem oved as required w ith care n ot to dam age
th e radicular arteries. On ce th e decom pression or diskectom y
is com p lete, in st ru m en ted or n on in st rum en ted fusion m ay be
con sidered based on path ology. Again , par t ial vertebrectom y
m ay be ach ieved. Pleu ral tears are rep aired if p resen t an d ch est
t ubes are used if n ecessar y.
Th e lat e ral ext racavit ar y ap p roach is a m ore exte n sive p oste rolat e ral ap p roach w h ich again d oes n ot violat e t h e ch est
cavit y. Th e p at ie n t is p lace d in a p ron e p osit ion . A h ockey
st ick (m id lin e in cision cu r ve d 4 5 d egre es o m id lin e for 6 to
8 cm in t h e low e r p or t ion ) or p aram e d ian in cision (ce n t e re d
ove r t h e lat e ral p arasp in al m u scles) can be u se d . A p lan e is
d evelop e d b et w e e n t h e su p e r cial an d d e e p p arasp in al m u scles, an d a m yocu t an e ou s ap is lift e d o to exp ose t h e lat eral p arasp in al m u scles an d r ib cage. Th e p arasp in al m u scles
are t h e n m ob ilize d from t h e r ib an d t ran sve rse p rocess. Th e
r ibs, ligam e n t ou s at t ach m e n t s, an d associate d t ran sve rse
p rocesses are t h e n re m ove d . Sim ilarly to ab ove, t h e n e u ro vascu lar b u n d le is isolat e d an d act s a gu id e for id e n t i cat ion of t h e resp e ct ive foram e n an d p e d icles. Th e re m ain d e r
of exp osu re is com p let e d sim ilarly t o t h e ot h e r p oste rolate ral
te ch n iqu es.
264
References
1. Vialle LR, Vialle E. Th oracic sp in e fract u res. Inju r y 2005;36
Suppl 2:B6572
2. Den is F. Th e th ree colu m n sp in e an d it s sign i can ce in th e classi cat ion of acu te th oracolum bar spin al injuries. Spin e (Ph ila Pa
1976) 1983;8(8):817831
3. Magerl F, Aebi M, Ger t zbein SD, Harm s J, Nazarian S. A com p reh ensive classi cat ion of th oracic an d lu m bar injuries. Eur Spin e J
1994;3(4):184201
4. Vaccaro AR, Leh m an RAJ, Hu rlber t RJ, et al. A n ew classi cat ion
of th oracolum bar injuries: th e im por t an ce of injur y m orph ology,
th e in tegrit y of th e p osterior ligam en tou s com p lex, an d n eu rologic st at us. Spin e (Ph ila Pa 1976) 2005;30(20):23252333
5. el-Kh ou r y GY, W h it ten CG. Trau m a to th e u p p er th oracic sp in e:
an atom y, biom ech an ics, an d un ique im aging feat ures. AJR Am J
Roen tgen ol 1993;160(1):95102
6. Maim an DJ, Pin t ar FA. An atom y an d clin ical biom ech an ics of th e
th oracic spin e. Clin Neu rosu rg 1992;38:296324
7. Lou is R. Su rger y of th e Sp in e. New York: Sp ringer; 1983
8. W h itesid es TEJ. Trau m at ic kyp h osis of th e th oracolu m bar sp in e.
Clin Orth op Relat Res 1977;(128):7892
9. Boh lm an H. H. Treat m en t of fract u res an d d islocat ion s of th e
th oracic an d lu m bar spin e. J Bon e Join t Su rg Am 1985;67(1):
165169
10. An driacch i T, Sch u lt z A, Belyt sch ko T, Galan te J. A m odel for st u dies of m ech an ical in teract ion s bet w een th e h um an spin e an d rib
cage. J Biom ech 1974;7(6):497507
11. Sm ith JS, Bh at ia N. Th oracic sp in al st abilit y: d ecision m aking.
In Patel V, Burger E, Brow n C, eds. Spin e Traum a: Surgical Tech n iques. Berlin : Springer, 2010: 213228
12. An derson S, Biros MH, Reardon RF. Delayed diagn osis of th oracolum bar fract ures in m u lt iple-t raum a pat ien t s. Acad Em erg Med
1996;3(9):832839
13. St an islas MJ, Lath am JM, Por ter KM, Alpar EK, St irling AJ. A h igh
risk group for th oracolum bar fract ures. Inju r y 1998;29(1):1518
14. van Beek EJ, Been HD, Pon sen KK, Maas M. Up p er th oracic sp in al fract ures in t raum a pat ient s - a diagn ost ic pitfall. Injur y
2000;31(4):219223
15. Argen son C. Traitem en t des fract u res d u rach is d orso-lom baire
ch ez ladu lte. Cah iers den seignem en t de la SO FCOT Con feren ces
. 1984
16. Coh en MS, BlairB. Th oracolu m bar com p ression fract u res. AM
Levin e. 1998
17. Mu n t ing E. Su rgical t reat m en t of p ost-t rau m at ic kyp h osis in
th e th oracolu m bar sp in e: in dicat ion s an d tech n ical asp ect s. Eu r
Spin e J 2010;19 Suppl 1:S6973
18. Sm ith MW, Reed JD, Facco R, et al. Th e reliabilit y of n on recon st ru cted com p u terized tom ograp h ic scan s of th e abdom en an d
pelvis in detect ing th oracolu m bar sp in e inju ries in blu n t t rau m a pat ien t s w ith altered m en t al st at us. J Bon e Join t Surg Am
2009;91(10):23422349
19. Bracken MB, Sh epard MJ, Collin s W F, et al. A ran dom ized, con t rolled t rial of m ethylpredn isolon e or n aloxon e in th e t reatm en t of acute spin al-cord injur y. Result s of th e Secon d Nat ion al
Acu te Spin al Cord Injur y St udy. N Engl J Med 1990;322(20):
14051411
20. Gern dt SJ, Rodrigu ez JL, Paw lik JW, et al. Con sequ en ces of h igh dose steroid th erapy for acute spin al cord inju r y. J Traum a
1997;42(2):279284
21. Hu rlber t RJ, Hadley MN, Walters BC, et al. Ph arm acological th erapy for acu te sp in al cord inju r y in gu idelin es for th e m an agem en t
265
16
Thoracolumbar Fractures
Michael Y. W ang and Brian Hood
Introduction
Th e t ran sit ion zon e at th e th oracolum bar jun ct ion di ers bio m ech an ically from th e st i th oracic spin e to th e m obile lu m bar spin e. Th is zon e of t ran sit ion is related to th e loss of th e
rib cage as w ell as th e ch anging orien tat ion of th e facet join ts.
Becau se of th ese factors th is area is p ron e to t rau m at ic inju r y
an d accou n t s for ap proxim ately u p to 50% of all vertebral body
fract u res an d u p to 40% of all spin al cord inju ries.1,2
Man agem en t of th oracolu m bar fract u res is a con t roversial
topic in con tem porar y spin e su rger y. Early su rger y for decom p ression an d st abilizat ion is gen erally accepted for pat ien t s
w ith clear in st abilit y an d an in com plete n eu rologic inju r y. Advan t ages of su rger y in clu de a bet ter correct ion of deform it y
th an closed redu ct ion an d bracing, an opport un it y to perform
d irect or in d irect decom p ression of th e n eural elem en t s, decreased requ irem en t for extern al im m obilizat ion , an d few er
com plicat ion s du e to prolonged recu m ben cy. Th e su rgical
t reat m en t is m ore con t roversial for pat ien t s w ith m ild to m oderate d eform it y, w ith ou t n eu rologic de cit , an d residu al sp in al can al com p rom ise, an d th e ideal solu t ion rem ain s largely
u n kn ow n .1,39
Classi cation
Th e m ost com m on fract ure pat tern s at th e th oracolum bar jun ct ion in clude com pression fract ures, burst fract ures, exion -dist ract ion injuries, an d fract ure-dislocat ion s.
Burst Fractures
Com pression failure of th e an terior an d m iddle spin al colum n s
A: Failure of both superior an d in ferior en dplates
B: Su p erior en dp late failu re on ly (m ost com m on t ype of bu rst
fract u re)
C: In ferior en dplate failu re on ly
266
Flexion-Distraction
(Ch an ce): Prim ar y an terior force vector act ing along an axis of
rotat ion located an terior to m iddle colum n . Th e p osterior an d
m iddle colu m n s fail in ten sion an d th e an terior colu m n fails in
ten sion or com pression depen ding on th e axis of rot at ion .
Fracture -Dislocation
Results from violen t com plex sh earing force an d by de n it ion
involves all th ree spin al colum n s. High est rate of com plete n eu rologic inju r y.
AO Thoracolumbar System
(of Magerl)
De n es th e m ajor m ech an ism of sp in al inju r y com p ression (A),
dist ract ion (B), an d torsion (C) to in dicate in creasing inju r y severit y occu rring w ith in creasing grade of inju r y. Th ree grou p s
exist w ith in each t ype (A1, A2, A3) an d each grou p is divided
in to subgrou ps (A1.1, A1.2, A1.3). Th e classi cat ion is based on
m orp h ological criteria. Th e categories are est ablish ed according to th e m ain m ech an ism of injur y, an d take in to con siderat ion th e progn ost ic aspect s of poten t ial h ealing. Th e t ypes are
determ in ed by th e th ree m ost im por t an t m ech an ism s act ing
on th e spin e: com pression , dist ract ion , an d axial torque. Th e
t ype A is a ver tebral body com pression injur y; t ype B inju ries
involve an terior an d posterior elem en t inju ries w ith dist ract ion s; an d t ype C lesion s refer to an terior an d posterior elem en t
injuries w ith rot at ion con sisten t w ith axial rot at ion inju ries.
Th e AO system is ver y com preh en sive an d good for describ ing fract ure pat tern s, but it is a vict im of it s com p reh en siven ess; it does n ot con sider n eu rologic st at u s, an d does n ot aid in
decision m aking.10
16
Quali er
Points
Injury morphology
Compression
Burst
1
11
Rotation/translation
Distraction
Intact
Nerve Root
Incomplete
Complete
Intact
Suspected/Indeterm inate
Disrupted
Neurologic status
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
Preprocedure Considerations
Radiographic Imaging
An teroposterior (AP) an d lateral radiograph s of th e cer vical,
th oracic, an d lum bar spin e are stan dard im aging st udies follow ing spin al t rau m a. In som e cen ters th is h as been largely
rep laced for su r vey purposes by w h ole body com puted tom ograp hy (CT) scan n ing.
Becau se th ere is a h igh p ercen t age of n on con t igu ou s associated sp in al fract u res, en t ire n euraxis im aging m ay be w arran ted if clin ical su spicion is h igh .
267
Surgical Management
Th e goals of surgical t reat m en t in clude: (1) decom pression of
th e spin al can al an d n er ve root s to facilit ate n eurologic recover y, (2) restorat ion an d m ain ten an ce of ver tebral body h eigh t
an d align m en t to m in im ize post t rau m at ic deform it y, (3) ob tain ing rigid xat ion to facilitate n ursing care an d allow early
m obilizat ion , (4) obtain ing a solid ar th rodesis of dam aged
segm en ts or fract u re h ealing, an d (5) lim it ing th e n u m ber of
in st ru m en ted vertebral m ot ion segm en ts. Surgical algorith m s
can gen erally be classi ed in to on e of ve grou ps: (1) posterior
decom pression an d st abilizat ion , (2) costot ran sverse/lateral ext racavitar y/t ran spedicular decom pression an d recon st ruct ion /
stabilizat ion , (3) an terior corp ectom y/st abilizat ion , (4) com bin ed an terior/posterior decom pression /st abilizat ion (360),
an d (5) p ercu t an eou s fract u re xat ion .
268
used.
Altern at ively, alcoh ol an d ch lorh exidin e can be u sed.
Th e au th ors u se van com ycin an d ceft riaxon e for an t ibiot ic
prophylaxis provided th e pat ien t does n ot h ave ren al failure
or oth er con t rain dicat ion s.
16
Operative Procedure
Open Approach
Positioning (Fig. 16.2)
Figure
Procedural Steps
Pearls
Fig. 16.2
269
270
Figure
Procedural Steps
Pearls
Fig. 16.3
16
Figure
Procedural Steps
Pearls
Fig. 16.4
271
272
16
Figure
Procedural Steps
Pearls
Fig. 16.5
(a) The facet joint is stripped of its capsule. The inferior portion of
the inferior facet is removed w ith a rongeur or osteotome. Partial
facetectomy should reveal a pedicle blush.
(b) At T12 the starting point is the junction of the bisected transverse
process and border of the lateral pars. The starting point trends medially
and cephalad as one moves cranially tow ard the midthoracic region.
273
274
Figure
Procedural Steps
Pearls
Fig. 16.6
16
Figure
Procedural Steps
Pearls
Fig. 16.7
275
276
Figure
Procedural Steps
Pearls
Fig. 16.8
16
Percutaneous Approach
Positioning and Pedicle Targeting (Fig. 16.9ac)
Figure
Procedural Steps
Pearls
Fig. 16.9
277
278
16
c
b
Figure
Procedural Steps
Pearls
Fig. 16.10
279
280
Figure
Procedural Steps
Pearls
Fig. 16.11
16
Figure
Procedural Steps
Pearls
Fig. 16.12
If a long-term fusion is required, dilators are then placed over the K w ire
and docked on the pedicle screw starting point. A tubular retractor is then
placed (1). The facet is superior and medial to the starting point. The soft
tissue is then removed w ith electrocautery, and the facet decorticated
w ith a high speed bur (2). Bone graft is then laid on the facet.
281
Figure
Procedural Steps
Pearls
Fig. 16.13
(b) We tap the pedicle under lateral imaging (1). At this point, the
tap can be stimulated to assess for a medial pedicle breach. The tap
is removed w ith care to not dislodge the K w ire. A cannulated screw
w ith a screw extension is then advanced (2). Several images are
taken as the screw is advanced. It is important to not advance the K
w ire w ith the screw. The K w ire is then removed.
282
16
Figure
Procedural Steps
Pearls
Fig. 16.14
283
Closing
Open Approach
For th e open approach , m et iculous h an dling of th e exten sor
m u scu lat u re follow ed by a t igh t fascial closu re im proves th e
m u scles abilit y to p rom ote sagit t al balan ce an d ap prop riate
skelet al loading. Th e w ou n d is closed in su ccessive layers (deep
fascia, su p er cial fascia, th en skin ) u sing resorbable su t u re.
Percutaneous Approach
For th e percut an eou s approach , th e in dividual st ab w ou n ds
are irrigated w ith an t ibiot ic im p regn ated salin e. Lit tle bleeding is en cou n tered due to a t am p on ade e ect from th e dilators an d screw exten sion s.
Th e fascia is reapproxim ated w ith in terrupted 2-0 resorbable
su t u res.
Th e skin is closed w ith a 3-0 m ono lam ent , resorbable sut ure.
Fin al AP an d lateral im ages are obtain ed w ith C-arm u oroscopy before th e w oun d is closed.
Postoperative Management
Monitoring
Fig. 16.15 Lateral X-ray of patient depicted in Fig. 16.1 showing posterior
rod construct and vertebroplasties at T12 and L1 to add structural support.
Medication
It is ou r pract ice to place p at ien t s on a p at ien t-con t rolled
Radiographic Imaging
We t ypically obtain uprigh t AP an d lateral im ages prior to
Special Considerations
The optim al surgical approach and treatm ent of unstable thoracolum bar spine injures are poorly de ned because of a lack
of w idely accepted level I clinical literature. When treating
284
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th oracolu m bar fract u re. Sp in e 2010;35(8):E295E302
21. Katonis P, Pasku D, Alpan taki K, et al. Com binat ion of the AOMagerl an d load-sh aring classi cat ion s for th e m an agem en t of
th oracolu m bar burst fract ures. Or th opedics 2010;33(3):158163
285
17
Introduction
Non t rau m at ic spin al epidu ral com p ression can resu lt from several di eren t en t it ies, bu t acu te deteriorat ion alm ost alw ays
occurs as a result of a few con dit ion s, th ree of w h ich are h igh ligh ted in th is ch apter: spon t an eou s epidural h em atom a, spin al
ep idu ral abscess, an d m et astat ic ep idu ral spin al cord com p ression syn drom e.
Incidence
Spontaneous Spinal Epidural Hematoma
Sp in al ep idu ral h em atom as (SEHs) are a rare cau se of sp in al
cord com pression . How ever, th ey con st it ute th e m ajorit y (u p
to 75%) of spin al h em atom as. Th e peak in ciden ce occurs in pat ien ts in th eir sixth decade of life, th ough a secon d peak is seen
in adolescen ts bet w een 15 an d 20 years of age. A m ale predom in an ce h as frequ en tly been docu m en ted.
286
Etiologies
Spinal Epidural Hematoma
Sp on t an eou s SEH can be divided in to t rau m at ic an d n on t rau m at ic. Cau ses of t rau m at ic SEH in clu de lu m bar p u n ct u re or
ep idu ral an esth esia, fract u re, spin al su rger y, p hysical exert ion ,
bir th t raum a, an d ch iropract ic m an ipu lat ion . Causes of spon t an eous SEH in clu de h em orrh age from an arterioven ous m alform at ion (AVM), h em angiom a, or t u m or. In u p to 30% of cases,
n o et iology is discern ed .2 Follow ing th ese idiopath ic cases, an t icoagulan t th erapy an d vascular m alform at ion s are m ost often
im plicated. An t icoagulat ion or any bleeding diath esis is a risk
factor for SEH.3
17
MESCC
Met a st at ic d isease sp read s to e p id u ral sp ace in t w o w ays:
(1) d ire ct ly in t o t h e sp in a l can al t h rough in t e r ve r t ebral fo ram e n from a p arave r t eb ral m ass (1 5 % of m et ast at ic cord
com p ression ); an d (2 ) t h e re m ain in g 8 5% from h e m at oge n ou s sp read (h ist or ica lly t h ough t via Bat son s p lexu s, n ow
b elieve d t o be m ore likely a r t e r ia l) t o t h e ve r t ebral bod y,
from w h e re t h e lesion grow s p ost e r iorly in to t h e e p id u ral
sp a ce. Th ese m et ast at ic lesion s can cau se b on e e rosion ,
p at h ologic fra ct u res, a n d ext r u sion of b on y fragm e n t s in t o
can al, w h ich can all fu r t h e r com p ou n d can a l n a r row in g or
cord com p ression .
Pathophysiology
t ien t s of t h e 46- to 75-year-old year age grou p , t h e low er t h o racic an d lu m bar region s are m ost com m on , w it h a sm aller
frequ en cy m a xim u m in t h e cer vical levels.8 A p ain -free in terval m ay occu r, bu t t h en is ge n erally follow ed by p rogression
of n e u rologic d e cit ove r h ou rs to days tow ard accid p aresis
or p legia.
MESCC
MESCC
Hyp ot h esized m ech an ism s by w h ich dam age occu rs in clu d e
(1) direct com p ression t h at lead s to dem yelin at ion an d a xon al dam age; (2) vascu lar com p rom ise, w h ere occlu sion of ven ou s p lexu s p rom otes breakd ow n of cordblood barr ier an d
t h u s vasogen ic ed em a; an d (3) ter m in al ar ter ial occlu sion
w it h isch em ia/in farct ion m ay follow lead ing to ir reversible
dam age. Cer t ain au t h ors h ave hyp oth esized th at in p at ien t s
rap id ly d eteriorat in g ar terial in farct ion m ay u n d erlie d eclin e
w h ereas ven ou s congest ion m ay in it ially be m ore relevan t in
p at ien t s w it h slow d eclin e.6 Th is disp ar it y m ay exp lain t h e
w orse ou tcom e associated w it h a m ore rap id evolu t ion of m o tor w eakn ess.7
Presentation
Spinal Epidural Hematoma
SEH is u su ally acu te an d p rogressive, lead in g to p e r m an e n t
n eu rologic d e cit if n ot m an aged im m ed iately. Sym p tom s
con sisten t ly begin w it h severe back p ain in t h e locat ion of
t h e h em or rh age, w it h or w it h ou t a rad icu lar com p on en t . Th e
com m on segm en t al levels involve d var y by age; in t h e p a-
Indications
Spinal Epidural Hematoma
Most SEHs are located d orsal to t h e sp in al cord , w it h a large
m et a-an alysis qu ot in g
75% in t h is sagit t al locat ion .8 Em ergen t or u rgen t d ecom p ression w it h in h ou rs is associated w it h
bet ter ou tcom es. In t h e sam e m et a-an alysis, for p at ien t s w h o
received t reat m en t w it h in 12 h ou rs of on set of sym ptom s,
66% recovered com p letely, 13% recovered w it h m ild resid u al
n eu rologic d e cit , an d 13% con t in u ed to h ave severe im p air m en t or sh ow n o im p rovem en t . In con t rast , for p at ien t s
w h ose t reat m en t w as in it iated 1324 h ou rs after sym ptom
on set , 64% h ad severe d e cit s or n o im p rovem en t , versu s 36%
w it h su bst an t ial recover y. Th erefore, t h e t reat m en t of ch oice
is im m ed iate d ecom p ression in t h ose p at ien t s t h at can tolerate su rger y. Asym ptom at ic p at ien t s w it h ou t n eu rologic d e cit
can be con sid ered for obser vat ion , esp ecially in ch ild ren an d
teen agers in w h ich a lam in ectom y m ay d est abilize t h e p oster ior colu m n .
287
MESCC
Con sen su s an d exper t opin ion s regarding in dicat ion s for surger y largely d erive from st u dies invest igat ing th e p rogn ost ic value of surgical in ter ven t ion given variou s pat ien t group
at t ribu tes. Th e eviden ce dictat ing th e app ropriate approach to
t um or decom pression h as evolved sign i can tly over th e past
50 years. Early t reat m en t un derscored in direct decom pression of th e ep idu ral sp ace via st raigh t lam in ectom y, follow ed
by radiat ion th erapy (RT).13,14 How ever, later st u dies 15,16 dem on st rated n o advan t age for lam in ectom y, ren dering radiat ion
alon e th e p referred th erap eu t ic st rategy for a p eriod of years.
More recen t st u dies w ith m odern an esth et ic an d im aging tech n iqu es h ave led to a resu rgen ce of su rgical decom pression as
p ar t of th e t reat m en t st rategy.6,17 A large ran dom ized con t rol
t rial6 assessed decom pressive resect ion in conjun ct ion w ith RT
versu s RT alon e. Criteria for st u dy in clu sion requ ired MESCC
rest ricted to a single area; accept able surgical can didates w ith
life expect an cy . 3 m on th s; on e n eurologic sym ptom (in clu ding pain ); n ot tot ally p araplegic for . 48 h ou rs. Radiosen sit ive
t um ors an d sole root com pression or cau da equin a syn drom es
w ere exclu ded; 84% of th e su rger y grou p versu s 52% of th e RT
group w ere able to w alk after t reat m en t , 62% versus 19% regain ed am bu lat ion w h en ce lost , an d 94% versu s 74% rem ain ed
am bulator y. Ad dit ion ally, th e st u dy revealed sign i can t d ifferen ces bet w een t reat m en t grou p s w ith resp ect to m ain ten an ce of con t in en ce; m u scle st rength ; fu n ct ion al abilit y; an d
in creased sur vival (126 versu s 100 days), w ith am bulat ion an d
con t in en ce persist ing for th e lifet im e of th e surger y group.
Spin al in stabilit y can in depen den tly con tribu te to sym ptom s,
by directly causing m echan ical injur y to the spinal cord. As RT
is un likely to am eliorate spinal in st abilit y, su rger y m ay be m ore
ap prop riate in th ese circu m stan ces. An an alysis focu sing on
form s of com pression for patien ts w h o w ere, at th e on set , eith er
in depen den tly am bulator y, assisted am bulator y, paraparet ic,
an d paraplegic: w ith ou t bony com pression , post -RT am bulat ion rates w ere 100%, 94%, 60%, 11%, respectively. These rates
dropped to 92%, 65%, 43%, and 14%, respectively, w hen all pat ients (w ith bony an d non bony com pression ) w ere considered.18
A com preh en sive literat ure review 19 suggested that w ith RT
alon e, 36%subjects im proved w h ile 17%w orsen ed; w ith decom pressive lam inectom y 6 RT, 42%im proved w h ile 13%w orsen ed;
288
Preprocedure Consideration
Radiographic Imaging
Com pu ted tom ography (CT) m yelography w as on ce th e diagn ost ic tool of ch oice for evalu at ion of SEH. CT m yelogram also
is m ore invasive an d carries th e risk of seeding in fect ion . It is
th erefore n o longer recom m en ded in th e con text of spin al
ep idu ral abscess. Magn et ic reson an ce im aging (MRI) w ith or
w ith out CT h as em erged as th e less invasive an d m ore available
m eth od of ch oice. MRI also o ers th e advan t age of di eren t iating bet w een t um or, in fect ion , h ern iated disk, an d h em atom a 20
(Figs. 17.1 an d 17.2). CT is also n ecessar y to evaluate for bony
invasion an d st abilit y (Fig. 17.3).
Medication
For SEH, in pat ien t s w h o cann ot tolerate surger y, an t icoagu lat ion sh ould be stopped an d possibly reversed; h igh dose steroids sh ould be con sidered alth ough th eir u se is con t roversial.21
For SEA, broad-sp ect rum IV an t ibiot ics sh ould be in it iated
im m ediately, in cluding coverage for Gram -posit ive cocci an d
Gram -n egat ive rods.
For MESCC, steroids decrease edem a and m ay have an oncolytic e ect on som e t um ors such as lym phom a and breast cancer.
17
Fig. 17.1a, b Spinal epidural hem atoma. (a) Axial and (b) sagit tal MRI in a patient with focal spontaneous hematoma around the central herniated
disk located ventral to the cord.
Operative Management
Anesthesia
For all cases, gen eral en dot rach eal an esth esia is th e preferred
tech nique, assum ing favorable an atom y an d th e pat ien ts con dit ion . In t ubat ion -related m an ipulat ion of th e n eck con cern s
in pat ien t s w ith cer vical spin al cord com pression n eed to be
w eigh ed again st th e u rgen cy of obt ain ing a reliable air w ay.
W h ere possible, a m in im ally m an ipulat ion tech n iquesu ch as
aw ake beropt ic, lar yngeal in t ubat ion w ith an illum in ated lar yngoscope w ith cam era, or n asal in t u bat ion in a pat ien t w ith
n o risk factors for cribriform fract u re or in com p eten cesh ou ld
be used.
W h en em ergen t air w ay com prom ise is presen t an d in t ubat ion is n ot likely to be able to be perform ed in a t im ely fash ion ,
th en em ergen t cricothyroid or t rach eostom y in t u bat ion w ill
n eed to be p erform ed , an d it w ou ld be pru den t to h ave a t rach eostom y kit at th e side of any pat ien t w ith em ergen t spin al cord
com pression in case th ey deteriorate on th eir w ay to or from
Fig. 17.2a, b Spinal epidural abscess. (a) Axial T2-weighted MRI of the cervical spine in a patient who presented with acute rapidly progressive
paraplegia and respiratory failure. There is a large dorsal epidural abscess collection with cord compression. (b) Sagit tal postcontrast image of a
posterior thoracolumbar spine abscess associated with multiple areas of vertebral body osteomyelitis including T11, L2 through L5, and diskitis at L23.
289
any procedu re, or even in th e op erat ing room d u ring stan dard
en dot rach eal in t u bat ion .
For those cases w here the opportunit y presents and the surgeon w ishes, if intraoperative m onitoring is to be used, then
the anesthetic should take into account any potential e ects on
electrom yography or m otor evoked potential (MEP) m onitoring
by focusing on a total intravenous anesthetic (TIVA) technique to
prevent the detrim ental im pact of inhalational anesthetic. TIVA
also includes the absence or m inim al use of paralytics to prevent
their im pact upon the m uscle activit y being m onitored by electrom yography (EMG) or MEP. Som atosensory evoke potentials
(SSEPs) are used to avoid potential peripheral nerve com plications such as arm positioning apraxias, or even in ltration of an
IV leading to com partm ent syndrom e, w hich if caught intraoperatively instead of identi ed postoperatively m ay result in im m ediate treatm ent of the problem and prevent perm anent m orbidit y.
W here practical and feasible, m ean arterial pressures (MAP)
sh ould be m ain tain ed as h igh as can be tolerated (u p to 100 m m
Hg), an d w h en a n eu rologic de cit is presen t , if th e pat ien t can
tolerate, MAPs in th e 901 m m Hg range sh ould be th e goal, to
m ain tain spin al cord perfusion given th e presum ably edem atou s
state of th e spin al cord. Th is can be correlated w ith in t raoperative evoked potent ial m onitoring, and m any tim es a decrem ent
in evoked poten tials can be corrected w ith elevat ion of the MAP.
Surgical Approach
General Principles
Posit ion select ion d ep en ds on several factors, in clu ding th e locat ion of th e prim ar y path ology (an terior, posterior, or lateral
w ith in th e can al), n um ber of levels, an d di cult y approach ing
290
17
u n ilateral h em ilam in ectom y w ith part ial t ran spedicular decom pression to gain access to th e ven t ral locu s of purulen ce,
leaving th e posterior m idlin e an d con t ralateral st ru ct ures in t act
to m in im ize delayed in st abilit y, reduce th e size of th e w oun d
an d cavit y to be closed, an d redu ce in t raoperat ive bleeding. Th e
less p ed icle rem oved, th e m ore st able th e sp in e w ill be over
t im e. Should a m ore exten sive exposure n eed to be perform ed
(com plete pedicle rem oval, bilateral decom pression plus t ran sp edicu lar, or rem oval of th e pars in terart icu laris), a fusion of
th e poten t ially un stable segm en ts m ay be n ecessar y, an d w h ere
app ropriate, in st ru m en tat ion sh ou ld be u sed. In st ru m en tat ion
sh ou ld n ot be forgon e ju st becau se th e p rim ar y p ath ology is in fect ion . W h ere ap p rop riate, a bilateral p osterolateral m in im ally
invasive approach from a part ial t ran sp edicu lar or costot ran sverse ap proach on eith er side can be p erform ed as w ell, w ith
angled in st ru m en ts pu sh ing p ath ology dow n an d aw ay from
th e cord. W h en th e path ology is liquid (acute abscess or relat ively lique ed h em atom a), an angled in ser t ion tech n ique can
allow for placem en t of a sm all-caliber d rain (like a ven t ricu lostom y cath eter) th at can be used to rem ove ven t ral path ology
an d facilit ate irrigat ion in th e abscess plan e.
In gen eral, w e do n ot recom m en d a st raigh t lam in ectom y for
p redom in ately ven t rally located in fect ion s at cord-level cases,
u n less th ere is en ough room to reach th rough laterally located
p u ru len t collect ion s an d p ass a righ t-angled in st ru m en t ven t ral to th e th eca in to th e ven t ral pus w ith out pressure on th e
already ten u ou s sp in al cord .
In acu te cases, th ere is rarely m u ch ep idu ral bleed ing, bu t in
m ore ch ron ically in fected cases, th ere m ay be an in am m ator y
rin d th at h as sign i can t vascu lar inp u t . Ep idu ral d rain s sh ou ld
be left beh in d, an d drain age con t in ued longer th an st an dard
durat ion to preven t any furth er collect ion or con t am in at ion of
in fected m aterial in th e epid ural space.22
For m et ast at ic epidural disease, th e locat ion of th e origin of
th e t u m or (isolated epidural disease versus arising from osseou s lesion w ith exten sion ) as w ell as con sid erat ion s of sp in al st abilit y sh ou ld dict ate ch oice of op erat ive p rocedu re.23
A th orough descript ion of all surgical approach es is beyon d th e
scop e of th is ch apter. How ever, a sim p le lam in ectom y sh ou ld
be reser ved for dorsally located disease, an d a posterolateral or
ven t ral ap proach sh ou ld be u t ilized w h en ever ven t ral d isease
is presen t , as t u m ors m ay con t in u e to grow or sw ell an d th u s
w ith out a direct rem oval of th e o en ding path ology, an in direct decom p ression w ill resu lt in fu rth er deform at ion of th e
sp in al cord. At th e spin al cord level (occip u t to bot tom of con u s
m edu llaris), th e cord sh ou ld n ever be ret racted to gain access to
ven t ral t u m or; th e ap proach sh ou ld be selected th at obtain s th e
m ost advan t ageou s angle to access th e t u m or in stead.
Posterior Approaches
Lam in ectom y alon e is to be u sed at th e spin al cord level on ly
w h en th e disease is w h olly dorsal or ju st posterior to th e n er ve
root if lateral. Any m ass ven t ral to th e n er ve root , u n less prim arily liqu id an d able to be drain ed w ith a cath eter p assed in
an exist ing m ass ch an n el (e.g., an abscess th at w raps arou n d
th e lateral aspect of th e dura), sh ould be resected or drain ed
via a posterolateral ap p roach , an d th e m ore ven t ral an d m ed ial
th e locat ion , th e m ore lateral th e approach sh ould be. Th e posterolateral approach es, in order of successively m ore lateral
(an d th erefore m ore ven t ral access) locat ion , in clude: lam in ectom y, t ran spedicular, costot ran sversectom y (in th oracic spin e
on ly), an d lateral ext racavitar y. Th e parascapular approach is a
varian t of th e costot ran sversectom y or lateral ext racavit ar y at
th e levels of T27 w h ere th e m uscles of th e scapu la n eed to be
carefully separated an d th e scapula m obilized for th e exposu re,
an d recon n ected carefu lly after w ard to p reven t m orbidit y.
Anterior Approaches
Cervical
Tran soral, w h ich gives good access from th e clivus to C3
St an dard ven t rom edial an terior cer vical, w h ich gives good
access from C2 to T1 or T2
Lumbar
Ret rop eriton eal or direct lateral exposu res from L1-S1. Varia-
t ion s of th ese can be used at di eren t levels, w ith good exposu re of th e vertebral bodies w ith less risk to in t rap eriton eal
organ s, alth ough th e t ran spsoas tech n iques do h ave greater
risks to th e n er ves, an d th e m ore ven t ral ap p roach es h ave a
greater risk of inju r y to u reters an d great vessels.
Tran speriton eal, w h ich gives good exposu re from L1/2 to th e
u pper sacrum ; th is can give good exp osu re to th e bodies an d
th ecal sac, but lim itat ion s in clude w orking arou n d th e aort a
an d in ferior ven a cava (IVC); risk to bow el, bladder, or u reter;
an d in m ales a risk of sexu al dysfu n ct ion d u e to ret rograde
ejacu lat ion , believed by som e to be related to injur y to th e
sym path et ic p lexu s.
291
Operative Procedure
Positioning for Posterior and Posterolateral Procedures
Positioning and Incision (Fig. 17.4a, b)
292
Figure
Procedural Steps
Fig. 17.4
(a) The patient is placed prone on a spinal table and/or Wilson frame
(b) w ith an incision marked as diagrammed.
17
Figure
Procedural Steps
Fig. 17.5
After incising the fascia and dissecting the muscle o of the spinous processes and laminae, the laminae are
removed w ith a drill/ Leksell rongeur exposing the epidural hematoma. It is important to remove as much of
the laminae at consecutive levels until the superior and inferior limits of the hematoma have been reached.
293
294
Figure
Procedural Steps
Fig. 17.6
A Woodson or Pen eld dissector is used in conjunction w ith suction to removed congealed hematoma taking
care not to put undue pressure on the thecal sac and spinal cord. Irrigation is helpful in assisting hematoma
removal.
17
Figure
Procedural Steps
Fig. 17.7
After incising the fascia and dissecting the muscle o of the spinous processes and laminae, the laminae are
removed w ith a drill/ Leksell rongeur and Kerrison rongeurs.
295
Figure
Procedural Steps
Pearls
Fig. 17.8
296
17
Figure
Procedural Steps
Fig. 17.9
After incising the fascia and dissecting the muscle o of the spinous processes and laminae, the laminae are
removed w ith a drill/ Leksell rongeur exposing the epidural tumor. It is important to remove as much of the
laminae at consecutive levels until the superior and inferior limits of the epidural mass have been reached.
297
Figure
Procedural Steps
Pearls
Fig. 17.10
Many tum ors arising from the vertebrae have eroded the
298
17
Figure
Procedural Steps
Fig. 17.11
Without retracting the thecal sac and spinal cord, lateral and ventral tumor is removed w ith Pen eld and
Woodson dissectors. Dow n-going spinal curettes can be used to push ventral tumor aw ay from the thecal sac.
The tumor is collected by suction and small pituitary rongeurs.
299
Special Considerations
Closing
Th e w oun ds are irrigated copiou sly w ith n orm al salin e.
All e p id u ral ble e d in g sh ou ld b e coagu lat e d an d h e m ost at ic
8
Postoperative Management
Monitoring
Close n eu rologic m on itoring sh ou ld be p erform ed in all cases
after su rger y.
SEH: if a coagu lop athy w ere presen t p reop erat ively, it sh ou ld
be follow ed w ith h em atology laboratories an d t reated to n orm al valu es for at least 1 to 2 days after w ard su rger y. Treatm en t beyon d th at rarely h as ben e t , as th e p at ien t w ill revert
to th eir n orm al state even t u ally.
SEA: W h ile single valu es of er yth rocyte sedim en t at ion rate
(ESR)/C-react ive protein (CRP) are m in im ally in form at ive, serial ESR an d CRP levels can be t ren ded to re ect th e cou rse
of in fect ion .
Medication
SEA: An t ibiot ics are con t in u ed u p to 12 w eeks p ostoperat ively,
Radiographic Imaging
MESCC: Recu r ren ce sh ou ld be w atch ed for via p osit ron
em ission tom ograp hy (PET)/CT, MRI, or CT scan . Progressive sp in al d eform it y m ay suggest eith er t u m or recu r ren ce
or p rogression , or develop m en t of late rad iat ion -in du ced
osteon ecrosis.
Adjuvant Treatments
MESCC: Radiat ion th erapy is u su ally an app rop riate adju n ct to
t reat m en t postoperat ively after rem oval of epidural t um ors.
300
MESCC
Em erging technologies becom ing increasingly relevant, especially
for those w ho cannot tolerate surgery, include stereotactic radiosurgery, proton beam , radiofrequency ablation, and cryotherapy.
17
Minim ally invasive surgical treatm ents m ay lower the bar for
surgical intervention, especially if it facilitates reoperation or
reim aging w ith less artifact If postoperative radiation is anticipated, incision placem ent m ay be m odi ed in a m anner that w ill
m inim ize exposure to the eld of radiation and m axim ize potential for wound healing.
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de cit s before irrad iat ion in m et ast at ic sp in al cord com p ression .
In t J Radiat On col Biol Phys 2002;53(4):975979
8. Krep p el D, An ton iadis G, Seeling W. Sp in al h em atom a: a literat ure sur vey w ith m et a-an alysis of 613 pat ien t s. Neurosu rg Rev
2003;26(1):149
9. Joh n son KG. Sp in al ep idu ral abscess. Crit Care Nu rs Clin Nor th
Am 2013;25(3):389397
10. Heusn er AP. Non t uberculous spinal epidural infect ion s. N Engl J
Med 1948;239(23):845854
11. Yang SY. Spin al ep idu ral abscess. N Z Med J 1982;95(707):
302304
301
18
Introduction
Acu te cau da equ in a syn drom e is th e su dden com p ression of th e
n er ves in th e lu m bar cistern resu lt ing in p ain an d n eu rologic
im p airm en t . Th e spin al cord en d s at approxim ately th e L1 to
L2 levels an d, th erefore, cau da equin a com pression involves th e
n er ve roots rath er th e spin al cord. Clin ically it m ay n ot be p ossible to di eren t iate bet w een a con u s m edu llaris inju r y versu s
a cau da equ in a syn drom e. Neu rologic m an ifestat ion s in clu de
bilateral leg w eakn ess, loss of sen sat ion , an d bladder an d bow el
p roblem s. True cau da equ in a syn drom e is rare because th e
n er ve root s are m ore resist an t to com p ression th an th e spin al
cord. Acute cau da equin a syn drom e th erefore requires severe
com pression an d a rapid on set of com pression . Causes in clude
an acu te lu m bar disk h ern iat ion or a lu m bar fract u re/dislocat ion . Ch ron ic com pression is an ext rem ely rare cau se of cauda
equ in a sym ptom s. Treat m en t involves gen erally a w ide lu m bar
lam in ectom y an d rem oval of th e com p ression . In cases w h ere
th ere is a fract u re or dislocat ion , spin al redu ct ion an d in st ru m en tat ion m ay be n ecessar y. Oth er cau ses of cau da equ in a
syn drom e in clu de h em atom as, t u m ors, an d in fect ion s su ch as
ep idu ral abscesses.
Indications
Pat ien t s w ith acu te cau da equ in a syn drom e h ave leg w eak-
302
Preprocedure Considerations
Radiographic Imaging
MRI is th e p referred im aging st u dy to evalu ate for severe
lum bar com pression . T2-w eigh ted MRI is excellen t in sh ow ing th e absen ce h igh in ten sit y cerebrospin al uid sign al at
th e level of th e com pression (Fig. 18.1).
If MRI in u n available or pat ien t factors p reclu d e get t ing an
MRI, th en a com p u ted tom ograp hy (CT) m yelogram m ay
dem on st rate severe sten osis or a com plete block to con t rast
ow at th e level of com p ression .
For pat ien ts w ith t raum at ic lu m bar fract ures, X-rays an d CT
scan s are essen t ial to evalu ate align m en t an d fract u res.
Medication
An t ibiot ics are adm in istered prior to in cision .
Updated guidelines released in 2013 recom m end against the
use of steroids in spinal cord injur y. The guidelines conclude,
In su m m ar y, th ere is n o con sisten t or com pelling m edical evidence of any class to just ify the adm inistration of MP
[m ethylprednisolone 1,2 ] for acu te SCI [spin al cord injur y]. Both
consistent and com pelling Class I, II, and III m edical evidence
exists suggest ing th at high -dose MP adm in ist rat ion is associated w ith a variet y of com plicat ions including infection , respirator y com prom ise, GI hem orrhage, and death. MP sh ould not
be routinely used in the t reatm ent of patients w ith acute SCI.3
18
Pat ien t s m ay h ave sign i can t u rin ar y reten t ion leading to hy-
idin e application .
Th e in cision s are m arked an d in lt rated w ith 1% lidocain e
w ith epin eph rin e 1:100,000.
Fig. 18.1 Lumbar T2-weighted MRI sagit tal and axial images with severe stenosis at L5-S1.
303
Operative Procedure
Positioning (Fig. 18.2)
304
Figure
Procedural Steps
Pearls
Fig. 18.2
There are several options for beds. Bolsters can be used for the chest. A Wilson fram e
allows for opening up of the lum bar spine. A spinal table with hip and chest pads avoids
abdom inal compression and m ay reduce bleeding due to venous congestion. In patients
undergoing a fusion, a Wilson fram e should be used carefully to avoid an iatrogenic at
back syndrom e.
18
Figure
Procedural Steps
Fig. 18.3
(a) The incision is made w ith a no. 10 blade and extends about 5 cm.
(b) A monopolar is used to extend the incision through the posterior lumbar fascia.
305
306
Figure
Procedural Steps
Pearls
Fig. 18.4
Staying in the subperiosteal space helps reduce bleeding. Constant bleeding from
the m uscle m ay interfere with subsequent steps. Preserving the facet capsule rather
may prevent future facet arthropathy. Fluoroscopy or X-ray im aging is used to
con rm the level.
18
Figure
Procedural Steps
Pearls
Fig. 18.5
307
308
Figure
Procedural Steps
Pearls
Fig. 18.6
18
Closing
Lumbar Incision
Th e w oun d is h eavily irrigated.
A m edium suct ion drain age device is placed deep an d brough t
Postoperative Management
Medication
Tw o to th ree doses of prophylact ic an t ibiot ics in th e im m ediate postoperat ive period are opt ion al. Longer term an t ibiot ics
or an t ibiot ics for drain m an agem en t are discouraged.
Further Management
Drain s are rem oved w h en drain age is m in im al (less th an
50 m L per sh ift).
Skin su t u res or st aples are rem oved after 2 w eeks.
Special Considerations
Timing of Surgery
The tim ing of surgery and in uence on outcom e in cases of
cauda equina surgery is the subject of m ultiple investigations.4
The literat ure indicates outcom e is m ore related to preoperative
con dition th an th e speci c tim ing of inter vention . Studies sh ow
people w ith com plete urinary incontinence have a poor outcom e
an d patients w ith a w eak stream or decreased sensation having
a bet ter outcom e. Sh apiro et al reported an im provem ent for
patients operated on w ithin 48 hours 5 after review ing 14 patients
w ith cauda equina syndrom e. All patients had bilateral sciatica
an d leg w eakness. Of the 14 patien ts, 13 had urinar y in contin ence, 9 m assive disk h erniations, and 5 sm all disk herniations
superim posed on stenosis. All patients were am bulatory. Sh apiro
foun d 7/10 patients w ith no in continence had surgery w ith in
48 hours. The four patients w ith incontinence after surger y all
h ad surgery after 48 hours. Shapiro et al concluded surgery w ithin 48 hours is w arranted in cauda equina patients.
Tator et al u sed a sur vey to determ in e curren t pract ices in
t im ing of surger y for spin al cord injur y. Of th e 585 cases th ey
su r veyed, 5.6%w ere cau da equ in a cases.6 In gen eral 23.5%of pat ien ts h ad su rger y w ith in 24 h ours of injur y. In an other st udy,
Tator et al fou n d n o im provem en t w ith acute surger y for spin al
cord injur y.7 Th e coh or t of 208 pat ien t s in clu ded som e pat ien t s
w ith cauda equ in a injur y. In a review of th e literat ure, Feh lings
et al con clu ded an im al st u dies sh ow bet ter ou tcom e w ith early
References
1. Bracken MB, Sh ep ard MJ, Holford TR, et al. Adm in ist rat ion of
m ethylpredn isolon e for 24 or 48 h ours or t irilazad m esylate for
48 h ou rs in th e t reat m en t of acute spin al cord injur y: result s of
th e th ird n at ion al acu te sp in al cord inju r y ran dom ized con t rolled
t rial. JAMA 1997;277:15971604
2. Bracken MB, Shepard MJ, Holford TR, et al. Methylprednisolone or
tirilazad m esylate adm inistration after acute spinal cord injury:
1-year follow up. Results of the third National Acute Spinal Cord
Injury random ized controlled trial. J Neurosurg 1998;89(5):699706
3. Hurlbert RJ, Hadley MN, Walters BC, et al. Pharm acological therapy
for acute spinal cord injury. Neurosurgery 2013;72(Suppl 2):93105
4. Kingw ell SP, Cu r t A, Dvorak MF. Factors a ect ing n eu rological outcom e in t raum at ic con us m edullaris an d cauda equin a
inju ries. Neurosurg Focus 2008;25:E7
5. Sh apiro S. Cau da equ in a syn drom e secon dar y to lu m bar d isc
h ern iat ion . Neurosu rger y 1993;32(5):743747
6. Tator CH, Feh ling M, Th orp e K, Math M, Taylor W. Cu rren t u se
an d t im ing of spin al surger y for m an agem en t of acute spin al
cord injur y in Nor th Am erica: result s of a ret rospect ive m ult icen ter st udy. J Neurosurg 1999;91(1):1218
7. Tator CH, Du n can eG, Edm on ds VE. Com p arison of su rgical an d
con ser vat ive m an agem en t in 208 pat ien t s w ith acu te spin al cord
inju r y. Can J Neurol Sci 1987;14:6069
8. Feh lings M, Perrin RG. Th e t im ing of su rgical in ter ven t ion in th e
t reat m ent of spin al cord injur y: a system at ic review of recen t
clin ical eviden ce. Spin e 2006;31:S32S35
9. Feh lings MG, Vaccaro A, Wilson JR, et al. Early versu s d elayed d ecom pression for t raum at ic cer vical spinal cord injur y: result s of
th e su rgical t im ing in acu te spin al cord inju r y st u dy (STASCIS).
PLoS On e 2012;7:e32037
10. Gleave JRW, Macfarlan e R. Cauda equin a syn drom e: w h at is
th e relat ion sh ip bet w een t im ing of su rger y an d ou tcom e? Br J
Neurosurg 2002;16:325328
11. Olivero W, Wang H, Han igan W, et al. Cauda equin a syndrom e
(CES) from lu m bar disc h ern iat ion s. J Spin al Disord Tech
2009;22(3):202206
12. Quresh i A, Sell P. Cauda equin a syndrom e t reated by surgical
decom pression : th e in u ence of t im ing on surgical outcom e.
Eur Spin e J 2007;6(12):21432151
13. DeLong W B, Polissar N, Neradilek B. Tim ing of su rger y in cauda
equin a syn drom e w ith urinar y retent ion : m et a-an alysis of
obser vat ion al st udies. J Neurosurg Spine 2008;8(4):305320
309
III
Nontraumatic Emergencies
19
Removal of Spontaneous
Intracerebral Hemorrhages
Just in Mascitelli, Yakov Gologorsk y, and Joshua Bederson
Introduction
Preprocedure Considerations
Radiographic Imaging
Com puted tom ography (CT) can be obtained rapidly and clearly
Indications
Supratentorial ICH
Infratentorial ICH
2010 ASA/AHA in dicat ion s for surgical evacuat ion of cerebellar ICH1
Pat ien t s w h o are deteriorat ing n eu rologically
Brain stem com p ression
Hydrocep h alu s from ven t ricu lar obst ru ct ion
312
19
313
Operative Procedure
Frontal Craniotomy10
Positioning and Skin Incision (Fig. 19.3)
Figure
Procedural Steps
Pearls
Fig. 19.3
The May eld skull clamp is placed w ith the single pin at the equator
in contralateral frontal bone above the orbit and the paired pins
placed at the equator in the ipsilateral occipital lobe.
The super cial temporal artery (STA) should be palpated at the level
of the zygoma and the vertical limb of the incision should be placed
betw een the artery and the tragus.
The incision begins at the zygoma and then curves posteriorly to the
parietal eminence and upw ard from the auricle to reach 2 cm from
the midline.
The incision is then carried forw ard to the frontal region and curved
across the midline just behind the hairline.
314
19
Figure
Procedural Steps
Pearls
Fig. 19.4
315
Figure
Procedural Steps
Pearls
Fig. 19.5
316
19
Figure
Procedural Steps
Pearls
Fig. 19.6
317
Figure
Procedural Steps
Pearls
Fig. 19.7
318
19
Figure
Procedural Steps
Pearls
Fig. 19.8
319
Closing
closed using run n ing or in terrupted 4-0 braided nylon sut ures (th e dura m ay be left open if in creased ICP is a poten t ial
con cern ).
Th e bon e ap is placed an d secured w ith plates an d screw s
(th e bon e plate m ay be m arsupialized in th e abdom en if in creased ICP is a poten t ial con cern ).
plan e.
Th e tem poralis m uscle is reapproxim ated w ith 2-0 braided
absorbable su t u res.
Th e galea is approxim ated w ith 3-0 braided absorbable su t ure in an inverted, in terrupted fash ion .
Th e skin is closed w ith 3-0 nylon sut ure in a run n ing fash ion
or st aples.
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
Figure
Procedural Steps
Pearls
Fig. 19.10
321
322
Figure
Procedural Steps
Pearls
Fig. 19.11
19
Figure
Procedural Steps
Pearls
Fig. 19.12
323
324
19
Figure
Procedural Steps
Fig. 19.13
There are a number of w ays to perform the dural opening ; the authors prefer a Y-shaped opening w ith
the superior dural ap re ected over the transverse sinus.
325
326
Figure
Procedural Steps
Pearls
Fig. 19.14
19
Closing
On ce adequ ate h em ostasis h as been ach ieved, th e d u ra is
closed using ru n ning or in terrupted 4-0 braided nylon sut ures (Valsalva m an euver sh ou ld be used to assure a w atert igh t dural closure).
If th e cerebellu m is sw ollen , con sid erat ion sh ou ld be given to
a du ral p atch graft .
Th e w oun d is h eavily irrigated.
A m edium suct ion drain age device is placed in th e epidural/
su bfacial p lan e.
Th e m uscle an d fascia sh ould be approxim ated in layers using 2-0 braided absorbable su t ure (again , a w ater t igh t fascial
closure sh ould be obt ain ed to preven t CSF leakage th rough
th e w oun d).
Th e derm is is approxim ated w ith 3-0 braided absorbable su t ure in an inver ted, in terrupted fash ion .
Th e skin is closed w ith 3-0 nylon su t ure in a run n ing fash ion
or staples.
Postoperative Management
Special Considerations
Other Surgical Considerations
In addit ion to stan dard cran iotom y, m ore m in im ally invasive
tech n iques h ave been con sidered in cluding en doscopic aspirat ion an d stereot act ic in fu sion of th rom bolyt ics in to th e clot cavit y. En doscopic asp irat ion via a single bu r h ole h as been sh ow n
to im prove ou tcom e.14 Alth ough in fu sion of th rom bolyt ics h as
been sh ow n to reduce clot bu rden an d risk of death , rebleeding
is a greater con cern an d fun ct ion al outcom e is n ot n ecessarily
im proved.15 Both m inim ally invasive techn iques are st ill un der
invest igat ion. Curren tly th ere is too lit tle dat a to com m en t on
th e role of decom pressive h em icran iectom y as a t reat m en t
opt ion for spon tan eous ICH alth ough it h as been sh ow n to be
ben e cial for deep ICH in an im al m odels.16 Su rgical t im ing rem ain s con t roversial as w ell as th e de n it ion of early su rger y.
Cu rren tly th ere is n o clear eviden ce th at th ere is a ben e t from
eith er u lt ra early or delayed evacu at ion . In fact , u lt ra early
cran iotom y h as been associated w ith recu rren t bleeding.1
Sp on t an eou s ICH can be secon dar y to AVM, an eu r ysm , or ven ou s angiom a ru pt u re. AVM h em orrh age p rod u ces ICH in
82% of cases an d less com m on ly in t raven t ricular h em orrh age
(IVH), subarach n oid h em orrh age (SAH), or subdural h em orrh age (SDH). AVM resect ion is gen erally an elect ive p rocedu re.
Many recom m en d, if p ossible, delaying AVM su rger y w eeks to
m on th s after h em orrh age th u s allow ing th e p at ien t to st abilize
an d th e clot to liqu efy.1719 It h as been suggested th at if an AVM
associated ICH is m an aged op erat ively, th e h em atom a sh ou ld
be addressed rst as w ell as aggressive m an agem en t of in t raop erat ive ICP20 an d th at th e AVM sh ou ld on ly be addressed at th e
sam e t im e if it is su per cial w ith easily elu cidated an atom y.21
As a caut ion , if AVM bleeding occurs, h em ostasis in th ese
cases can be ext rem ely di cult . Gen tle an d prolonged t am pon ade is often ver y h elp ful an d h em ost at ic adjun ct s su ch as
gelat in sp onge or p ow der are im p ort an t tools. Occasion ally
persisten t bleeding an d can be m it igated w ith in d u ced hypotension . Cerebral perfusion pressure (CPP) sh ould alw ays be
kept in m in d, h ow ever, esp ecially in p at ien t s w ith elevated ICP.
327
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).
Aneurysmal ICH
An eu r ysm ru pt u re t yp ically resu lt s in SAH bu t can also p rod u ce
ICH an d u su ally involves an eu r ysm s distal to th e circle of Willis su ch as th e m id dle cerebral ar ter y (MCA) or an eu r ysm s th at
h ave becom e adh eren t to th e brain . Pat ien t s w ith an eur ysm al
ICH in gen eral h ave p oorer ou tcom es du e to m ass e ect an d in creased ICP.22 Un like th e t reat m en t for AVM associated ICH, ult ra
early h em atom a evacu at ion an d an eu r ysm clipp ing in p at ien t s
w ith poor clin ical grade h as been advocated for an eur ysm al
ICH.23 Th ere is a m u ch greater im p or tan ce in secu ring th e an eu r ysm given th e prop en sit y for an d devastat ing con sequ en ces
of an eur ysm re-rupt ure. Alth ough cath eter angiography is th e
gold stan dard for an eu r ysm diagn osis an d p reop erat ive evalu at ion , som e advocate operat ing based on CTA alon e as th e delay
could lead to w orse outcom e.24 If t im e p erm it s, h ow ever, con siderat ion sh ou ld be given to p reop erat ive angiography an d coil
em bolizat ion to p rotect th e an eu r ysm from re-ru pt u re an d , in
328
t urn , allow for a m uch safer ICH evacuat ion .25 If preoperat ive
em bolizat ion is n ot an opt ion du e to t im e con strain t s, th e su rgeon sh ou ld be fu lly p repared to clip th e an eu r ysm .
Prior to en tering or evacu at ing th e ICH, th e operat ing room
an d p erson n el sh ou ld be p rep ared for poten t ial an eu r ysm ru p t ure. Ideally, a discussion of the follow ing steps sh ould occur
before th e skin in cision is even m ade. Th e operat ing m icroscop e sh ou ld be d raped an d ready. A fu ll select ion of tem p orar y
an d perm an en t clip s sh ou ld be open on th e surgical eld. Th e
an esth esiologist sh ou ld be p rep ared to adju st blood p ressu re
rapidly. At least t w o (possibly th ree) large suction s sh ou ld be
prepared an d ready. On ce th e h em atom a is en tered, a con ser vat ive evacuat ion is w arran ted. Part icular care sh ou ld be t aken
n ear th e bot tom of th e ICH (n ear th e an eu r ysm ) to avoid u n du e
m an ipu lat ion . If ru pt u re occu rs, su ct ion an d p recise tam p on ade
are perform ed w h ile p roxim al arterial con t rol is obt ain ed. Th e
an eu r ysm an atom y is de n ed su rgically an d th e an eu r ysm n eck
is recon st ructed. After clipping an d ICH evacuation , th e pat ient
sh ou ld h ave im m ediate angiograp hy, ideally in th e operat ing
room . Fin ally, a th ird reason able opt ion in clu des cran iectom y
w ith out ICH evacuat ion to im m ediately address ICP follow ed by
im m ediate coil em bolizat ion .
19
ven t ricu lar drain age alon e is n ot an acceptable treatm en t for
cerebellar h em orrhage w ith associated hydroceph alus. Th ese
patien ts should undergo surgical decom pression.1
References
1. Morgen stern LB, Hem p h ill JC 3rd, An d erson C, et al. Gu id elin es
for th e m an agem ent of spon t an eous int racerebral h em orrh age:
a guidelin e for h ealth care profession als from th e Am erican
Hear t Associat ion /Am erican St roke Associat ion . St roke 2010;
41(9):21082129
2. Broderick J, Connolly S, Feldm ann E, et al; Am erican Heart
Association/Am erican Stroke Association Stroke Council; Am erican
Heart Association/Am erican Stroke Association High Blood Pressure Research Council; Qualit y of Care and Outcom es in Research
Interdisciplinary Working Group. Guidelines for the m anagem ent
of spontaneous intracerebral hem orrhage in adults: 2007 update:
a guideline from the Am erican Heart Association/Am erican Stroke
Association Stroke Council, High Blood Pressure Research Council,
and the Qualit y of Care and Outcom es in Research Interdisciplinary Working Group. Circulation 2007;116(16):e391413
3. Men delow AD, Gregson BA, Fern an d es HM, et al. Early su rger y
versu s in it ial con ser vat ive t reat m en t in p at ien t s w ith sp on t an eous su praten torial in t racerebral h aem atom as in th e In tern at ion al Surgical Trial in In t racerebral Haem orrh age (STICH): a
ran dom ised t rial. Lan cet 2005;365(9457):387397
4. Teern st ra OP, Evers SM, Kessels AH. Met a an alyses in t reat m en t
of spont an eous supraten torial in t racerebral h aem atom a. Act a
Neuroch ir (Wien ) 2006;148(5):521528
5. Green berg, Mark S. Han dbook of Neurosurger y. New York:
Th iem e; 2010
6. Broderick JP, Brot t TG, Du ldn er JE, Tom sick T, Hu ster G. Volu m e of
in t racerebral h em orrh age. A pow erful an d easy-to-use predictor
of 30-day m or t alit y. St roke 1993;24(7):987993
7. Bradley WG Jr. MR ap p earan ce of h em orrh age in th e brain . Radiology 1993;189(1):1526
8. Zh u XL, Ch an MS, Poon WS. Sp on t an eou s in t racran ial h em orrh age: w hich pat ien t s n eed diagn ost ic cerebral angiography?
A prospect ive st udy of 206 cases and review of th e literat u re.
St roke 1997;28(7):14061409
9. Diringer MN, Skoln ick BE, Mayer SA, et al. Th rom boem bolic
even t s w ith recom bin an t act ivated factor VII in Spon t an eous In t racerebral h em orrh age: result s from the factor seven for acute
h em orrh agic st roke (FAST) t rial. St roke 2010;41:4853
10. Clat terbuck RE, Tam argo RJ. Surgical posit ion ing and exposures
for cran ial procedures. In : Win n HR, ed. Youm ans Neurological
Surger y. 5th ed. Ph iladelphia: Saun ders; 2004
11. Yasargil MG, Reich m an MV, Ku bik S. Preser vat ion of th e fron totem poral bran ch of th e facial n er ve using th e in terfacial tem poralis ap for pterion al craniotom y. Tech n ical ar t icle. J Neurosurg
1987;67:463466
329
20
Introduction
Sp ace-occu pying in t racran ial in fect ion m ay arise via con t iguous spread from adjacen t st ruct ures, th rough h em atogen ous
dissem in at ion , follow ing operat ive n eurosurgical procedures,
or after h ead t raum a. Th e sam e st ruct ural elem en ts th at den e th e variou s in t racran ial com p ar t m en tsep id u ral, su bdu ral, p aren chym al, an d ven t ricu laralso dictate th e p ath w ays
for sp read of in fect ion across th ose n at u ral barriers. Man agem en t t yp ically involves a com bin at ion of m edical an d su rgical
m odalit ies.
Epidural Abscess
In fect ion w ith in th e space bet w een th e in n er t able of th e calvariu m an d d u ra occu rs m ost com m on ly as a com plicat ion of
p aran asal sin u sit is, orbit al cellu lit is, m astoidit is, or ch ronic
ot it is m edia. It m ay also occu r follow ing t rau m at ic fract u re of
th e calvarium or follow ing cran iotom y. Rarely, epidural abscess
m ay follow from fetal scalp m on itoring or th e ap p licat ion of
h alo p in s to th e sku ll.1 Clin ical p resen t at ion is often in sidiou s.
Headach e m ay be accom pan ied by a relat ive p au cit y of oth er
sym ptom s u n less m ass e ect is p resen t or th e in fect iou s p rocess exten ds to th e subdu ral space as w ell. Periorbit al edem a
occurs in conjun ct ion w ith bon e osteom yelit is or orbital cellulit is. (Pot ts pu y t um or is th e h istorical term applied to th e clin ical n ding of foreh ead soft t issue sw elling du e to th e presen ce
of subgaleal uid.2 ) An in fect ious n idus adjacen t to th e pet rous
ap ex m ay p resen t as Graden igo syn drom e. St reptococci (St reptococcus m illeri grou p) p redom in ate, th ough p ost t rau m at ic an d
p ostcran iotom y in fect ion s are m ore com m on ly associated w ith
st ap hylococci.3
Subdural Empyema
In fect ion w ith in th e p oten t ial sp ace bet w een du ra an d arach n oid m ater arises eith er from th e sp read of in fect ion via valveless em issar y vein s (in associat ion w ith th rom bop h lebit is) or
via exten sion of an osteom yelit is of th e sku ll w ith an accom panying epidural abscess. Oth er predisposing con dit ion s in clude
sku ll t rau m a, in fect ion of a p reexist ing su bd u ral h em atom a,
or prior n eurosurgical procedu re. A sm all n um ber are m et ast at ic (often from a p u lm on ar y sou rce). Su bd u ral em pyem a
m ay also occu r in u p to 10% of in fan t s w ith bacterial m en ingit is, presum ably as th e result of in fect ion of a previously sterile
330
Intracerebral Abscess
Focal, en capsulated in fect ion w ith in th e brain t issu e m ay be
single or m u lt ifocal. A single abscess t yp ically arises by d irect
exten sion of a paran asal sin u s, m astoid, or m iddle ear in fect ion ;
a solitar y focu s m ay also arise follow ing p en et rat ing t rau m a.
Mu lt ifocal d isease m ore com m on ly resu lt s from h em atogen ou s
dissem in at ion of prim ar y cardiac, pulm on ar y, periodon t al, ab dom in al, or derm atologic in fect ion . Less th an 50% of pat ien t s
w ill presen t w ith th e classic t riad of h eadach e, fever, an d focal
n eu rologic de cit .6 In fact , pat ien t s m ay p resen t w ith h eadach e
or n ausea alon e. Fever, w h en presen t , is t ypically low -grade;
a tem perat ure of greater th an 101.5 F (38.6 C) sh ou ld raise
su sp icion for a system ic in fect ion . Focal n eu rologic sym ptom s
re ect th e locat ion of th e path ology. Hem iparesis is com m on .7
New on set of m en ingism u s, associated w ith su dd en n eu rologic
w orsen ing, m ay in dicate ru pt u re in to th e ven t ricu lar sp ace.
Mort alit y in su ch cases is h igh .8 Isolated p ath ogen s are p redom in an tly bacterial, com m on ly polym icrobial, an d re ect th e
site of origin . St reptococci are isolated in u p to 70% of cases.
Bacteroides an d Prevotella are presen t in 2040% of cases an d
often occur in m ixed cult ure. Staphylococcus aureus is p resen t
in 1015% of brain abscessesusually p ost t raum a or in th e
set t ing of en docardit isan d is u su ally m on om icrobial. En teric
Gram -n egat ive bacilli are presen t in up to 2233% of cases, often in associat ion w ith ot ic foci, bacterem ia, or prior n eurosu rgical p rocedu re.9 Diagn ost ic con siderat ion s m u st be exp an ded
in cases of im m unocom prom ise. Gram -n egat ive organ ism s an d
fu ngal isolates are com m on in cases of n eu t rop h il de cien cy,
w h ile Listeria, Nocardia, Cryptococcus, an d Toxoplasm a are en coun tered in th e set t ing of T-cell de cien cy.
20
Indications
Th e in dicat ion s for surgical in ter ven t ion are dict ated by size,
an atom ic locat ion , an d accessibilit y, as w ell as by kn ow n or
p resu m ed p ath ogen . In all cases, su rgical in ter ven t ion m ust be
cou pled w ith appropriate in t raven ou s (an d, in cert ain cases,
in t rath ecal) an t im icrobial th erapy.
Epidural Abscess
Most cases requ ire op en n eu rosu rgical debrid em en t . Bu r h ole
drain age gen erally is in e ect ive given th e ten acit y of th e pu ru len t m aterial; h ow ever, in select cases w h ere a ver y sm all
collect ion is presen t , t rial bur h ole drain age m ay be at tem pted.
Th e par t icipat ion of Otolar yngology m ay be n ecessar y for sim u ltan eou s debridem en t of th e a ected sin u s(es).
coexisten t hydroceph alus w h ere sh un t placem en t risks con t am in at ion, or w h ere m edical con t rain dicat ion s to invasive in ter ven t ion m ay exist .13
In a p at ien t w ith docu m en ted bacterem ia an d a posit ive
cult ure, con siderat ion m ay be given to a t rial of system ic an t im icrobial th erapy, provided th e ch osen agen t(s) o ers good
cent ral n er vous system pen et rat ion . If th e diagn osis is in quest ion an d/or th ere is a quest ion of a polym icrobial in fect ion in
an im m u n ocom p rom ised h ost , con sid erat ion sh ou ld be given
to early biopsy to perm it t ailoring of m edical th erapy.
Preprocedure Considerations
Radiographic Imaging
CT h ead p re- an d p ost-con t rast w ill provid e basic in form a-
Subdural Empyema
Th e vast m ajorit y of cases requ ire open n eurosurgical debridem en t . More lim ited bu r h ole drain age m ay be con sidered in cases of p arafalcin e em pyem a, crit ically ill p at ien ts in sept ic sh ock,
an d ch ildren p resen t ing w ith em pyem a secon dar y to m en ingit is.10 Repeated drain age an d/or conversion to cran iotom y m ay
be n ecessar y in such cases.
Intracerebral Abscess
Several factors dictate th e in dication s for an d exten t of n eu rosurgical in ter ven tion . Prim ar y con siderat ion s in clu de th e m at urit y of th e capsule, size, an d location . Brit t an d En zm an n sough t
to de n e stages in th e m at u ration of th e abscess capsule.11 Cort ical in am m ationor, cerebritisalone is not a surgical disease.
Dem arcation of an abscess cavit y w ith respect to th e surroun ding parenchym a begins abou t 10 days after the onset of infection. The capsule w all, how ever, rem ain s thin and discontinuous
at this t im e. Abscesses m ay be am enable to cannulation and
drain agew ithout at tem pted resection of the w allduring this
early en capsulat ion ph ase. Th is strategy m ay also be appropriate
in th e set t ing of a m ore m at ure lesion in a less accessible location. With further m at urit y com es greater collagen deposition
an d, con sequen tly, a capsule m ore con sisten t w ith th at of a m etastat ic lesion . Con siderat ion m ay be given to drain agew ith resect ion of capsulein th e case of a m at ure an d accessible lesion .
This is generally feasible after 2 w eeks.
Th e size of th e lesion also m ay in uen ce t reat m en t st rategies. It h as been suggested th at abscesses of a cert ain size
(1.7 cm or less) m ay be t reated by m edicat ion alon e, w hereas
lesion s of greater th an 2.5 cm rarely resolve w ith ou t surgical
in ter ven t ion .9,12
Medical th erapy alon e m ay be con sidered in cases of m u lt ifocal disease, lesion s in eloquen t areas, con com it an t m en ingit is,
t ion regarding lesion locat ion , th e degree of associated edem a/m ass e ect , an d bony involvem en t . Cerebrit is w ill ap pear
as a n on sp eci c region of hypoden sit y. A m ore m at u re ab scess w ill d em on st rate ring-en h an cem en t w ith associated
p erilesion al edem a. CT of th e sin u ses (w ith coron al an d sagit t al recon st ruct ion s) m ay be a n ecessar y adju n ct if con t iguous
exten sion is su sp ected.
MRI brain pre- an d p ost-gadolin iu m m ay provide add it ion al
in form at ion to assist diagn osis an d th erap eut ic in ter ven t ion s. MRI m ay de n e th e st age of abscess or cerebrit is. In
cases of epidural or subdural em pyem a, m agn et ic reson an ce
ven ograp hy (MRV) w ill de n e th e exten t of sin u s th rom bosis,
if presen t . Magn et ic reson an ce di usion im ages are u seful in
diagn osing subdural em pyem a, w h ich often sh ow s hyperin ten se sign al in dicat ing di usion rest rict ion .14
Magn et ic reson an ce spect roscopy or posit ron em ission tom ograp hy m ay h elp dist ingu ish an in fect iou s from a n eoplast ic process.
Lum bar pun ct ure gen erally is n ot n ecessar y an d, w h en a
m ass lesion is p resen t , m ay be con t rain dicated. Given p hysical separat ion from th e subarach n oid space, cerebrospin al
u id sh ou ld be sterile (perh ap s w ith n on sp eci c in am m ator y ch anges) in th e set t ing of epidural em pyem a.
Blood cu lt u res sh ou ld be draw n (p referably p rior to in it iat ion
of an t im icrobial th erapy).
In th e set t ing of bacterem ia, an ech ocardiogram is in d icated
to exclu de en docardit is as th e et iology for in t racran ial
in fect ion .
HIV test ing sh ou ld be u n dert aken as th e spect ru m of in fect ious path ology (an d th e approach to t reat m en t) in th e im m u n ocom prom ised p opu lat ion m ay di er.
A ch est X-ray sh ould be com pleted. A puri ed protein derivat ive skin test sh ould be placed if t ubercu losis is suspected.
A pan oram ic X-ray m ay de n e an odon tologic et iology for in t racran ial in fect ion .
Preoperat ive im aging (Fig 20.1af).
331
Fig 20.1af Axial CT (a) soft tissue and (b) bone windows, as well as (c) sagit tal MRI post-gadolinium T1-weighted image demonstrating a Pot ts
pu y tumor. Note the extracranial soft tissue collection in communication with the epidural space, via the frontal air sinus. (d) Axial MRI postgadolinium T1-weighted image demonstrating a right frontal subdural empyema. (e) The di usion-weighted imaging sequence, in this set ting,
demonstrates hyperintense signal, indicating di usion restriction. (f) Axial MRI post-gadolinium T1-weighted image demonstrating an intracerebral
abscess with loculations and peripheral enhancem ent, extending to the local meninges.
332
20
Medication
Em piric, broad-spect rum an t im icrobial th erapy sh ould be
333
Operative Procedure
Positioning (Fig. 20.2a, b)
334
20
Figure
Procedural Steps
Pearls
Fig. 20.2
(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
Figure
Procedural Steps
Fig. 20.3
(a) An incision is planned extending from tragus to tragus, just posterior to the hair line.
(b) A no. 10 blade is used to initiate the skin opening. The incision initially is carried dow n to the level of
pericranium centrally and temporalis fascia laterally. Hemostatic scalp clips are applied to the skin edges. The
scalp ap is re ected forw ard until the orbital rim and root of zygoma are palpable bilaterally.
336
20
Figure
Procedural Steps
Fig. 20.4
A no. 15 blade is used to open the pericranium bilaterally just superior and parallel to superior temporal line ;
a third, transverse cut is made at the level of coronal suture. A periosteal elevator is used to advance the ap
forw ard to the level of the superior orbital rim. The vascularized ap is w rapped in a saline moistened sponge
and secured temporarily w ith 4-0 braided nylon sutures under minimal tension.
337
Figure
Procedural Steps
Pearls
Fig. 20.5
The position of the bone ap, too, will depend on the location of the target
pathology. A rectangular frontal bone ap will address frontal lobe and
unilateral frontal sinus pathology. If pathology is present along the bilateral
falx, a mirror image bone ap may be necessary over the contralateral
frontal lobe, leaving a strip of bone along the midline sagittal sinus.
For a unilateral frontal bone ap, holes may be placed w ith a high
speed drill at three points: (1) the keyhole, (2) at the level of coronal
suture and just inferior to superior temporal line, and (3) just anterior
to coronal suture and lateral to midline. Bone w ax is applied to the bony
edges. A Pen eld no. 3 is used to strip the dural attachments from the
undersurface of the calvarium betw een each set of bur holes.
338
20
Figure
Procedural Steps
Fig. 20.6
The craniotome is used to create a roughly rectangular bone ap. A periosteal elevator or Pen eld no. 3 is used
to elevate the bone ap aw ay from the underlying dura. The dural surface is irrigated w ith saline. Hemostasis is
attained w ith bipolar electrocautery. Bleeding attributable to the midline sinus may be controlled w ith brillar
hemostatic material and/or gelatin foam soaked in thrombin. Epidural tacking stitches may be used to augment
these techniques. If epidural abscess is present, proceed to the next step. If not, proceed to Dural Opening and
Addressing Subdural Empyema (Fig. 20.8).
339
340
Figure
Procedural Steps
Pearls
Fig. 20.7
20
Figure
Procedural Steps
Fig. 20.8
The dural opening w ill depend on the position of the bony defect. In the setting of a frontal craniotomy, a no. 15
blade is used to initiate a trap doortype opening that may be apped tow ard the midline sagittal sinus. A mirror
image opening is made if a bifrontal craniotomy is present.
341
342
Figure
Procedural Steps
Pearls
Fig. 20.9
20
Figure
Procedural Steps
Pearls
Fig. 20.10
343
Figure
Procedural Steps
Pearls
Fig. 20.11
344
20
345
346
Figure
Procedural Steps
Pearls
Fig. 20.12
20
Closing
Medication
Em piric, broad-spect rum antim icrobial therapy should be con -
Radiographic Imaging
Early post procedure CT im aging is in dicated to assess th e
Postoperative Management
Monitoring
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
Further Management
Reaccum ulat ion of epidu ral, su bdural, an d in t raparen chym al
collect ion s m ay occur. Pat ien ts m ay require m ult iple operat ive in ter ven t ion s for debridem en t .
In th e set t ing of in t raven t ricu lar ru pt u re of an abscess, p lacem en t of an extern al ven t ricu lar drain is app ropriate to p erm it
con t in uou s drain age of cerebrospin al uid, as w ell as in t rath ecal adm in ist rat ion of ant im icrobial th erapy.
Special Considerations
If in fect ion arises from th e sin u ses or m astoid p rocess, si-
References
1. Dill SR, Cobbs CG, McDon ald CK. Su bdu ral em pyem a: an alysis of
32 cases an d review. Clin In fect Dis 1995;20:372386
2. Flam m ES. Percivall Pot t: an 18th cen t u r y n eu rosu rgeon . J Neu rosurg 1992;76:319326
3. Hall WA. Cerebral in fect iou s p rocesses. In : Loft u s CM, ed . Neu rosurgical Em ergen cies. Vol. 1. Park Ridge, IL: Am erican Associat ion of Neurological Surgeon s Publicat ions; 1994: 165182
348
4. Nath oo N, Nadvi SS, van Dellen JR, Gouw s E. In t racran ial su bdu ral em pyem as in th e era of com puted tom ography: a review of
699 cases. Neurosurger y 1999;44:529535
5 . Har t m an BJ, Helfgot t DC, We in gar t e n K. Su b d u ral em pyem a an d su p p u rat ive in t racran ial p h lebit is. In : Sch eld W M,
W h it ley RJ, Mar ra CM, e d s. In fe ct ion s of t h e Cen t ral Ner vou s
Syst e m . Ph ilad elp h ia: Lip p in cot t W illiam s & W ilkin s; 2 0 04 :
52 3 53 6
6. Riech ers RG, Jarell AD, Ling GSF. In fect ion of th e cen t ral n er vou s
system . In : Suarez JI, ed. Crit ical Care Neurology an d Neurosurger y. New York: Hum an a Press; 2004: 515532
7. Yang S-Y. Brain abscess: a review of 400 cases. J Neu rosu rg
1981;55:794799
8. Math isen G, Joh n son JP. Brain abscess. Clin In fect Dis 1997;
25:763779.
9. Tu n kel AR. Brain abscess. In : Man dell GL, Ben n et t JE, Dolin R, eds.
Prin ciples an d Pract ice of In fect ious Diseases. 6th ed. Ph iladelph ia: Elsevier; 2005: 11501163
10. Nath oo N, Nadvi SS, Gouw s E, van Dellen JR. Cran iotom y im proves ou tcom es for cran ial su bd u ral em pyem as: Com p u tedtom ograp hy era experien ce w ith 699 p at ien t s. Neu rosu rger y
2001;49:872878
11. Brit t R, En zm an n D. Clin ical st ages of h u m an brain abscesses
on serial CT scans after con t rast in fusion . J Neurosurg 1998;59:
972989
12. Oban a WG, Rosen blu m ML. Non op erat ive t reat m en t of n eu rosurgical in fect ion s. Neurosurg Clin N Am 1992;3:359373
13. Rosen blu m M, Ho J, Norm an J, Edw ards M, Berg B. Non op erat ive t reat m en t of brain abscesses in select h igh -risk pat ien t s.
J Neu rosu rg 1980;52:217225
14. Wong AM, Zim m erm an RA, Sim on EM, et al. Di u sion -w eigh ted
MR im aging of su bdu ral em pyem as in ch ildren . AJNR Am J Neu roradiol 2004;25:10161021
15. Tu n kel AR, Har t m an BJ, Kaplan SL, et al. Pract ice gu idelin es
for th e m an agem ent of bacterial m en ingit is. Clin In fect Dis
2004;39:12671284
16. Kasten bau er S, P ster H-W, W h isp elw ey B, et al. Brain abscess.
In : Sch eld W M, W h itley RJ, Marra CM, eds. Infect ion s of th e
Cen t ral Ner vou s System . Ph iladelp h ia: Lipp in cot t William s &
Wilkin s; 2004: 479508
17. Bh at ia K, Jon es NS. Sept ic cavern ou s sin u s th rom bosis secon dar y
to sin u sit is: are an t icoagu lan t s in dicated ? A review of th e literat ure. J Lar yngol Otol 2002;116:667676
18. Tu n kel AR. Su bdu ral em pyem a, epid u ral abscess, an d su p purat ive in t racran ial throm boph lebit is. In : Man dell GL, Ben n et t
JE, Dolin R, eds. Prin cip les an d Pract ice of In fect iou s Diseases.
6th ed. Ph iladelph ia: Elsevier; 2005: 11641171
21
Introduction
A ven t ricu lar sh u n t (VS) m alfu n ct ion is a com m on n eu rosu rgical em ergen cy. In fact , a sh un t revision is on e of th e m ost com m on p roced u res a n eu rosu rgeon m ay perform . It is est im ated
th at up to 50% of sh un t s m ay fail w ith in 2 years. Despite it s
ap paren t sim plicit y, a sh u n t revision requ ires m et icu lou s atten t ion to detail an d vigilan ce in diagn osis an d m an agem en t
to en su re th e pat ien t is t reated in a t im ely an d adequ ate m an n er. Th e w orku p an d su rgical t reat m en t of a VS m alfu n ct ion is
fraugh t w ith risks an d com plicat ion s even in th e m ost exp erien ced h an ds. In th e Un ited St ates, sh u n t revision costs are h igh ,
perh aps over $1 billion a year. Th e h um an costs are st aggering.
Com m on causes of sh un t m alfun ct ion in clude m ech an ical failu re (obst ru ct ion , discon n ect ion , or m igrat ion ), h ardw are failure
(valve), in fect ion , fun ct ion al (u n derdrain age or overdrain age),
or a com bin at ion of th ese aforem en t ion ed issues.1,2
A t ypical clin ical presen t at ion of an acu te VS m alfu n ct ion
in clu des drow sin ess, severe h eadach es, an d vom it ing.3 How ever, th e presen t at ion m ay be qu ite d iverse, from rap id to slow /
su btle an d ch ron ic. Th e com m on sign s an d sym ptom s m ay be
as m od est an d in con sp icu ou s as d eteriorat ion in sch ool perform an ce, irritabilit y, in crease in h ead circu m feren ce over th e
95th percen t ile, in creased leth argy or sleep, clu m sin ess, ch ron ic m alaise, ch ron ic fever, abdom in al pain , or sw elling aroun d
th e sh un t t ract . More im pressive presen tat ion s in clude seizu re,
cran ial n er ve paresis (III, IV, or VI), decrease in visual acuit y,
p aralysis of u pw ard gaze, papilledem a, w eakn ess or paralysis,
st u por, com a, or ch ange in vital sign s (decreased p u lse or in creased m ean arterial pressu re).
Obt ain ing m et icu lou s in form at ion from a p at ien t or h is/h er
caregiver or th e m edical records about th e t ype of sh un t im p lan ted an d previou s sh un t failure presen tat ion is im port an t .
Previou s im aging, especially w h en don e during sym ptom -free
p eriod, is vital in su rgical decision m aking. Kn ow ledge of th e
t yp e of sh u n t an d in form at ion abou t th e set t ing, date, an d sp eci cs of previous operat ion s m ay in u en ce t reat m en t st rategy
in com p lex cases. How ever, th ese det ails m ay often be in com p lete. It is im p or tan t to n ote th at a sh un t can m alfun ct ion w ith out cau sing an obvious ch ange in ven t ricular size, in part , du e
to poor com plian ce of th e brain . How ever, th e in t racran ial pressu re (ICP) can be elevated an d on ly th e h istor y from th e pat ien t
or fam ily m em ber, sym ptom s, or exam m ay be h elpfu l. In th ose
p at ien t s w h ose scan s m ay n ot ch ange during a t yp ical sh u n t
m alfu n ct ion , it is im p erat ive to listen to th e h istor y provided
by a know ledgeable caregiver w h o can accurately com pare th is
Indications
Clin ical sym ptom s of sh un t m alfun ct ion su ch as th ose listed
in th e in t rodu ct ion
Radiological sym ptom s of sh u n t m alfu n ct ion w ith ven t ricu lar dilatat ion
Posit ive cerebrosp in al u id (CSF) cu lt u res, posit ive eviden ce
of m icroorgan ism or elevated w h ite coun t con sisten t w ith
in fect ion , an d oth er possible clin ical scen arios described
elsew h ere 1,2
Discon t in u it y in sh u n t t u bing or d islodgem en t of t u bing from
ven t ricle or abdom en (VP), pleu ra (Vp leu ral), or h ear t (VA)
Exposure of sh un t t u bing
Sh u n t explorat ion w ith ou t ven t ricu lom egaly in p at ien t w h o
h as poor com plian ce of brain , an d p resen ts w ith sign s an d
sym ptom s of in creased in t racran ial pressu re
Slit-ven t ricle w ith in term it ten t sh u n t m alfu n ct ion
Desire to convert sh u n t p at ien t in to a sh u n t-free p at ien t by
an ETV, in th e face of a sh u n t obst ru ct ion
Th ere is a sim pli ed algorith m for decision m aking in ven t ricular sh un t m alfun ct ion in Fig. 21.1.
349
Sh un t Tap
Yes
Posit ive
Negat ive
No
Sh u n t
Extern alizat ion
+ ABx
Pseu docyst
No
Sh u n t Revision
Yes
Sh u n t
Extern alizat ion
+ ABx
Fig. 21.1 Simpli ed algorithm for decision making in ventricular shunt malfunction.
Preprocedure Considerations
Radiographic Imaging
Head com p u ted tom ograp hy (CT; m ay be com bin ed w ith
Diagnostic Procedures
Sh un t tapif th e fever is greater th an 101 F or th ere is a p osit ive blood cult ure in last 48 h ours an d/or sh un t system in ter-
b
Fig. 21.2a, b Preoperative imaging of shunt malfunction of the same patient. (a) Head CT and (b) brain
MR (Haste T2 protocol).
350
21
Fig. 21.3ac Shunt series. (a) Anteroposterior (AP) and (b) lateral
skull showing ventricular catheter disconnection. (c) AP abdom en
showing distal catheter disconnection (arrow).
Medication
Antibiotics
Any n ew sh un t placem en t or revision : t w o doses of cefazolin
or any late gen erat ion ceph alosporin ; rst dose is adm in istered during an esth esia in duct ion (45 m in utes to 1 h our prior
to th e in cision ) an d th e secon d dose after th e surger y w ith in
8 h ours. Som e surgeon s cover th e pat ien ts w ith an t ibiot ics
for 24 h ou rs; h ow ever, th e eviden ce m ostly su pp or t s a single
p reoperat ive dose p rior to skin in cision . Con sid er van com ycin 1 h ou r in advan ce of surger y in m eth icillin -resistan t
Staphylococcus aureuscolon ized pat ien t s.
Sh u n t in fect ion : tap sh u n t , th en im m ed iately begin t riple
an t ibiot ics (ceft riaxon e, van com ycin , an d m et ron idazole in
com m u n it y-acquired an d im ipen em /cilast in in stead of ceft riaxon e in h ospit al-acqu ired in fect ion ).6
351
Wait 3 m in u tes
# w h o scru bbed
# w h o w ash ed h an ds correctly
# w h o d ou ble-gloved
Yes
An t ibiot ics in ?
No
Wait
Inject ion of van com ycin /gen t am ycin in to shu n t reser voir
Closure
Dressing
352
21
Operative Procedure
Shunt Revision
Positioning and Preparation (Fig. 21.5)
Figure
Procedural Steps
Pearls
Fig. 21.5
The patient is placed supine w ith the head on a gel donut, head
mildly rotated aw ay from valve site for adequate exposure
of operative eld. A gel roll is placed under the shoulders to
extend and maintain the appropriate plane for tunneling. Ensure
appropriate foam or gel padding to reduce pressure sore risk at
every pressure point.
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
354
21
Figure
Procedural Steps
Pearls
Fig. 21.6
Evaluate ventricular catheter skull entry site and valve location based on
review of imaging, palpation, and navigation assistance. (a) An incision
is made w ith a no. 10 or no. 15 blade often through a preexisting
incision w ith extension along the valve for appropriate exposure of
distal part of the valve. The incision should not be over the hardw are
to avoid w ound breakdow n. After w e score the skin w ith a blade, w e
use Bovie electrocautery dow n to and around the shunt hardw are
because it does not cause harm to the valve or tubing. (b) The careful
dissection of soft tissue in the galeal-pericranial plane to preserve
pericranium and appropriate exposure of both ventricular catheter and
valve is performed. Wound edges are retracted carefully w ith Weitlaner
retractor(s) or retraction sutures. Wound hemostasis is obtained w ith
monopolar or bipolar electrocautery.
electrocautery.
One can utilize a custom tailored skin
incision or curvilinear incision to provide
adequate scalp coverage and release
tension from the wound. In patients with
a comprom ised scalp, the surgeon m ay
need to perform a Z-plast ya rotational
ap or score the galeal layer to ensure
adequate scalp coverage over the tubing
without tension.
355
Figure
Procedural Steps
Pearls
Fig. 21.7
Carefully disconnect the ventricular catheter from the valve and assess
CSF ow. If no ow, the catheter is replaced. If partial ow, connect the
ventricular catheter to a manometer and obtain the opening pressure. If
there is partial obstruction, so identi ed due to high ICP or no pulsatility
in the CSF uid column then proceed w ith catheter revision.
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
Figure
Procedural Steps
Fig. 21.8
During catheter revision, if the ventricular catheter is adherent to the choroid plexus in the ventricle, a monopolar
w ire is used to release the catheter. It takes careful monopolar coagulation, gentle manipulation, or tw isting of the
catheter until a burst of CSF signals the release of the catheter. We use a Jake clamp to hold the catheter during
this maneuver. 8 If there is intraventricular blood, gently irrigate the ventricle via barbotage w ith normal saline or
lactated Ringers until it clears.
357
358
Figure
Procedural Steps
Pearls
Fig. 21.9
21
Figure
Procedural Steps
Pearls
Fig. 21.10
359
360
Figure
Procedural Steps
Pearls
Fig. 21.11
21
Figure
Procedural Steps
Fig. 21.12
The anterior rectus sheath is opened along the tissue bers and the rectus muscle is identi ed. Straight clamps are
used to separate along the muscle bers. A self-retaining retractor is placed to keep the anatomic layers spread.
The posterior rectus sheath can be gently elevated w ith an atraumatic toothed forceps and sharply opened w ith
no. 15 blade or cautery. The incision may be extended w ith curved Metzenbaum scissors. After advancement of the
retractor, the transversalis fascia is opened often revealing extraperitoneal fat.
361
362
Figure
Procedural Steps
Pearls
Fig. 21.13
21
Figure
Procedural Steps
Pearls
Fig. 21.14
track. One technique is to pass the shunt through the hollow end of
the shunt passer while saline is irrigated through the tube from the
other end. Another technique includes using a heavy 72-inch 2-silk
ligature at the end of the shunt passer and pulling the silk through
the subcutaneous track. The new tubing is tied to the silk ligature and
pulled through the subcutaneous track as the silk is pulled toward the
surgeon. Alternatively, a silk ligature could be placed on the old distal
tubing and pulled through the subcutaneous track. The new tubing is
tied to the end of the silk ligature and it is pulled toward the surgeon
with the new tubing which is then laid in its new position. The proxim al
catheter/reservoir and valve can subsequently be sutured to the tubing.
363
364
Figure
Procedural Steps
Pearls
Fig. 21.15
21
Placement: Ventricular Catheter and Tunneling for External Drainage (Fig. 21.16)
Figure
Procedural Steps
Pearls
Fig. 21.16
Closing
After appropriate irrigat ion w oun ds are closed in a m ult ilay-
365
366
Figure
Procedural Steps
Pearls
Fig. 21.17
21
Figure
Procedural Steps
Pearls
Fig. 21.18
A nylon purse string suture is used at tubing exit site and the catheter
is connected to a sterile, external CSF collection bag (inset).
367
Fig. 21.19 Postoperative CT scan of same patient depicted in Fig. 21.2 after shunt revision.
Postoperative Management
Pract ice pat tern s var y: w e rout in ely obt ain an im m ediate postoperat ive CT if th e ven t ricu lar cath eter is revised. Th e im m ediate postop CT ser ves as a baselin e for th e follow up (Fig. 21.19).
A sh u n t series con sist ing of p lain radiograph s is reason able
after m ost p rocedu res to en su re proper p lacem en t of sh un t an d
as a baselin e assessm en t for com p arison in follow -u p sh ou ld
problem s arise.
Th e usual length of st ay in th e h ospital is 2472 h ou rs
dep en ding on com p lexit y of th e case an d clin ical con dit ion of
th e pat ien t . Typical follow -up occu rs at 2 w eeks for a w oun d
ch eckup th en at 6 w eeks w ith repeat im aging, t ypically a rapid
sequ en ce MRI.
Special Considerations
In pediat ric pat ien t s w e t yp ically follow -u p at yearly in tervals w ith or w ith ou t im aging, dep en d ing on sym ptom s. If th e
pat ien t is w ell, n o im aging m ay be n eeded except at sur veillan ce scan in ter vals of 15 years. We obtain a sh u n t series to
en su re n o cath eter discon n ect ion s are seen an d to follow th e
length of th e distal cath eter after th e last sh u n t in sert ion . If th e
pat ien t goes th rough a rapid grow th period or if th ere is any
368
References
1. Brow d SR, Ragel BT, Got tfried ON, et al. Failu re of cerebrosp in al
uid sh un t s: part I: Obst ruct ion an d m ech an ical failure. Pediat r
Neurol 2006:34;8392
2. Brow d SR, Got tfried ON, Ragel BT, et al. Failu re of cerebrosp in al
uid sh un t s: part II: overdrain age, loculat ion , an d abdom in al
com plicat ion s. Pediat r Neurol 2006:34;171176
3. Barn es NP, Jon es SJ, Hayw ard RD, et al. Ven t ricu lop eriton eal
sh un t block: w h at are th e best predict ive clin ical in dicators?
Arch Dis Ch ild 2002:87;198201
4. ONeill BR, Pru th i S, Bain s H, et al. Rap id sequ en ce m agn et ic reson an ce im aging in th e assessm en t of ch ildren w ith hydroceph alus. World Neurosurg 2013;80(6):e307312
5. Pitet t i R Em ergen cy dep ar t m en t evalu at ion of ven t ricu lar sh u n t
m alfun ct ion: is th e sh un t series really n ecessar y? Pediat r Em erg
Care 2007:23;137141
6. Kestle JR, Garton HJ, W hitehead W E, et al. Managem ent of shunt infections: a m ulticenter pilot study. J Neurosurg 2006:105;177181
21
7. Kestle JR, Riva- Cam brin J, Wellon s JC, 3rd , et al. A st an dard ized protocol to reduce cerebrospin al uid shu nt in fect ion : th e
Hydroceph alu s Clinical Research Net w ork Qu alit y Im provem en t
In it iat ive. J Neu rosu rg Pediat r 2011:8;2229
8. Stein bok P, Coch ran e DD Rem oval of ad h eren t ven t ricu lar cath eter. Ped iat r Neu rosu rg 1992:18;167168
9. Parke r SL, An d e rson W N, Lilie n feld S, et al. Ce reb rosp in al
sh u n t in fe ct ion in p at ie n t s re ce ivin g an t ibiot ic- im p regn at ed ve rsu s st an d ard sh u n t s. J Ne u rosu rg Pe d iat r 2011:8;
259265
10. Hayh urst C, Beem s T, Jen kin son MD, et al. E ect of elect rom agn et ic-n avigated sh un t placem en t on failure rates: a prospect ive
m u lt icen ter st udy. J Neurosu rg 2010:113;12731278
11. Tubbs RS, Maher CO, Young RL, et al. Dist al revision of ven t riculoperiton eal sh un t s using a peel-aw ay sh eath . J Neurosurg Pediat r
2009:4;402405
12. Naftel RP, Argo JL, Sh ann on CN, et al. Laparoscopic versus open
in sert ion of th e periton eal cath eter in ven t riculoperiton eal
sh un t placem ent: review of 810 consecut ive cases. J Neurosurg
2011:115;151158
369
22
Pituitary Apoplexy
Kalm on D. Post and Soriaya Mot ivala
Introduction
Pit uit ar y apoplexy is a n eu rosurgical em ergency in w h ich
p rom pt in ter ven t ion m ay h alt an d even reverse associated n eu rologic de cit s an d possible m or talit y. Th e con dit ion results
from h em orrh age or n ecrosis of a pit u it ar y t u m or. It h as been
fou n d to occu r in 0.6 to 10.5% of all p it u itar y aden om as.1
In 1950, Brough am w as th e rst to describe th e clin ical an d
p ath ologic n dings of ve p at ien t s w h o presen ted w ith ch anges
in m en tal st at u s, h eadach es, m en ingism u s, an d ocu lar dist u rban ces.2 Sin ce th en , th ere h as been exten sive in terest in th e
en t it y as w ell as con siderable debate on w h at th e term pit uitary apoplexy en com p asses. In fact , th ere h ave been rep or t s
of silen t pit uit ar y apoplexy.3 Moh r est im ated th e in ciden ce
of asym ptom at ic h em orrh ages in pit u it ar y aden om as to be
9.9% as opposed to 0.6% th at presen ted w ith clin ical n dings.4
Furth erm ore, On est i described ve pat ien ts w ith subclin ical
p it u it ar y ap oplexy, th at is, a clin ically silen t yet exten sive
h em orrh age in to a pit u it ar y aden om a.5
With su ch a broad in terp retat ion in th e literat u re it is in creasingly h elpfu l to de n e th e diagn osis of pit uitar y apoplexy by
clin ical param eters th at in clude th e sudden on set of h eadache,
m en ingism u s, visu al im p airm en t , an d occu lom otor abn orm alit ies in var ying com bin at ion s along w ith radiologic eviden ce of
h em orrh age in or su dden exp an sion of a pit u it ar y aden om a.
Preprocedure Considerations
Radiographic Imaging
CT w ith ou t con t rast is m ost valu able th e
Indications
Diagn osis of ap oplexy requ ires evid en ce of h em orrh age or
370
rst 2 days of
22
Fig. 22.1ac (a) Axial and (b, c) coronal CT scans showing hemorrhagic
cavit y with uid- uid level and surrounding enhancing sellar lesion.
b
Fig. 22.2a, b (a) T1-weighted sagit tal and (b) coronal MRI demonstrating a sellar m ass of heterogeneous signal intensit y, with suprasellar extension
of increased signal intensit y consistent with acute hemorrhage.
371
Medication
After in t ubat ion th e pat ien ts eyelids are gen tly t aped sh ut
372
22
Operative Procedure
Microscopic Pituitary Tumor Resection
Positioning and Fluoroscopy (Fig. 22.3a, b)
a
Figure
Procedural Steps
Pearls
Fig. 22.3
Patient is placed on far right edge of table in supine position. Right arm
is bent 90 degrees and secured across chest w ith padding and tape.
(a) Head is placed on a foam holder w ith right ear tilted 45 degrees
in relation to right shoulder. Head of bed is exed just slightly such that
the chest does not interfere w ith use of instruments.
373
374
Figure
Procedural Steps
Fig. 22.4
Initial lateral skull uoroscopic images are obtained to evaluate trajectory to the sella.
22
Figure
Procedural Steps
Pearls
Fig. 22.5
(a) Surgical elds of the nasal passages and the right low er abdominal
quadrant are prepped and draped in a sterile fashion. (b) The
operating microscope is sterilely draped and positioned for optimal
view through the right nasal passage.
375
Figure
Procedural Steps
Pearls
Fig. 22.6
(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
Figure
Procedural Steps
Fig. 22.7a, b
(a) The septum is the deviated to the patients left and the keel-shaped vomer of the sphenoid is exposed.
(b) A hands free speculum is then placed w ith one blade on either side of the vomer.
377
378
22
Figure
Procedural Steps
Pearls
Fig. 22.8
(b) A small osteotome and mallet is used to fracture the sella oor,
and then Kerrison rongeurs are used to remove it.
(c) Lateral uoroscopy image depicting the trajectory of the
speculum w ith instruments marking the superior and inferior limits
of the sella turcica.
at closure.
It is im portant to note that sphenoid sinus
septations are not usually m idline; the
vom er marks the m idline.
Fluoroscopy or im age guidance allows the
surgeon to be certain of being m idline at
this juncture.
379
380
Figure
Procedural Steps
Pearls
Fig. 22.9
22
Figure
Procedural Steps
Pearls
Fig. 22.10
381
382
Figure
Procedural Steps
Pearls
Fig. 22.11
22
Figure
Procedural Steps
Pearls
Fig. 22.12
It is im portant not to
contam inate the abdom en with
any instruments that have been
placed in the nose.
383
Postoperative Management
Dexam eth ason e or hydrocort ison e is con t in u ed in th e im m e
Special Considerations
It is ou r preferen ce to u se th e operat ing m icroscop e for th e
t ran ssph en oidal approach ; h ow ever, t ran ssph en oidal en doscopy is also often u sed to provide w ider exposure. Surgeon
com for t level sh ould dict ate w h ich tech n ique is u sed.
Cran iotom y is reser ved for pat ien ts w ith a n on aerated sph en oid sin u s, a sm all sella w ith a large su prasellar m ass, a t igh t
diaph ragm a sellae w ith a dum bbell-sh aped m ass, or an associated in t racerebral h em atom a.5,16
References
1. Naw ar RN, AbelMan n an D, Selm an W R, Arafan BM. Pit u it ar y
t um or apoplexy: a review. J In ten sive Care Med 2008:23(2):
7590
384
IV
23
Introduction
This chapter covers the procedure for a large hem icraniectom y
follow ing severe penetrating com bat traum a w ith m assive soft
tissue involvem ent. Sim ilar operative principles apply for less
severe penetrating w ounds, as well as for hem icraniectom y for
blunt traum a. W here blunt traum a is concerned, the m ost signi cant divergence involves preoperative decision m aking. We have
tended throughout recent con ict to be quite aggressive w ith surgical intervention for both blunt and penetrating traum a. Longterm outcom e studies are pending, but initial experience justi es
continuing this aggressive approach in our patient population.1,2
Com parisons bet w een civilian and com bat cranial traum a m ay
be di cult because of the service m em bers very young average
age and high overall level of tness, the nearly im m ediate availabilit y of basic and advanced life support care, and extraordinarily
robust resources on the bat tle eld and w ithin close proxim it y of
w ounding. Additionally, com bat injuries are n otable for m assive
soft tissue/bone/brain injury, gross contam ination (often w ith
aggressive organism s), concurrent injuries to face/neck/extrem ities/trunk, and extended patient transfers. Evacuation to facilities in Germ any and, then, onward to national m ilitary m edical
centers in Beth esda, Marylan d, con sists of t w o ights of m ore
than 6 hours duration w ithout in- ight neurosurgical capabilit y.3
How ever, th e m ajor goals of su rger y in both sit u at ion s are
rem oval of con tam in an ts (in clud ing devit alized t issue), brain stem decom pression , h em ost asis, sku ll base recon st ru ct ion
(w ith obliterat ion of air- lled sin u ses), dural coverage, soft t issue coverage, an d stabilizat ion for t ran sp or t w ith app rop riate
m on itoring in p lace an d fu n ct ion ing.
Indications
In t h e com bat set t in g, low GCS score (, 5) is n ot n ecessarily a con t rain d icat ion to su rgical in ter ven t ion . Ad d it ion ally, p u p illar y asym m et r y or d ilat ion m ay be t h e resu lt of
t rau m at ic ir id op legia or ch em ical ir r it at ion . Th e overall
clin ical p ict u re an d w ou n d ing h istor y m u st be t aken in to
accou n t before m akin g a d ecision to categor ize a p at ien t
as exp ect an t . Becau se of t h e d i eren ces in p at ien t p op u lat ion as ou t lin ed , t h is in d icat ion m ay n ot fu lly t ran slate in to
civilian p ract ice.
Preprocedure Considerations
Consultation/Teamw ork
Su ccessfu l m an agem en t of p at ien t s severely w ou n d ed in com bat operat ion s is t ruly a m ult idisciplin ar y e ort . Mult iple surgical sp ecialist s are often involvedin addit ion to e or ts from
an esth esiology, n u rsing, an d laborator y/blood ban k. A single
p at ien t m ay presen t w ith an ext rem it y am p ut at ion , an abd om in al pen et rat ion , exposed brain , a p ar t ially en ucleated globe,
an d severe soft t issu e/bon e loss involving th e m axilla, requ iring
sim u ltan eou s evalu at ion an d su rgical m an agem en t by ve sp ecialists. Con st an t com m un icat ion an d coordin at ion is required
am ong all m em bers of th e team .
Radiographic Imaging
Com puted tom ography (CT) scan is rou t in ely available at th e
386
sw elling or h em atom a.
Absen ce of m ajor disrupt ion of m idline deep cerebral n uclei
in th e region of th e sella (zon a fat alis). Disrupt ion of th e zon a
fatalist yp ically associated w ith Glasgow Com a Scale (GCS)
3 is a relat ive con t rain dicat ion to operat ive in ter ven t ion .4
23
b
Fig. 23.1a, b CT (a) brain and (b) bone images of a frontotemporoparietal IED injury demonstrating t ypical massive
soft tissue swelling, air- lled sinus disruption, intracranial fragments, and epidural hematoma. These are actual
hardcopy images from in-theater CT scan operating under extreme weather and force protection conditions. Digital
records are not available for higher resolution.
Medication
recom m en d an t ibiot ic prophyla xis w ith cefazolin . Prophyla xis t yp ically is con t in u ed u n t il 24 h ours follow ing rem oval
of extern al ven t ricular device (EVD) or in t racran ial pressu re
(ICP) m on itor, or a total of 48 h ours if n o such devices are
p resen t . Con siderat ion m ay be given to exten ded coverage
w ith gen t am icin an d pen icillin if gross con t am in at ion is
p resen t . Pat ien t s w h o are allergic to p en icillin m ay be t reated
w ith van com ycin an d cipro oxacin .6
Seizu re p rop hylaxis w ith dip h enylhydan toin is in it iated preoperat ively.
387
Operative Procedure
Positioning and Preparation (Fig. 23.2)
Figure
Procedural Steps
Pearls
Fig. 23.2
388
23
Figure
Procedural Steps
Pearls
Fig. 23.3
389
390
Figure
Procedural Steps
Pearls
Fig. 23.4
23
Figure
Procedural Steps
Pearls
Fig. 23.5
391
Figure
Procedural Steps
Pearls
Fig. 23.6
(c) In some cases, the very large scalp ap described above may be
vulnerable to posterior scalp breakdow n. The surgeon may consider
a midline incision and ipsilateral extension of Kempe, as revisited by
Martin, 1 taking advantage of the angiosomes of the occipital artery to
improve results w ith cosmetic reconstruction. 8
392
23
Figure
Procedural Steps
Pearls
Fig. 23.7
393
394
Figure
Procedural Steps
Fig. 23.8
Brain debridement is performed using normal saline bulb irrigation to w ash aw ay large fragments of obviously
devitalized brain tissue. Hemostasis is attained, further irrigation is applied, and gross areas of contamination
are removed. Gentle exploration of w ound tracts is appropriate in order to remove obvious and easily accessible
contaminants, but deeply embedded fragments are not removed unless indicated by later angiography or a
subsequent infection.
23
Figure
Procedural Steps
Fig. 23.9
Dural coverage is obtained using primary dural tissue w hen available. Fascia lata is harvested if su cient dura is not
available. Dural substitutes are available in theater if neither can be used.
Reconstruction of the skull base is done w ith local bone, if available ; otherw ise, harvested bone is employed for
this purpose. In the rare circumstance that neither is available, arti cial materials such as titanium can be used over
small areas as long as pericranial coverage is used.
It is important to ensure obliteration of any involved air- lled sinuses. This is done by w idely opening the sinus,
removing mucosa, and packing the sinus fully w ith muscle and/or fat.
Extensive pericranial graft tissue, w ith a vascularized pedicle, can be harvested due to the expansive scalp exposure
(see Fig. 23.6). The graft can be maneuvered into place to cover an exenterated air- lled sinus (or skull base
reconstruction) and sew n over the packed sinus cavity to the adjacent dura.
When possible, anchor the temporalis muscle to scalp or bone in order to preserve its normal anatomic position and
allow for later optimal cosmetic reconstruction.
395
Closing
Sedat ion , p ain con t rol m easu res, an d ven t ricu lar drain age to
con t rol ICP are closely m on itored an d m an aged by on board
in ten sivists an d crit ical care n ursing st a .
Cranial Incision
Th e in t racran ial space an d w oun d cavit y are irrigated w ith
Medication
An t iepilept ic prophylaxis is con t in u ed for 7 days.
Prophylact ic an t ibiot ics are con t in ued for 4872 h ours.
Radiographic Imaging
Repeat CT im aging is t ypically obt ain ed postoperat ively, th e
site is closed w ith a deep layer of 2-0 absorbable su t u re, follow ed by skin staples.
Postoperative Management
Monitoring
n ext m orn ing, an d on an as-n eed ed basis th ereafter for n eu rologic ch anges. Im aging requirem en t s are balan ced again st
h em odyn am ic st abilit y an d oth er risks of t ran sport to im aging suite.
We h ave becom e m uch m ore aggressive w ith angiography
due to in creased in ciden ce of vasospasm , pseudoan eur ysm ,
an d delayed h em orrh age in pat ien t s exp osed to blast en ergy.
In addit ion to in ciden ces of obviou s vascu lar inju r y, w e rou t in ely perform angiogram s in th e follow ing pat ien t s to look
for occu lt inju r y: p en et rat ing inju r y n ear th e circle of Willis, Sylvian ssure, or posterior fossa; kn ow n vasospasm ; an d
blast-associated blun t t raum a.
Postop erat ive im aging (Fig. 23.10a, b).
396
23
Special Considerations
We h ave n oted postoperat ive ch allenges w ith vasospasm ,
p seu doan eu r ysm form at ion , ver y low pressu re hydroceph alu s, an d m ult idrug resist an t organ ism ven t ricu lit is.
Additionally, reconstructive procedures for the m ore m assive
injuries require a m ultidisciplinary e ort involving neurosurgery,
plastic surgery, oral and m axillofacial surgery, otolaryngology
head and neck surgery, ophthalm ology, prosthodontics, and
im aging/three-dim ensional fabrication experts.
References
1. Bell RS, Mossop CM, Dirks MS, et al. Early decom pressive cran iectom y for severe pen et rat ing an d closed h ead injur y du ring
w ar t im e. Neu rosu rg Focu s 2010;28(5):E1
2. Ragel BT, Klim o P Jr, Mar t in JE, Te RJ, Bakken HE, Arm on da RA.
War t im e d ecom p ressive cran iectom y: tech n iqu e an d lesson s
learn ed. Neurosu rg Focu s 2010;28(5):E2
3. Fang R, Dorlac GR, Allan PF, Dorlac WC. In tercon t in en t al aerom edical evacuat ion of pat ien t s w ith t raum at ic brain inju ries during Operat ion s Iraqi Freedom an d En during Freedom .
Neurosurg Focus 2010;28(5):E11
4. Kim KA, Wang MY, McNat t SA, Pin sky G, Liu CY, Gian n ot t a SL,
Apu zzo ML. Vector an alysis correlat ing bu llet t rajector y to
ou tcom e after civilian th rough -an d-th rough gun sh ot w oun d to
th e h ead: u sing im aging cu es to p redict fat al ou tcom e. Neu rosu rger y 2005;57(4):737747; d iscu ssion 737747
5. Arm on da RA, Bell RS, Vo AH, et al. War t im e t rau m at ic cerebral
vasospasm : recen t review of com bat casualt ies. Neurosurger y
2006;59(6):12151225; discussion 1225
6. Wor t m an n GW, Valadka AB, Moores LE. Preven t ion an d m an agem en t of in fect ion s associated w ith com bat-related cen t ral nervous system injuries. J Traum a 2008;64(3 Suppl):S252256
7. Steph en s FL, Mossop CM, Bell RS, et al. Cran iop last y com plicat ion s follow ing w ar t im e decom pressive cran iectom y. Neurosu rg
Focus 2010;28(5):E3
8. Hou sem an ND, Taylor GI, Pan W R. Th e angiosom es of th e
h ead an d n eck: an atom ic st udy an d clin ical applicat ion s. Plast
Reconst r Surg 2000;105(7):22872313
397
24
Combat-Associated Penetrating
Spine Injury
Corey M. Mossop, Christopher J. Neal, Michael K. Rosner, and Paul Klim o Jr.
Introduction
Com bat-related pen et rat ing spin e inju ries (PSIs) are due to
rearm s an d exp losive devices, m ost n ot ably im p rovised exp losive d evices (IEDs).
PSIs accoun t for up to 25% of all spin al cord injuries, of w h ich
app roxim ately h alf presen t w ith com p lete parap legia an d
m ore th an on e-qu arter are associated w ith oth er inju ries.1
An ar t icle com paring pen et rat ing an d blun t m ilitar y spin e
injuries in th e recen t U.S. m ilit ar y con ict s (Operat ion Iraqi
Freedom an d Operat ion En during Freedom ) repor ted th at
of 598 injured ser vice m em bers, 104 (17%) sust ain ed spinal
cord injuries, com prising 10% of blun t injuries an d 38% of
p en et rat ing inju ries (p , 0.0001).2
Th e th oracic spin e accoun t s for th e m ajorit y of injuries, w ith
th e lu m bosacral an d cer vical spin e follow ing in secon d an d
th ird, respect ively.1,3
Given th e relat ion sh ip of kin et ic en ergy (KE), m ass (m ), an d
velocit y (v) (KE 5 1/2m v 2 ), th e m ost crit ical factor a ect ing
th e dest ruct iven ess of a project ile is its velocit y,4 m aking th e
h igh -velocit y PSIs seen in com bat set t ings part icu larly d evastat ing.3,5 Th erefore, it is n ot surprising th at pat ien t s w ith
m ilit ar y PSI in gen eral h ave a w orse n eu rologic inju r y on p resen t at ion an d h ave less poten t ial for n eu rologic recover y th an
th ose w ith closed spin al cord t raum a.3
Indications
Fig. 24.1 depicts a t reat m ent algorithm for com bat-related PSI.
In com p lete sp in al cord inju r y w ith m ass lesion in th e sp in al
can al, w ith or w ith out progressive n eurologic de cit
W h ile th e literat u re is m ixed regarding th e exact ben e t of
decom pressive su rger y (usu ally in th e form of m ult ilevel
lam in ectom ies), m ost st ill favor op erat ive in ter ven t ion in
a m edically st able p at ien t w ith an in com plete sp in al cord
inju r y an d eviden ce of persisten t cord com pression such as
Discla im e r : Th e vie w s e xp r e sse d in t h e follow in g t e xt (o r p r e se n t a t ion , m a n u scr ip t , e t c.) a r e t h o se of t h e a u t h o r s a n d d o n ot n e ce ssa r ily r efle ct t h e officia l p o licy or p o sit ion of t h e De p a r t m e n t o f
t h e Ar m y, De p a r t m e n t of t h e Nav y, De p a r t m e n t of Defe n se , n o r t h e
U.S. Gove r n m e n t .
398
bon e or m etallic fragm en t s w ith in 2448 h ours of th e in it ial injur y .1,310 An in com p lete spin al cord inju r y m ay exist
w ithout im pingem en t on th e sp in al can al du e to th e en ergy
released to th e surrou n ding st ru ct u res by th e p assage of
th e project ile (i.e., sh ock w ave). In th is scen ario, surger y
is n ot recom m en ded.
CSFcu t an eou s/p leu ral st u la
Prolonged CSF leakage an d it s con com itan t in fect ious risks
con st it u te a de n it ive surgical in dicat ion in PSI1,3 (Fig. 24.2).
Fragm en t-in duced n er ve root com pression
Pat ien t s w ith both clin ical an d radiograp h ic eviden ce of eith er bony or foreign bodyin duced n er ve root com pression
sh ou ld h ave th e involved root s decom pressed, ideally in
th e rst 2448 h ours after inju r y.1
Sp in al in stabilit y
Sin ce th e m ajorit y of civilian PSIs are from low -m u zzle
velocit y h an dgu n s an d kn ife w ou n ds, biom ech an ical in st abilit y is n ot , in gen eral, an issu e. As su ch , th ese pat ien t s require n o in st rum en t at ion an d/or fusion during
operat ive in ter ven t ion .1,3,9,10 In com bat PSI, h ow ever, th e
project iles involved (bullet s or fragm en t s from an explosive device) h ave a greater en ergy th at can be dissipated
to th e surrou n ding an atom ic st ruct ures, th us in creasing
th e likelih ood of spin al in st abilit y. With h igh -velocit y ballist ic t raum a, th e rate of in stabilit y can approach 20% an d
is m ost com m on in injuries w ith a side-to-side t rajector y
involving th e facet join t s bilaterally 7 ; h ow ever, th e con cept
of spin al stabilit y rem ain s n ebulous an d ult im ately rests on
a case-by-case con siderat ion of m u ltiple clin ical an d rad iograp h ic n dings w ith clin ical in t u it ion p laying an equ ally
st rong role (Fig. 24.3).
If t h e p at ien t h as a t ran sgast roin test in al an d u n st able
sp in al inju r y, w e recom m en d t h at in st r u m en t at ion be
p ost p on ed u n t il t h e p at ien t h as com p leted a fu ll cou rse of
in t raven ou s an t ibiot ic t h erapy an d , if n ecessar y, t h e abd om en h as been t h orough ly d ebr id ed an d w ash ed ou t by a
gen eral su rgeon .
Recen t literat ure h as est ablish ed th at th e follow ing clin ical
scen arios are not in dicat ion s (in an d of th em selves) for operat ive in ter ven t ion :
Com plete spin al cord injur y (in th e absen ce of spin al in st abilit y or CSF leakage) (Fig. 24.4) 1,310
Woun d debridem en t/closure (in th e absen ce of gross
w ou n d con t am in at ion ) 11
Copper- an d/or lead-based fragm en ts
Given h ow rare h eavy m et al toxicit y is w ith PSI, th e com p osit ion of a fragm en t sh ould n ot dictate operat ive in terven t ion based on cu rren t evid en ce.3
24
Com bat-Associated Penetrating Spine Injury
399
400
Fig. 24.3ae This 27-year-old man sustained a highvelocit y gunshot wound that entered through the left
neck (with associated tracheal/esophageal injuries and
severe bilateral pulmonary contusions) and resulted
in complex (a, b) multicolumn fractures of T2-4 with
bilateral facet joint involvement, (c, d) complete cord
transection, and a resultant complete (ASIA A) spinal
cord injury. His tracheal and esophageal injuries were
repaired and the entry/exit sites were debrided and
closed while in theater. Because of the patients poor
pulmonary and infectious status, his spinal injuries
could not be addressed until post-injury day 15.
(continued)
24
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.
401
Preprocedure Considerations
Initial Evaluation
Radiographic Imaging
Plain X-ray
Dem on st rates an atom ic align m en t , th e p resen ce or absen ce
of overt bony injur y, an d th e locat ion of m ost retain ed foreign bodies.
pat tern (s). In addit ion , it also provides in form at ion regarding
th e locat ion of retain ed foreign bodies. Met allic st reak ar t ifact from ret ain ed foreign bodies m ay degrade th e im aging.
For cer vical spin e injur y, CT angiography (CTA) sh ou ld be
perform ed on all pat ien t s to evaluate for carot id or vertebral
arter y inju r y: disru pt ion , dissect ion , th rom bosis, or pseu doan eu r ysm form at ion . For th oracic or lum bar involvem en t , CTA
an d CT ven ograp hy sh ou ld be don e to evalu ate for large vessel inju r y (e.g., th oracic an d abdom in al aort a, com m on iliac
arteries, in ferior ven a cava).
CT m yelograp hy is rarely in dicated in th e acu te set t ing;
it m ay be valu able in a p at ien t in w h om m agn et ic reson an ce
im aging (MRI) is con t rain dicated bu t in w h om con cern exist s
for a com p ressive dural lesion n ot app aren t on bon e w in dow s
su ch as an epidu ral or su bdu ral h em atom a.
Operative Considerations/
Techniques
Th e pat ien t w ith a PSI is at h igh risk for a w ide range of
perioperat ive com plicat ion s th at th e surgeon m u st an t icipate an d t r y to preven t . In a recen t art icle by Possley et al,17
com plicat ion sd e n ed as unplan n ed m edical even t s (su rgical or n on surgical) th at require furth er in ter ven t ion occurred
in 35% of ser vice m em bers w ith PSI w h o u n der w en t su rgical
in ter ven t ion .
Tactical Scenario
Does th e cu rren t t act ical set t ing allow for operat ive in ter ven t ion in a safe, sterile environ m en t?
Associated Injuries
For t ran sth oracic injuries: Is th e pat ien t able to tolerate being
402
Equipment/Set-Up
24
Anesthesia Issues
Con sider aw ake
Neuromonitoring
Recom m en ded if available for m on itoring of som atosen sor y
evoked p oten t ials (SSEPs) an d elect rom yograp hy (EMG)
su spected
Prophylact ic in t raven ous an t ibiot ics 30 m in utes prior to
in cision if n ot already on broad-sp ect rum an t ibiot ics
Foley cath eter
Prepping/ Incision
Sh ave w ith elect ric h air clip p ers
Su rgical prep arat ion in th e st an dard sterile fash ion
403
Operative Procedure
Positioning (Fig. 24.5a, b)
404
24
Figure
Procedural Steps
Pearls
Fig. 24.5
405
Figure
Procedural Steps
Fig. 24.6
406
24
Figure
Procedural Steps
Fig. 24.7
Using the high-speed drill and Leksell/ Kerrison rongeurs, remove the
spinous processes and perform laminectomies at least one level above
and below the pathologic level.
Remove the underlying ligamentum avum w ith Kerrison rongeurs.
407
408
Figure
Procedural Steps
Fig. 24.8
Carefully remove any foreign bodies or bony fragments causing any compression
on the underlying nerve roots, thecal sac, or spinal cord.
24
Figure
Procedural Steps
Pearls
Fig. 24.9
409
Instrumentation/ Fusion
(See Chapters 14 and 15)
in th ose pat ien t s w ith com plete spin al cord injur y an d th ose
w ith in com plete inju r y but w h o are n on am bulator y.
Closing
Su ct ion can ister/Jackson -Prat t drain (s) if n eeded (avoid w h en
Postoperative Management
Adm ission to a m on itored set t ing w ith con t in u ed blood p res
410
References
1. Bu xton N. Spin al injur y. In: Brooks A, et al, eds. Ryans Ballist ic
Trau m a: A Pract ical Gu ide. Lon don : Sp ringer; 2011: 341347
2. Blair JA, Possley DR, Pet eld JL, et al. Milit ar y p en et rat ing sp in e
injur y com pared w ith blu n t . Spin e J 2012;12:762768
3. Klim o P, Ragel BT, Rosn er M, et al. Can su rger y im prove n eu rological fun ct ion in penet rat ing spin al injur y? A review of th e
m ilitar y an d civilian literat ure an d t reat m en t recom m en dat ion s
for m ilit ar y neu rosurgeon s. Neurosurg Focus 2010;28(5):E4
4. DeMu th W E Jr. Bu llet velocit y as ap p lied to m ilit ar y ri e w ou n ding capacit y. J Traum a 1969;9:2738
5. Blair JA, Pat zkow ski JC, Sch oen feld AJ, et al. Are spin e inju ries
sust ain ed in bat tle t ru ly di eren t? Spin e J 2012;12:824829
6. Clin ical assessm en t after acute cer vical spin al cord inju r y.
Neurosu rger y 2002;50(3 Suppl):S2129
7. Man agem en t of acu te spin al cord inju ries in an in ten sive care
un it or oth er m on itored set t ing. Neurosurger y 2002;50(3 Suppl):
S5157
8. Blood pressu re m an agem en t after acute spin al cord injur y.
Neurosu rger y 2002;50(3 Suppl):S5862
9. St illerm an CB. Use of m ethylpred n isolon e as an adju n ct in th e
m an agem en t of pat ien t s w ith pen et rat ing spin al cord inju r y:
outcom e an alysis. Neurosurger y 1996;39:11411149
10. Lin SS, Vaccaro AR, Reisch S, et al. Low -velocit y gu n sh ot w ou n ds
to th e spin e w ith an associated t ran speriton eal injur y. J Spin al
Disord 1995;8:136144
11. Qu igley KJ, Place HM. Th e role of debridem en t an d an t ibiot ics in
gun sh ot w oun ds to th e spin e. J Trau m a 2006;60:814820
12. Aarabi B, Alibaii E, Taghipur M, et al. Com parative study of functional recovery for surgically explored and conservatively m anaged
spinal cord m issile injuries. Neurosurgery 1996;39:11331140
13. Du z B, Can sever T, Secer HI, et al. Evalu at ion of sp in al m issile
injuries w ith respect to bullet t rajector y, su rgical in dicat ion s
an d t im ing of su rgical in ter ven t ion : a n ew gu idelin e. Spin e
2008;33:E746E753
14. Ham m ou d MA, Haddad FS, Mou farrij NA. Sp in al cord m issile
injuries during the Leban ese civil w ar. Surg Neu rol 1995;43:
432442
15. Velm ah os GC, Degian n is E, Har t K, et al. Ch anging p ro les in sp in al cord injuries an d risk factors in uen cing recover y after pen et rat ing injuries. J Traum a 1995;38:334337
16. Waters RL, Sie IH. Sp in al cord inju ries from gu n sh ot w ou n ds to
th e sp in e. Clin Or th op Relat Res 2003;408:120125
17. Possley DR, Blair JA, Sch oen feld AJ, et al. Com plicat ion s associated w ith m ilit ar y sp in e inju ries. Spin e J 2012;12:756761
Reconstructive Surgery
25
Introduction
Cran iotom y bon e aps are often frozen or stored in th e su bcu t an eous layer of th e abdom in al w all after decom pressive cran iectom y for in t racran ial hyp erten sion from t rau m at ic brain
inju r y, cerebrovascular disease, or oth er causes. Bon e ap restorat ion w ill be n eeded on ce th e acute issues h ave resolved.
Th ere is n o con sen sus regarding th e opt im al t im ing of bon e ap
rep lacem en t .14 Replacem en ts can be p erform ed from as lit tle
as 2 w eeks to m ore th an 1 year after inju r y.5,6
Indications
Su cien t abatem en t of sw elling h as occu rred w ith th e brain
Medication
Th e auth or prefers van com ycin an d gen t am icin for an t ibi-
Preprocedure Considerations
Radiographic Imaging
412
idin e application .
Th e in cision s are m arked an d in lt rated w ith 1% lidocain e
w ith epin eph rin e 1:100,000.
25
Operative Procedure
Positioning and Preparation (Fig. 25.2a, b)
Figure
Procedural Steps
Pearls
Fig. 25.2
413
V Reconstructive Surgery
Figure
Procedural Steps
Pearls
Fig. 25.3
414
25
Figure
Procedural Steps
Pearls
Fig. 25.4
415
V Reconstructive Surgery
416
25
Figure
Procedural Steps
Pearls
Fig. 25.5
(b) The plane betw een the muscle layer and the underlying
duraplasty is developed w ith dissecting scissors. If a dural plane
is not w ell established underneath the muscle during the initial
procedure, disruption of the cerebral cortex may occur. Wellpreserved muscles can be separated from the underlying tissues
safely using sharp dissection and leaving behind a thin layer of
muscle bers.
(c) The fascia is incised w ith the temporalis muscle and re ected
inferiorly w ith a 2-0 suture although it is not alw ays easy to
distinguish the temporalis fascia from the surrounding tissues.
417
V Reconstructive Surgery
Figure
Procedural Steps
Fig. 25.6
(a) The prior abdominal w all incision is opened w ith a no. 10 blade dow n to the
bone. The bone is dissected from its pseudocapsule and surrounding tissues w ith
a periosteal elevator along the super cial surface, then the lateral edges, then the
undersurface, then, lastly, the superior, inferior, and medial edges. A laparotomy
pad is placed in the abdominal w all pocket to assist w ith hemostasis. The bone is
brie y soaked in a half peroxide/saline solution then irrigated clean w ith saline.
Debris is scraped from the bone surface w ith a periosteal elevator.
(b) Before bone ap replacement, tangential holes are created w ith the drill along
the superior temporal line for temporalis xation to re -create the temporalis
insertion, if the temporalis is to be transposed.
418
Pearls
25
Figure
Procedural Steps
Pearls
Fig. 25.7
419
V Reconstructive Surgery
Figure
Procedural Steps
Pearls
Fig. 25.8
420
25
Figure
Procedural Steps
Fig. 25.9
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
Postoperative Management
Monitoring
It is th e au th ors pract ice to p lace th e p at ien t in a m on itored
set t ing overn igh t in th e p ostoperat ive period to obser ve for
seizu re act ivit y or eviden ce of in t racran ial bleeding.
Medication
Th e prophylact ic an t iepilept ic agen t is cont in u ed for a total of
Radiographic Imaging
A p ostoperat ive CT scan m ay be obtain ed to evalu ate for
ext ra-axial collect ion s or oth er h em orrh age (Fig. 25.10).
Further Management
Drain s are rem oved in 1 or 2 days.
Skin su t u res or stap les are rem oved after 2 w eeks.
Special Considerations
Explan ted craniotom y aps can also be stored in sub-zero freezers u n der aseptic con dit ion s.12,13 Th e available literat u re suggests th at th e rate of in fection or com plicat ion s do n ot di er
bet w een grafts stored by either m ethod.9,12,13 The disadvan tage
of subcutan eously stored bone grafts is that bone rem odeling
422
25
References
1. Ch eng YK, Weng HH, Yang JT, et al. Factors a ect ing graft in fect ion after cran ioplast y. J Clin Neurosci 2008;15:11151119
2. Liang W, Xiaofeng Y, Weigu o L, et al. Cran iop last y of large cran ial defect at an early st age after decom pressive cran iectom y
perform ed for severe h ead injur y. J Cran iofac Surg 2007;18:
526532
3. Iw am a T, Yam ada J, Im ai S, et al. Th e u se of frozen au togen ou s
bon e aps in delayed cran ioplast y revisited. Neurosurger y
2003;52:591596
4. Hu ang YH, Lee TC, Yang KY, et al. Is t im ing of cran ioplast y follow ing post t raum at ic cran iectom y related to n eurological ou tcom e?
In t J Su rg 2013;11:886890
5. Beau ch am p KM, Kash u k J, Moore EE, et al. Cran iop last y after
post injur y decom pressive cran iectom y: is t im ing of th e essen ce?
J Trau m a 2010;69:270274
6. Piedra MP, Th om pson EM, Selden NR, et al. Opt im al t im ing of
autologous cran ioplast y after decom pressive cran iectom y in
children . J Neurosurg Pediat r 2012;10:268272
7. Gran t GA, Jolley M, Ellen bogen RG, et al. Failu re of au tologou s
bon e-assisted cran ioplast y follow ing decom pressive cran iectom y in ch ildren an d adolescen t s. J Neurosurg 2004;100:163168
8. Han PY, Kim JH, Kang HI, et al. Syn drom e of th e sin king skin - ap
secon dar y to th e ven t riculoperiton eal sh un t after cran iectom y.
J Korean Neu rosu rg Soc 2008;43:5153
9. Flan n er y T, McCon n ell RS. Cran iop last y: w hy th row th e bon e ap
out? Br J Neurosurg 2001;15:518520
10. Zingale A, Albanese V. Cryopreservation of autogenous bone ap in
cranial surgical practice: w hat is the future? A grade B and evidence
level 4 m eta-analytic study. J Neurosurg Sci 2003;47:137139
423
26
Introduction
W hen an autologous cranioplast y is not an optionw hether from
contam ination, infection, fragm entation, bony reabsorption, or
grow th in the cranial vault (in children)neurosurgeons often
have to turn to im plantable synthetic cranioplasties. The goals
of a cranioplast y rem ain the sam e: lasting repair of the cranial
defect w ith good anatom ic contour. This can be perform ed at any
tim e point follow ing a reduction in brain swelling.1 Since the
1600s, neurosurgeons have experim ented w ith several di erent
constructs in the quest for the perfect cranioplast y.2 Recent developm ents in com puter-aided design and m anufacturing, tissue
engineering, and osteoinductive capabilities allow for the fabrication of an alloplastic im plant w ith excellent aesthetics that w ithstands biom echanical stresses and allow s for tissue integration.3
Indications
Preprocedure Considerations
Radiographic Imaging
Neu roim aging is requ ired p rior to any cran iop last y to evalu -
Su cien t abatem en t of sw elling h as occu rred w h en n eu roim aging dem on st rates th at brain is n ot prot ruding beyon d th e
defect an d lacks any eviden ce of system ic or local in fect ion .
Un suitabilit y of au tologous cran ioplast y
Bon e w as fragm en ted (prim ar y inju r y w as a dep ressed
sku ll fract u re)
ate th e con dit ion of th e brain , it s relat ion sh ip w ith th e cran ial
defect , any degree of hydroceph alus, extern al hydroceph alu s,
an d/or leptom en ingeal cyst s.
Magn et ic reson an ce im aging (MRI), w h ile n ot n ecessar y,
allow s for m ore det ail of th e brain ; it also m ay be m ore
su itable for ch ildren w h en th ere is a goal to lim it radiat ion
exposu re.
424
26
Medication
Antibiotic prophylaxis includes the standard preoperative dose
425
V Reconstructive Surgery
Bony defect
s/p calvarial t um or
resect ion
s/p t rau m a
Im m ed iate
cran iop last y w ith
pre-ordered im p lan t
Im m ed iate
cran iop last y w ith
p orou s polyethylen e
or HA or PMMA
con tou red on th e
field
If sw elling th en
delayed
recon st ru ct ion
At tem pt p at ien t ow n
bon e if available (an d
n ot con tam in ated)
Bon e flap
fragm en ted or
con tam in ated
Use p re-ordered
im p lant for large
con st ru ct s
If n o sw elling th en
im m ediate
reconst ru ct ion
426
26
Operative Procedure
Positioning Unilateral Craniectomy (Fig. 26.4)
Figure
Procedural Steps
Pearls
Fig. 26.4
427
V Reconstructive Surgery
428
Figure
Procedural Steps
Pearls
Fig. 26.5
26
Figure
Procedural Steps
Pearls
Fig. 26.6
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
Figure
Procedural Steps
Pearls
Fig. 26.7
26
Figure
Procedural Steps
Fig. 26.8
431
V Reconstructive Surgery
432
26
433
V Reconstructive Surgery
434
Figure
Procedural Steps
Pearls
Fig. 26.9
26
Figure
Procedural Steps
Pearls
Fig. 26.10
435
V Reconstructive Surgery
436
26
437
V Reconstructive Surgery
438
26
Implant Type
Pros
Cons
Fig. 26.11a
Porous polyethylene
Price
Custom implants require advance
planning, usually 3D CT im aging
(but noncustom anatom ic implants
available)
Fig. 26.11b
PEEK (polyetheretherketone)
Price
Custom im plants require advance
planning, usually 3D im aging
Can be contoured with a drill but not
m olded in the eld
Fig. 26.11c
Titanium plate
Price
Custom implants require advance
planning
Radiopaque with artifact on im aging
Cannot be contoured or m olded in
the eld
May require special xation set
Fig. 26.11d
Titanium m esh
Fig. 26.11e
Osteoinductive
Radiolucent
Excellent cosm esis
Easily contoured
Easily xated
Less surgical tim e for implantation than
PMMA
No advance planning needed
Price
May require m esh for strength,
stabilit y, and contouring in larger
areas
Fig. 26.11f
PMMA
(polym ethylm ethacrylate)
Radiolucent
May be contoured in the eld
No advance planning needed
439
V Reconstructive Surgery
440
Figure
Procedural Steps
Fig. 26.12
26
Figure
Procedural Steps
Fig. 26.13
441
V Reconstructive Surgery
Closing
Special Considerations
Th e pat ien ts ow n bon e ap is th e ideal m aterial for a cran ioplast y; h ow ever, if th e bon e ap is lost to osteolysis or in fect ion ,
au tologou s bon e (sp lit th ickn ess or h ar vest from oth er p ar ts of
th e body) is less ideal because of don or site m orbidit y an d sh ap ing problem s. As such , in th ese sit uat ion s, an alloplast ic cran ioplast y is an app rop riate solu t ion . Th e t yp e of cran ioplast y
m ost often dep en ds on th e su rgeons preferen ce an d exp erien ce as w ell as costs an d availabilit y. Th e m ost frequ en tly u sed
cran ioplast y m aterials are polym ethylm eth acr ylate (PMMA),
hydroxyapat ite, t it an iu m , polyethylen eth erketon e (PEEK), an d
porous polyethylen e.
PMMA is th e m ost frequ en tly u sed allop last ic m aterial becau se of it s good biocom pat ibilit y an d low cost an d proven efcacy in th e long term .4 Alth ough it can be u sed at th e t im e
of cran iotom y for im m ediate single st age cran ioplast y, th e
in t raoperat ive t im e an d en ergy spen t con tou ring th e m aterial exceeds th at of oth er im p lan t s. In add it ion , it is d i cu lt to
obt ain a cosm et ic resu lt th at ap proxim ates th at of th e cu stom
im plan t s. Ut ilizing a cu stom design ed m esh w ith t h e PMMA
im plan t w ith larger cran ial defect s m ay allow for th e opt im al cosm et ic im p lan t at a lesser exp en se th an oth er cu stom
im plan t s.5
Hydroxyap at ite (HA) is probably th e m ost frequ en tly u sed
ceram ic in cran ioplast y secon dar y to its h igh biocom pat ibilit y
arising from osteoin tegrat ion .6 It set s u p faster, is easier to con tour, an d is isoth erm icall bene t s over PMMA.7 How ever, in am m ator y react ion s h ave been described in th e postoperat ive
period. Furth erm ore, th e cost s of HA, especially if com bin ed
w ith a custom m esh for larger im plan t s, m ay be exceed th at of
custom im plan ts an d thu s be cost proh ibit ive.
PEEK8 an d porous polyethylen e 9 are both biocom pat ible m aterials th at provide h igh st rength an d radiolu cen cy for postoperat ive im aging. Th e u se of custom design ed im plan t s for
cran ioplast y is in creasing in calvarial recon st ruct ion , due to
th e ease of use, st rength , an d excellen t cosm et ic results. Th ey
can both be con toured in th e surgical eld an d easily xated.
Furth erm ore, sh ou ld a postoperat ive in fect ion occur, th ey m ay
be rem oved an d re-sterilized for later reim plan t at ion . Porous
polyethylen e h as th e addit ion al advan tage of being able to be
Postoperative Management
Monitoring
It is th e au th ors p ract ice to place th e p at ien t in a m on itored
set t ing overn igh t in th e p ostoperat ive period to obser ve for
seizu re act ivit y or eviden ce of in t racran ial bleeding.
Medication
Ph enytoin or levet iracetam is m ain tain ed at previou sly m en
Radiographic Imaging
A postop erat ive CT scan m ay be obtain ed to evalu ate for su b dural collect ion s or oth er h em orrh age.
Further Management
Drain s are rem oved th e n ext p ostop erat ive day or soon er if
442
26
resh aped w ith h ot salin e at th e t im e of su rger y,10 an d prem ade
an atom ic con tou rs, sh eet s, an d blocks are available at a d ecreased cost com pared to custom im plan t s.11
Cu stom t itan iu m im plan t s o er a good ch oice for cran ioplast y
based on th eir st rength , biocom pat ibilit y, h an dling ch aracteristics, an d su it abilit y for postoperat ive im aging tech n iques.12
How ever, th ey are m ore di cu lt to sh ap e in th e eld an d m ay
requ ire sp ecial xat ion system s. In addit ion , th e t it an ium art ifact m ay be su bopt im al for th e follow -u p of m en ingiom a an d
oth er t u m ors.
An other con siderat ion after recon st ru ct ing th e calvarial defect is soft t issu e recon st ru ct ion over th e calvariu m /allop last ic
cran ioplast y. Often w h en a decom pressive cran iectom y h as
been perform ed, an d th e tem poralis m u scle u n dergoes w asting an d is n ever restored to it s previou s bulk, cau sing tem poral h allow ing. Both porou s p olyethylen e pterion al im p lan ts
(Fig. 26.14) an d/or hydroxyap at ite cem en t m ay be u sed to augm en t th e tem poralis an d restore aesth et ics.7
References
1. Goodrich, JT. Cranioplast y. In: Albright AL, ed. Principles and Practice of Pediatric Neurosurgery. New York: Thiem e; 2008:864877
2. San an A, Hain es SJ. Repairing h oles in th e h ead: a h istor y of
cran ioplast y. Neu rosurger y 1997;40(3):588603
443
27
Introduction
Extern al force directed to th e an terior por t ion of th e foreh ead
can result in injur y to th e front al sin us. Th e fron t al bon e is th e
st rongest com p on en t of th e cran iofacial skeleton an d can w ith st an d bet w een 800 an d 2200 lb of force before fract u ring.1,2 Th e
sin u s is rough ly pyram idal in sh ape an d often divided by a m idlin e or p aram idlin e sept u m of bon e. Th e sin us is absen t at birth ,
but begin s to act ively pn eum at ize bet w een 7 an d 8 years of age
to reach an adult volum e after pubert y. By th eir m ech anism ,
m ost inju ries p rodu ce p osterior disp lacem en t of th e bon e in to
th e fron t al sin us, alth ough bon e at th e periph er y of th e injur y
can prot rude out w ard. Depen ding on th e force an d direct ion
of th e injur y, fract ures can involve eith er th e an terior t able of
th e sin us, both th e an terior an d posterior t ables, or solely th e
p osterior table.
Indications
444
Preprocedure Considerations
Radiographic Imaging
CT is th e gold st an dard im aging m odalit y for th e cran iom a xillofacial skeleton . Historically, plain lm s w ere obt ain ed,
w h ich w ere able to iden t ify th e presen ce of uid in th e fron t al sin us, but presen ted di cult y w h en t r ying to determ in e
th e presen ce of an terior, posterior, or th rough -an d-th rough
injuries. CT scan s are able to provid e axial, coron al, an d sagitt al im ages th at can separately evaluate th e an terior an d posterior aspects of th e sin us (Figs. 27.1, 27.2, an d 27.3).
27
445
V Reconstructive Surgery
Operative Procedure
Bicoronal Incision (Fig. 27.4)
446
Figure
Procedural Steps
Fig. 27.4
A bicoronal incision several centimeters behind the hairline provides the best
access for exposure of the anterior forehead and frontal sinus. The residual scar is
inconspicuous if attempts to minimize alopecia are taken. Super cial electrocautery
should be avoided. A stair-step incision is designed along the w ound to break up the
w ound and prevent the hair, especially w hen w et, from falling all in one direction.
A strip of hair over the area of the incision is shaved for exposure and to facilitate
ultimate closure. The incision is in ltrated w ith 1%or 0.5%lidocaine w ith 1:100,000
or 1:200,000 epinephrine, respectively. After prep and drape, the incision is made
w ith a scalpel blade in the direction of the hair follicles. The deeper subcutaneous
tissues may be divided w ith electrocautery dow n to the level of the periosteum.
27
Figure
Procedural Steps
Fig. 27.5
(a) Dissection superior to the fractured area may proceed in either a subgaleal
or subperiosteal plane. How ever, once the fracture fragments are encountered,
dissection in a subperiosteal plane is required to mobilize and reduce the fracture
fragments. If the entire supraorbital rim needs to be visualized, the supraorbital
nerves may need to be taken out of their foramina. This does not need to be done if
the nerves merely rest w ithin a notch.
(b) To easily convert each foramen into a notch, a 2-mm osteotome is placed inside
the medial and lateral aspects of the foramen and directed inferiorly. Once the
nerves are free, the soft tissues on the orbital rim and roof can be dissected in a
subperiosteal plane for exposure.
447
V Reconstructive Surgery
448
Figure
Procedural Steps
Pearls
Fig. 27.6
27
Figure
Procedural Steps
Fig. 27.7
Pearls
449
V Reconstructive Surgery
450
Figure
Procedural Steps
Pearls
Fig. 27.8
The bone fragm ents rem oved from the posterior table can
then be used for autogenous graft m aterial to plug the
frontonasal ducts. Alloplastic m aterial should be avoided.
When possible, dural breaches should be repaired either
prim arily or with a dural patch.
27
Figure
Procedural Steps
Fig. 27.9
The sinus mucosa does not stretch at against the w all of the sinus but
rather follow s small invaginations across the surface. Therefore, adequate
removal of the mucosa requires obliteration of the super cial depressions
in the bone w ith a pow er bur. Every surface and facet of the sinus should
be debrided to remove the mucosa.
451
V Reconstructive Surgery
452
Figure
Procedural Steps
Fig. 27.10
If the posterior table is removed and the sinus allow ed to cranialize, the
frontonasal ducts must be obliterated to avoid an ascending infection
from the nonsterile respiratory tract. Plugging of the ducts has been
described using muscle, fat, or alloplastic material. How ever, morselized
bone graft from the remnants of the posterior table provides excellent
graft material. The bone is crushed w ith a rongeur on a back table and
packed into the ducts.
27
Figure
Procedural Steps
Fig. 27.11
(a) A ap of pericranial tissue provides further separation of the nasal mucosa and
meningeal space. The ap is harvested from the deep surface of the bicoronal ap
and based inferiorly along the supraorbital rim.
(b) The pericranium should be elevated as large as possible to w rap over the
inferior aspect of bone and dow n into the anterior fossa. It can be incised w ith the
electrocautery and dissected free w ith a scissors.
453
V Reconstructive Surgery
454
Figure
Procedural Steps
Fig. 27.12
27
Figure
Procedural Steps
Pearls
Fig. 27.13
455
V Reconstructive Surgery
Closing
Special Considerations
Cranial Incision
Postoperative Management
Th e pat ien t is kept in th e h ospital u n t il aw ake an d alert . Th e
drain is kept to self-suct ion an d th e out put follow ed for quan t it y an d color. If it is n oted to be too sanguin eous, th e scalp
sh ou ld be carefu lly in sp ected for eviden ce of h em atom a an d a
seru m h em atocrit ch ecked. Eviden ce of ongoing bleed ing w arran ts ret urn to th e op erat ing room for evacu at ion an d h em ost asis. W h en drain age is m in im al, it m ay be rem oved.
Radiographic Imaging
Postop erat ive im aging w ith CT can be obt ain ed at th e discre
456
t ion of th e surgeon .
Pat ien t s sh ou ld be follow ed closely in t h e early p ostop erat ive p eriod for th e develop m en t of m en ingit is, en cep h alit is,
brain abscess, osteom yelit is of th e fron t al bon e, n on u n ion ,
caver n ou s sin u s th rom bosis, CSF leak, m u copyocele, an d
m en in goen cep h alocele.
Mu coceles h ave an in sid iou s cou rse over m any years, w arran t ing long-term follow -u p w ith im aging.1,4
References
1. Man olid is S, Hollier LH Jr. Man agem en t of fron t al sin u s fract u res.
Plast Recon st r Surg 2007;120(7 Suppl 2):32S48S
2. Strong EB, Kellm an RM. Endoscopic repair of anterior tablefrontal
sinus fractures. Facial Plast Surg Clin North Am 2006;14(1):2529
3. Bu llock MR, Ch esn u t R, Gh ajar J, et al. Su rgical m an agem en t of
dep ressed cran ial fract u res. Neu rosu rger y 2006;58(3 Su p p l):
S5660; discussion Si-iv
4. Rodrigu ez ED, St anw ix MG, Nam AJ, et al. Tw en t y-six-year experien ce t reat ing fron t al sin us fract ures: a n ovel algorith m based
on an atom ical fract ure pat tern an d failure of conven t ion al tech n iques. Plast Recon st r Surg 2008;122(6):18501866
5. Tedaldi M, Ram ieri V, Forest a E, et al. Exp erien ce in th e m an agem en t of fron t al sin u s fract u res. J Cran iofac Su rg 2010;21(1):
208210
6. Lau der A, Jalisi S, Spiegel J, et al. An t ibiot ic prophylaxis in th e
m an agem en t of com plex m idface and fron t al sin us t raum a.
Lar yngoscope 2010;120(10):19401945
7. Brat ton SL, Ch est n u t RM, Gh ajar J, et al. Gu idelin es for th e m an agem en t of severe t raum at ic brain injur y. XV. Steroids. J Neurot raum a 2007;24(Suppl 1):S9195
8. Rontal ML. State of the art in craniom axillofacial traum a: frontal
sin us. Curr Opin Otolaryngol Head Neck Surg 2008;16(4):381386
VI
28
Introduction
Ch ildren an d adults are physiologically di eren t . Even w ith in
th e pediat ric populat ion , th ere is a w ide range of physiological
n orm at ive valu es across th e age sp ect ru m . Th is is p erh aps m ost
relevan t in th e n eurosu rgical set t ing for th e m an agem en t of in t racran ial pressure (ICP) an d blood pressure. Path ophysiology
after t rau m at ic brain inju r y (TBI) is also di eren t in ch ild ren .
Di u se brain inju r y is m ore com m on . Focal inju r y an d ext raaxial h em atom as are less com m on . Th ere also are di eren ces in
th e pressurevolum e relat ion sh ips w ith in th e skull, m et abolic
resp on ses to inju r y, an d cerebral h em odyn am icsall of w h ich
h ave clin ical im p licat ion s for t reat m en t . Fu r th erm ore, th e tech n ical asp ect s of op erat ive m an agem en t in th e p ediat ric pop u lat ion w ith regard to an esth et ic con t rol, operat ive plan n ing,
an d t issu e h an dlingrequ ire sp ecial con siderat ion . Alth ough it
is beyon d th e scope of th is ch apter to cover all th e det ails of
ever y sp eci c em ergen cy op erat ion perform ed in ch ildren , key
p rin cip les com m on to th e m ost im por tan t of th ese procedures
are addressed .
Indications
Insertio n o f parenchym al m o nito rs (ICP, brain oxygen , m i-
458
crodialysis, etc.). It is th e auth ors pract ice to place (at m in im u m ) an ICP m on itor for all p at ien t s w h o requ ire ven t ilat ion
after TBI an d w h o h ave an abn orm al h ead com pu ted tom ograp hy (CT) scan . Invasive m on itoring m ay also be con sidered
for pat ien t s w ith di u se inju ries, as a n orm al CT does n ot preclude a pat ien t from poten t ially h aving in t racran ial hyperten sion . In t racran ial m on itoring also m ay be con sidered for
p at ien t s w ith oth er acute n eurologic path ologies th at result
in com a an d th at m ay be associated w ith brain sw elling an d
brain isch em ia. Open sut ures an d fon tan els in young ch ildren
sh ou ld n ot discou rage m on itoring, as th ese pat ien t s rem ain
at risk for in creased ICP.
Insertio n o f ventricular drainage cathete rs. Extern al ven t ricular drain (EVD) placem en t en ables accurate m onitoring
of ICP an d allow s for th erapeut ic drain age of cerebrospin al
u id (CSF) in th e set t ing of in creased ICP. Ap prop riate in dicat ion s for EVD placem en t in clude a n eed for ICP m on itoring
in pat ien t s w ith severe TBI (Glasgow Com a Scale [GCS] 8)
28
Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury
Preprocedure Considerations
X-ray
Plain sku ll radiograph s are obt ain ed on ly on rare occasion .
Radiographic Imaging
CT
CT scan s of th e h ead (6 cer vical spin e) sh ou ld be acquired
Anesthetic Considerations in
Children
It is essen t ial th at th e an esth esiology team h ave both p ediat-
MRI
Magn et ic reson an ce im aging (MRI) of th e brain is rarely in -
ric an d p olyt rau m a exp erien ce. Secon dar y in su lt s con t ribu te
su bstan t ially to w orse ou tcom e an d so sh ou ld be aggressively
avoided.
In adequ ate m an agem en t of th e resp irator y an d circu lator y
system s m ay lead to secon dar y in su lt s su ch as hyp oxia an d
hypoten sion . Brain sw elling m ay be exacerbated by hypo- or
hyperten sion , hypercarbia, an d in adequate pain con t rol.
Th e en dot rach eal t u be m ust be fasten ed securely, part icu larly if th e ch ilds h ead is to be t urn ed. Loss of th e air w ay is
of greater con sequen ce in ch ildren because th ey deteriorate
rap idly. Th e TBI pat ien t , in p art icu lar, h as a redu ced capacit y
to tolerate hypoxic in sults. Hypocarbia m ay exacerbate th e
Fig. 28.1a, b Axial CT (a) bone and (b) soft tissue windows demonstrating a bony defect with protrusion of meninges. This patient fell from a bed,
striking his head on the concrete oor, and presented approximately 8 months later with a tender, pulsatile postauricular mass.
459
Operative Management
An exh aust ive descript ion of th e full range of em ergen cy procedures perform ed in pediat ric pat ien t s presen t ing w ith TBI
w ou ld exceed th e scop e of th is p u blicat ion . Th erefore, w e review som e basic prin ciples th at d ist ingu ish th e su rgical ap proach to pediat ric pat ien t s an d o er operat ive pearls relevan t
to speci c procedures. Fin ally, w e provide m ore detailed guid an ce regarding th e rep air of grow ing sku ll fract u resan en t it y
th at is un ique to th e pediat ric populat ion .
su t u res.
Con t rol bleeding from th e scalp ap early w ith th e applicat ion of scalp clips. Con t in ued ooze during th e operat ion can
lead to sign i can t blood loss in young ch ildren . On ce th e
scalp ap h as been t u rn ed, rem em ber to ch eck in term it ten tly
th at th e ap rem ain s dr y th rough ou t th e operat ion .
Th e skin an d scalp of young ch ildren is th in n er th an in adult s.
Treat th e t issues gen tly an d do n ot cru sh th em bet w een
pick-ups. Avoid acute ben ds in th e re ected scalp ap as th is
m ay cu t o its blood su p p ly. Th is p oses a greater risk th an in
adu lt s becau se th e scalp ap is th in n er an d th e blood p ressu re is low er.
Th e du ra is often adh eren t w h ere cran ial su t ures are st ill
open . Use a dissector to separate th e dura from th e bon e carefu lly an d th orough ly ben eath su t u re lin es.
460
planned. If the spine has not been cleared, pay careful attention
to protecting the cervical spin e w hile positioning for surgery.
An t ist aphylococcal an t ibiot ics are given rou t in ely at th e t im e
of skin in cision .
Th e h ead of th e operat ive t able is sligh tly elevated to prom ote
ven ou s ret u rn .
Blood pressure sh ould be w ell m ain tain ed th rough out surger y. At n o t im e sh ou ld th e blood p ressu re be allow ed to d rop .
If brain sw elling an d in creased ICP are su sp ected, a dose of
m an n itol can be given ju st after in du ct ion .
En sure th at th e plan n ed skin ap allow s adequate access for
th e path ology con cern ed. As a gen eral prin ciple of t raum a
su rger y, a w ider exp osu re is preferred .
Prepare th e skin w idely to allow for an in crease in th e exposu re sh ou ld th is becom e n ecessar y du ring th e operat ion .
Th e plan n ed skin in cision is in lt rated w ith 0.25%local an esth et ic an d epin eph rin e 1:400,000.
Drap e an d p osit ion th e pat ien t so th at th e an esth esiologist
h as adequ ate access to th e air w ay.
Th e surgeon sh ould h ave a clear view of th e an esth esiology
m on itors d u ring th e operat ion .
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
Craniotomy
Th e skin in cision sh ould be plan n ed based on th e locat ion of
th e lesion .
Typically, for a un ilateral lesion , an ipsilateral quest ion m ark
or T-sh aped in cision is perform ed to en able w ide access to
th e h em isph ere.
In gen eral, aim for as large a ap as p ossible. Th e base of th e
skin ap sh ou ld be broad en ough to en su re adequ ate perfusion to th e skin .
W h en th e ap is t urn ed, w rap an d t u ck an an t ibiot ic-soaked
sw ab or cot ton sp onge ben eath th e ap to preven t th e creat ion of an acu te angle th at m igh t com p rom ise perfu sion
to th e ap. Th is m ay be a par t icular problem in ver y you ng
ch ildren . In term it ten tly m oisten th e sponge during th e
p roced ure.
Dissect th e ap in a su bgaleal p lan e to p rep are a free bon e
ap. Preser ve th e p ericran iu m as th is can be u sed later for a
dural graft if n eeded.
Th e exten t of th e bony open ing is plan n ed according to th e
u n derlying lesion . If th ere is gen eralized sw elling, th e bon e
sh ou ld be rem oved dow n to th e tem p oral base to m axim ize
th e space ach ieved at th e level of th e ten torial hiat us.
If du ral op en ing is n ecessar y to evacu ate a h em atom a, a cru ciate in cision is perform ed over th e h em isph ere. Any su bdural h em atom a th en m ay be evacu ated.
If evacu at ion of a con t u sion is p lan n ed, carefu l preoperat ive plan n ing or n euron avigat ion is required to opt im ize th e
locat ion of th e cort icectom y. Often a subdu ral h em atom a is
associated w ith a bu rst lobe in w h ich th e con t u sion can
be iden t i ed at th e surface. A discrete h em atom a can be
evacu ated aggressively. A con t u sion m ixed w ith brain t issu e
sh ou ld be h an dled w ith greater cau t ion , d ep en ding on several factors, in clu ding th e eloqu en ce of th e involved brain an d
th e degree of brain sw elling. Th e con ser vat ive approach of
allow ing th e con t u sion /h em atom a to decom p ress it self m ay
be all th at is required.
If th e brain is sw ollen , th e du ra sh ou ld be exp an ded w ith a
dural graft h ar vested from local pericran ium . Use n on absorb able su t u res an d close th e du ra in a w atert igh t fash ion .
Th e decision of w h eth er to replace th e bon e ap depen ds on
th e preoperat ive im aging, in t raoperat ive n dings, an d an t icip ated postop erat ive risk for ongoing in creased ICP. If th e bon e
ap is left ou t , it sh ou ld be m an aged as below for decom pressive cran iectom y.
Decompressive Craniectomy
Several di eren t ap p roach es h ave been d escribed for decom p ressive cran iectom y (DC). Th e follow ing re ects a com bin at ion of gen eral prin ciples an d person al pract ice.
461
462
u n ilateral or bilateral app roach as approp riate, m ake th e cran iectom y as large as possible, an d con t rol th e brain sw elling
before open ing th e dura.
Th e ch oice of a bifron t al or h em icran iectom y depen ds both
on person al preferen ce an d th e n at ure of th e injur y. Predom in an tly un ilateral h em isph eric injur y m ay be bet ter
su ited to h em icran iectom y, w h ereas di u se inju r y or fron tal con t usion s m ay be bet ter suited to bifron t al cran iectom y.
Th ough th e speci cs of each tech n ique di er, th e prin ciples
of decom pression are th e sam e.
Du rap last y in creases th e com p licat ion s associated w ith cran iectom y; h ow ever, open ing an d expan ding th e dura leads
to su bst an t ially low er ICP, an d com p licat ion s are gen erally
avoidable if don e correctly.
Th e h em icran iectom y is perform ed sim ilar to th e h em isph eric
cran iotom y. Maxim izing th e bony open ing h elps m in im ize
th e degree to w h ich th e sw ollen brain push es again st th e
bony lim it s. Pressure at th e bony edges m ay fu rther injure
th e sw ollen brain an d con st rict ven ou s out ow of th at segm en t . Th e tem poral bon e is rem oved as low as possible d ow n
to th e base to m axim ize th e decom pression at th e level of th e
ten torial in cisura. Th e du ra is open ed an d expan ded w ith a
large pericran ial graft , th e edges of w h ich can be sut ured so
th at th ey lie w ith in th e dural edge, to m in im ize th e risk of th e
sh arp du ral edge cu t t ing in to th e sw ollen brain .
Th e bifron tal cran iectom y is perform ed th rough a bicoron al
skin in cision , posit ion ed beh in d th e h airlin e. Th e scalp is
re ected an teriorly, preser ving th e pericran ium for a dural
graft . Keyh ole an d p aram edian bu r h oles lateral to th e sagittal sin us are used to create a large bifron tal, single-piece bon e
ap exten ding posteriorly to th e coron al su t u re. Pay part icu lar at ten t ion w h en separat ing th e dura from th e bon e, esp ecially over th e m idlin e, to avoid injur y to th e sagit t al sinu s
an d it s bridging vein s. Th e du ra is in cised in a U-sh ap e from
lateral to m edial. Th e m idlin e sagit tal sin us is t ied o at th e
fron t al base an d th e falx is sect ion ed from an terior to p osterior along th e skull base to allow for m a xim al expan sion
28
Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury
Operative Procedure
Repair of Grow ing Skull Fractures
Positioning (Fig. 28.2)
Figure
Procedural Steps
Fig. 28.2
463
464
Figure
Procedural Steps
Pearls
Fig. 28.3
28
Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury
Figure
Procedural Steps
Fig. 28.4
(a) Subgaleal dissection of the scalp ap is used to expose the full extent
of the defect. (b) The periosteum is incised, follow ing the edges of the
cranial defect. The periosteum is re ected inw ard, tow ard the defect.
Using a sharp periosteal dissector, the periosteumdura junction is freed
circumferentially from the edges of the bone margin.
465
Figure
Procedural Steps
Pearls
Fig. 28.5
(a) Several bur holes are placed at the periphery of the bony
defect, overlying normal dura. The exact position of the bur
holes in relation to the defect depends on the anticipated dural
retraction beneath the bone edges. Typically, larger lesions
are associated w ith greater retraction of the dura beneath the
bone edges. Preserve the periosteum overlying the bone to use
as a dural graft.
466
28
Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury
Figure
Procedural Steps
Fig. 28.6
Pearls
467
468
Figure
Procedural Steps
Pearls
Fig. 28.7
(a) The harvested bone ap can be divided into tw o halves. If possible, each
half then can be split w ith an osteotome (though the diploic space) into
inner and outer tables, yielding a total of four pieces that may be used to
cover the defect. (b) The bone graft is secured to the surrounding bone
using resorbable or permanent mini plates. If the bone can be secured w ith
sutures, this is preferable. Alternatively, mini plates are used.
28
Special Considerations in the Surgical Managem ent of Pediatric Traum atic Brain Injury
Closing
If th e bon e is replaced, it is secu red w ith absorbable or n on -
Postoperative Management
Monitoring
Further Management
Con cern s about ongoing injur y to th e unprotected brain h ave
driven th e t ren d tow ard early replacem en t of bon e aps after cran iectom y. Reim plan t at ion m ay be appropriate w ith in
4 w eeks of th e in it ial surger y, provided th e brain sw elling h as
su bsided, th e w ou n d is h ealed, an d th e p at ien t is free of in fect ion . How ever, th e t im ing of reim p lan t at ion sh ou ld n ot be
accelerated if con dit ion s are su bopt im al, as bon e ap sep sis
can create subst an t ial problem s.
Th e bon e m ust n ot be au toclaved. It is rem oved from sealed
bags an d allow ed to soak in a diluted solut ion of betadin e at
th e st ar t of surger y.
Th e pat ien ts bon e is alw ays preferred to ar t i cial subst it utes,
n ot on ly becau se of th e bet ter t bu t also becau se ad dit ion al
grow th of th e sku ll is exp ected in you nger ch ildren .
Ver y you ng ch ildren m ay be at in creased risk for bon e ap
resorpt ion problem s.
Wound Management
Su bgaleal drain s m ay be u sed in th e im m ediate postoperat ive
Radiographic Imaging
As a gen eral prin ciple, th e frequen cy of CT im aging of ch il-
dren sh ould be lim ited because of th e long-term risk of radiat ion . Un n ecessar y follow -up im aging also exposes th e ch ild
w ith severe injur y to poten t ial secon dar y in sult s associated
w ith t ran spor t out of th e in ten sive care un it environ m en t .
How ever, if in dicated, ap p rop riate im aging m ay be lifesaving. Th ere sh ou ld alw ays be a clear in dicat ion for rep eat
im aging, su ch as clin ical deteriorat ion . W h en th e in it ial scan
Fig. 28.8 Axial CT im age demonstrating repair of the dural tear and
bony defect.
469
29
Introduction
Sp in e t rau m a in th e p ediat ric pop u lat ion is a relat ively u n com m on occu rren ce (12% of all p ediat ric fract u res 1 ), but h as been
obser ved m ore frequen tly w ith im provem en t s in em ergen cy
care, t ran spor t ser vices, an d t raum a life support .2 Ch ildren differ from th eir adu lt cou n terp ar t s w ith regard to spin e an atom y,
p hysiology, an d body propor t ion s:
Ligam en ts an d join ts can st retch an d expan d con siderably
w ith out tearing
Facet join t s are sh allow an d h orizon t ally orien ted
Vertebral bodies are w edged an teriorly
Un cin ate processes, w h ich lim it rotat ion , do n ot form u nt il
age 10
Disp rop or t ion ately larger h ead in conju n ct ion w ith w eaker
an d in com p letely d evelop ed m u scu lar an d ligam en tou s su p p or t ing st ru ct ures
Th ese u n ique di eren ces resu lt in a spin e th at is m ore m alleable th an th at of an adult . Pediat ric cer vical spin al injuries
follow a p redict able pat tern related to th e ch ilds age. Sp in al in ju ries in ch ildren younger th an 810 years of age are m ore likely
to involve th e upper cer vical spin e, from th e occiput to th e th ird
cer vical ver tebra. Most injuries in th is age group are ligam en tous axis-atlan to-occipit al dislocat ion s or spin al cord injuries
w ith ou t radiograph ic abn orm alit y (SCIWORA). Ch ildren older
th an 810 years of age are m ore vuln erable to cer vical spin e
inju ries involving th e low er segm en t s (C3C7); th e pat tern of
inju r y in th is group is sim ilar to th e adu lt popu lat ion .3,4
Sp in al cord inju r y (SCI) is a rare occu rren ce in th e pediat ric
p op u lat ion an d accou n t s for less th an 4% of th e tot al an n u al
in ciden ce of SCI (Nat ion al Spin al Cord Inju r y St at ist ical Cen ter,
2004). Neurologic recover y in ch ildren w ith SCI ten ds to be bet ter th an in adult s.5 SCI occurring before th e adolescen t grow th
sp u rt is a great risk factor for th e developm en t of p ost t rau m at ic
scoliosis.5
Indications
Pediat ric cer vical spin e inju ries can be divided in to inju ries th at
a ect th e u p p er cer vical sp in e (occip u tC2) an d th ose th at affect th e su baxial sp in e (C3C7). Below is a list of th e inju ries
th at are m ore com m on ly en coun tered in children . As st ated
p reviou sly, older ch ildren w ill h ave a physiologically developed
adu lt spin e, an d th u s, th e sp in e inju ries are sim ilar to th ose
seen in adu lt s. Th ere is a m yriad of congen it al cer vical an om alies th at m ay cause or place a ch ild at risk for spin al cord inju r y.
470
Preoperative Considerations
Field and Emergency Room
Management
Field m an agem en t follow s th e basic prin ciples of th e Advan ced
Trau m a Life Suppor t (ATLS). Air w ay, breath ing, an d circu lat ion (ABCs) m ust be addressed. Because of a relat ively larger
29
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.
Radiographic Imaging
After a careful n eurologic evaluat ion , cer vical spin al im aging
sh ou ld be obt ain ed . Plain radiograph s, com p u ted tom ograp hy
(CT), an d m agn et ic reson an ce im aging (MRI) m ay be con sidered. On ce a sp in e inju r y is detected, clearan ce an d im aging of
all sp in e segm en ts sh ou ld be u n dert aken , con sidering a sign i can t prevalen ce of n on con t igu ous fract u res.4,8
Som e varian t s of th e n orm al an atom y or congen ital an om alies
m ay be m isin terp reted as t rau m at ic inju r y.9,10 An an terolisth esis of C2C3 is a ver y com m on n ding an d cou ld be m isdiagn osed as a ligam en tou s inju r y w h en , m ost of th e t im e, it is a
p hysiologic pseu dosublu xat ion cau sed by th e hyper exibilit y of th e im m at ure cer vical spin e. A syn ch on drosis bet w een
th e odon toid an d th e body of C2w h ich m ay persist un t il a
ch ild is 12 years of agem ay be m isin terpreted as an odon toid
fract u re. Fu rth erm ore, a persisten t n eu rocen t ral syn ch on drosis
of C2 can be m isdiagn osed as a h angm ans fract ure. Th e atlan toden tal in ter val (ADI) in th e ch ild spin e is greater th an in th e
adu lt , bu t sh ou ld n ot exceed 5 m m ; th is lim it is becau se of th e
th icker ch ild cart ilage th at does n ot appear in radiograph s. Any
p ersist ing doubt w ith st an dard radiograph s sh ould be furth er
evalu ated w ith CT an d MR.
Preoperat ive im aging (Fig. 29.2a c).
Medication
Steroid adm inistration in the set ting of a spinal cord injury is still
controversial and should be based on the institutional protocol.
A recent system atic review of the literature found no evidence
supporting the use of neuroprotective interventions for the treatm ent of spinal cord injury in children, including hypotherm ia and
steroids.7 Furtherm ore, all studies that have evaluated steroids in
spinal cord injury have speci cally targeted the adult population.
Surgical Timing
Th e opt im al t im ing for surgical decom pression an d xat ion is
also con t roversial. A recen t system at ic review st ates th at early
su rgical d ecom p ression (i.e., in less th an 72 h ou rs) m ay im p rove
n eu rologic ou tcom esespecially in th e set t ing of in com plete
SCI an d w h en p erform ed in less th an 24 h ou rs.11 W h ile th is
review suggest s early decom pression m ay ben e t th e gen eral
SCI p opu lat ion , n eu rologic recover y seem s to be bet ter in th e
pediat ric popu lat ion th an in adults.
471
Fig. 29.2ac (a) Lateral radiograph and (b) sagit tal and (c) coronal CT
reconstructions demonstrating an atlanto-occipital dislocation. Note
the widened intervals bet ween C0C1 and C1C2.
Operative Management
Su ccessfu l in t raop erat ive m an agem en t of th e ch ild w ith a cervical spin e inju r y dep en d s on a team ap p roach w ith th e sp in al
su rgeon , pediat ric t rau m a su rgeon , an esth esiologist , an d su rgical an d radiology tech n ician s.
Anesthesia
In cervical spin e injuries w ith gross in stabilit y, the neck m ust be
m ain tained in a n eutral position throughout the procedure; in tubation m ay be challenging. In-line beroptic intubation should
be considered, followed by induction of general anesthesia. Care
to prevent both sublu xation an d distraction is im perative w h en
intubating, turning, or transferring. Preoperatively, antibiotics
are adm in istered at least 30 m inutes before the procedure; the
authors prefer van com ycin an d cefazolin. If neurom onitoring
(e.g., m otor-evoked potentials [MEPs] and som atosensory-evoked
potentials [SSEPs]) is used, the anesthesia team should be alert
472
that alterations in anesthetic depth can a ect the abilit y to ob tain useful signals; the use of bispectral index (BIS) m onitoring
can m inim ize this e ect. It is im perative that the anesthesiologist
avoid hypotension and hypovolem ia during surgery.
Positioning
Anterior Cervical Approach
29
Longit u din al in cision p rovides a greater exp osu re (u su ally
w h en th ree or m ore levels are exposed) w h ereas a t ran sverse in cision h eals w ith bet ter cosm esis
Care m ust be taken not to dist ract the injured spine w ith either
m anipulat ion or inadvertent elevat ion of the head of bed w hen
the pat ient is in Mayf eld f xat ion.
Occipitocervical Arthrodesis
Indications
Atlan to-occipit al dislocat ion s, atlas fract u res, congen it al occip itocer vical an om alies.
Atlantoaxial Arthrodesis
Indications
Atlas fract u res, odon toid fract u re, t rau m at ic C1- C2 ligam en tou s
disru pt ion s, an d congen it al atlan toaxial in st abilit y.
473
Operative Procedure
Occipitocervical Arthrodesis w ith Contoured Rod and Segmental Wire
Positioning and Preparation (Fig. 29.3)
Figure
Procedural Steps
Pearls
Fig. 29.3
474
29
Figure
Procedural Steps
Pearls
Fig. 29.4
incision at C3 level.
Do not expose m ore than needed because there is a high rate of
fusion in the child spine just by exposing the posterior elements.
475
Figure
Procedural Steps
Pearls
Fig. 29.5
476
very di cult to repair the dural tear prim arily. Use gelatin sponge or
onlay dural graft substitutes. Lam inectomy is not recomm ended for
repair.
While dissecting bet ween C1 and C2 laterally, there is often a robust
perivertebral artery venous plexus. Bleeding from this plexus may be
brisk but easily controlled with gelatin sponge.
Exercise caution while exposing the C1 posterior arch: do not to expose
m ore than 12 m m to 20 mm laterally, depending on age and anatomy,
to reduce the risk of vertebral artery injury. (Always stay on bone!) In
young children, there m ay be a brous union in the m idline of the arch,
which can be easily breached with monopolar electrocautery.
29
Figure
Procedural Steps
Pearls
Fig. 29.6
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
Figure
Procedural Steps
Pearls
Fig. 29.7
478
29
Figure
Procedural Steps
Fig. 29.8
After posterior approach to the arch of C1, use blunt dissection to expose the posterior arch of C1 and C2. Use
the bipolar and hemostatic agents to control bleeding from the atlantoaxial perivertebral venous plexus. Using a
Pen eld no. 4, retract the C2 nerve root caudally in order to expose the C1 lateral mass and the C1C2 joint space
just inferior to its arch. Find the medial and lateral borders of the C1 lateral mass by palpation. The inferior aspect
of the posterior arch of C1 often needs to be drilled dow n to gain further access to this region and to allow the
screw to sit ush w ith the proper angulation. (a) For the screw entry point, make a small hole w ith a drill at the
center of C1 lateral mass. (b) With the aid of a uoroscopic lateral view of the high cervical spine, aim the drill
tow ard the anterior tubercle of C1 and medialize the trajectory by 5 to 10 degrees, depending on the anatomy of
the lateral mass of C1. Stop drilling w hen the drill tip is just short of posterior margin of the anterior tubercle or
you feel that you have gone through the anterior cortical margin of the lateral mass of C1. Tap the hole and insert
a partially threaded screw so that the shaft of the screw in contact w ith the C2 nerve root does not have any
threads. The screw length is typically 34 to 36 mm. For particularly unstable or immature spines, bicortical screw
xation is paramount and requires controlled tapping to penetrate the anterior cortical surface w ithout risking
vascular injury. A probe is helpful in determining depth and length of screw.
479
Figure
Procedural Steps
Fig. 29.9
After exposure of the posterior arch of C2, palpate the medial portion of the C2 pedicle w ith a nerve hook or
a small Pen eld and make reference of its trajectory. The entry point w ill be in the pars interarticularis of C2,
lateral to the superior margin of the C2 lamina. (a) Medial and (b) cranial angulation of the screw trajectory
is dependent on careful evaluation of the preoperative imagingusually 15 to 20 degrees and 20 degrees,
respectively. Again, the course of the vertebral artery on the preoperative CT w ill dictate w hether placement
is advisable ; the risks of vascular injury are low.
480
29
Figure
Procedural Steps
Fig. 29.10
After subperiosteal dissection of the C2 posterior arch, the entry point w ill be identi ed at the base of the
spinous process (i.e., the spinolaminar line), contralateral to the lamina intended for xation. The lamina itself
w ill de ne the screw trajectory; make a slight dorsal angulation to avoid vertebral canal breach. When using
this technique bilaterally, one entry point must be higher than the other so that one screw w ill not intersect
w ith the other. The lamina must be thick enough to allow the placement of 3.5 mm screw s. Frequently, the
anatomy requires a hybrid construct w ith di erent instrumentation on left and right. The C2 translaminar
screw head location in longer constructs may require o set xation and may pose occasional rod bending
challenges.
481
Atlantoaxial Arthrodesis
Technique : Brooks and Jenkins 15 (Fig. 29.11)
482
Figure
Procedural Steps
Pearls
Fig. 29.11
29
Figure
Procedural Steps
Pearls
Fig. 29.12
483
484
29
Figure
Procedural Steps
Pearls
Fig. 29.13
485
Technique : Harms Posterior C1-C2 Fusion w ith Polyaxial Screw and Rod Fixation 14
(Fig. 29.14a, b)
Figure
Procedural Steps
Fig. 29.14
Harms posterior C1C2 fusion w ith polyaxial screw and rod xation. C1 lateral mass xation is coupled w ith C2
pars or pedicle screw s. The construct is held together w ith a rod, providing rigid xation bilaterally.
A standard midline longitudinal posterior approach is used to expose the C1C2 complex. First, 3.5-mm polyaxial
screw s are inserted in the lateral masses of C1. Next, polyaxial screw s are placed bilaterally into the C2 pars
interarticularis or pedicle (as described above). Manipulation of the implants allow s reduction of C1 onto C2 w hen
necessary. A 3.2- to 3.5-mm rod is placed to connect the screw s and provide rigid xation. Bone graft is then
placed over the decorticated posterior elements for de nitive fusion. Intraoperative reduction of subluxation can
be achieved w ith placement of the screw s either recessed or proud in spite of their polyaxial nature.
(a) Figure demonstrates the desired entry point and (b) the optimal screw trajectory.
486
29
Figure
Procedural Steps
Pearls
Fig. 29.15
487
Technique : Posterior Arthrodesis w ith Lateral Mass Screw Fixation (Fig. 29.16ac)
488
Figure
Procedural Steps
Fig. 29.16
Several techniques to achieve lateral mass xation have been described. Most di er w ith respect to the entry
point and angulation of trajectory. The most popular are the Roy-Camille and the Magerl techniques. 1921 . (a)
The entry point for the Roy-Camille technique is at the intersection of tw o perpendicular lines that equally
divide the lateral mass into four quadrants. The drill is directed perpendicular to the posterior w all of the
vertebral body on sagittal view and 10 degrees lateral on coronal view. Magerls entry point is 1 mm medial
and rostral to the same center point of the posterior surface of the lateral mass. (b, c) The trajectory is
oriented parallel to the adjacent facet joint (about 45 to 60 degrees rostral) and 25 degrees lateral. Placing the
monopolar blade into the joint space may assist the operator w ith the proper orientation in the sagittal plane.
Careful use of variable drill bits allow s for the placement of bicortical screw s w hen extra xation is desired.
Screw heads are then connected w ith longitudinal rods. A rigid cervical collar is used postoperatively.
29
Closing
Th e m usculat ure an d fascia are reapproxim ated w ith 2-0
absorbable su t u res.
Su bcu t an eou s t issu e is closed w ith 3-0 absorbable su t u re in
an inver ted, in terru pted fash ion .
Th e skin is closed w ith a subcut icular, run n ing m on o lam en t
absorbable su t u re.
Postoperative Management
All th ese in st rum en tat ion tech n iques in ch ildren require a
p rotect ive extern al orth osis (collar). Th e collar is used n ot
on ly to lim it m ot ion but also to lim it th e act ivit y of en erget ic ch ild ren . W h ile p at ien t s t reated w ith w iring tech n iqu es
t ypically require a rigid extern al orth osis, pat ien t s w ith con st ru ct s th at u se screw s at each of th e levels m ay n ot requ ire
a rigid collar. Sp eci c recom m en dat ion s are n oted in th e text
accom p anying th e descript ion of each arth rodesis procedu re.
b
Fig. 29.17a, b (a) AP and (b) lateral radiographs showing the nal occipitocervical construct.
489
Special Considerations
SCIWORA
SCIWORA is a term u sed alm ost exclu sively in ch ildren . It is an
outdated term th at w as u sed previou sly to describe a ch ild presen t ing w ith a clin ical sp in al cord inju r yabsen t any obviou s
fract u re or su blu xat ion on p lain radiograp h s or CT im aging. In
you ng ch ildren , th e su pp ort ing m u scu loligam en tou s st ru ct u res
an d join ts can absorb forces by st retch ing an d m oving, resp ect ively. How ever, th is excess la xit y can place th e fragile an d in toleran t sp in al cord at risk for inju r y. High qu alit y MRI can alm ost alw ays iden t ify th e ligam en tou s an d sp in al cord inju r y in
ch ildren w h o w ere previously design ated as SCIWORA.
Halo Application
Th e applicat ion of h alos in th e pediat ric popu lat ion poses special ch allenges. Due to th e th in caliber of th e skull, pin s m ust be
placed un der less pressure; usu ally m ore th an four pin s are required for adequate xat ion . Pin s n eed to be m on itored closely
for in fect ion an d skull perforat ion (see Ch apter 11).
References
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an d associated inju ries. Inju r y 2007;38(2):188193
2. Herm an MJ, McCar thy J, Willis RB, Pizzu t illo PD. Top 10 p ediat ric
or th opaedic surgical em ergen cies: a case-based approach for the
su rgeon on -call. Inst r Course Lect 2011;60:373395
3. Klim o P Jr, Ware ML, Gupta N, Brockm eyer D. Cervical spine traum a
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6. Herzen berg JE, Hen singer RN, Dedrick DK, Ph illip s WA. Em ergen cy t ran spor t an d posit ion ing of young ch ildren w h o h ave an
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Acad Orth op Su rg 2011;19(6):319327
8. Mah an ST, Moon ey DP, Karlin LI, Hresko MT. Mu lt ip le level inju ries in pediat ric spin al t raum a. J Traum a 2009;67(3):537542
9. Lu st rin ES, Karakas SP, Or t iz AO, et al. Pediat ric cer vical spin e: n orm al an atom y, varian t s, an d t raum a. Radiograph ics 2003;23(3):
|539560
10. Kreykes NS, Let ton RW Jr. Current issues in the diagn osis of pediatric cer vical spin e injur y. Sem in Pediat r Surg 2010;19(4):257264
11. Feh lings MG, Perrin RG. Th e t im ing of su rgical in ter ven t ion in th e
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12. Bau er R, Kersch bau m er F, Poisel S, et al. An terior ap proach es. In :
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Index
A
abdom en , bon e ap storage in , 54, 63, 63f
ap ret rieval after, 418, 418f
abscess
epid u ral. See epidu ral abscess
in t racerebral. See in t racerebral abscess
sp in al. See abscess
ACA. See an terior com m u n icat ing arter y
air em bolism , ven ou s sin us inju ries w ith , 153
Allen classi cat ion , 197
alloplast ic cran ioplast y
bifron t al cran iectom y operat ive procedu re
cran iectom y site prep arat ion , 435, 435f
im plan t t ypes, 436f438f, 439
posit ion ing, 428, 428f
subcu t an eous dissect ion , 430432, 430f, 431f432f
tem poral defect repair, 440, 440f
tem poralis m u scle dissect ion , 433434, 433f434f
tem poralis t ran sp osit ion , 441, 441f
closing, 442
in d icat ion s for, 424, 424f, 425f
postoperat ive m an agem en t
m edicat ion , 442
m on itoring, 442
radiograph ic im aging, 442
preprocedu re con siderat ion s
m edicat ion , 425
operat ive site prep arat ion , 425
radiograph ic im aging, 424425
select ion algorith m for, 426f
special con siderat ion s, 442443, 442f
u n ilateral cran iectom y op erat ive p roced ure
cran iectom y site prep arat ion , 435, 435f
im plan t t ypes, 436f438f, 439
posit ion ing, 427, 427f
skin in cision , 429, 429f
subcu t an eous dissect ion , 430432, 430f, 431f432f
tem poral defect repair, 440, 440f
tem poralis m u scle dissect ion , 433434, 433f434f
tem poralis t ran sp osit ion , 441, 441f
Am erican Sp in al Injur y Associat ion (ASIA) classi cat ion
system , 200
an esth esia, pediat ric con siderat ion s for, 459460, 472
an eu r ysm , t raum at ic
in d icat ion s for surger y, 133, 134f, 135136, 135f
m an agem en t , 137, 139f, 142
preprocedu re con siderat ion s, 137
an eu r ysm al ICH, 328
angiography
t rau m at ic cerebrovascular injur y (TCVI), 137
ven ous sin us inju ries, 153
an terior com m un icat ing arter y (ACA), TCVI of, 135
491
492
Inde x
bicoron al surgical ap proach , for cerebral con t u sion s (cont inued)
closing, 51
cran iotom y, 39, 39f
dural open ing, 40, 40f
posit ion ing, 35, 35f
skin in cision , 36, 36f
subcut an eous dissect ion , 37, 37f
bifron t al cran iectom y
for alloplast ic cran ioplast y
cran iectom y site preparat ion , 435, 435f
im plan t t ypes, 436f438f, 439
posit ion ing, 428, 428f
subcut an eous dissect ion , 430432, 430f, 431f432f
tem poral defect repair, 440, 440f
tem poralis m u scle dissect ion , 433434, 433f434f
tem poralis t ran sp osit ion , 441, 441f
decom pressive, 53
closing, 70
cran iotom y, 67, 67f
dural open ing, 68, 68f
du rap last y, 69, 69f
in cision plan n ing, 65, 65f
pediat ric, 462
posit ion ing, 64, 64f
subcu t an eous dissect ion , 66, 66f
blu n t vascular injuries
h ead. See in t racran ial blu n t TCVI
n eck. See ext racran ial blu n t TCVI
bolt-t ype in t racran ial m on itors, placem en t of, 107, 107f
bon e ap replacem en t
closing
abdom in al in cision , 422
cran ial in cision , 422
in d icat ion s for, 412
operat ive p rocedure
com pleted con st ruct , 421, 421f
ap replacem en t , 419, 419f
iden t i cat ion an d separat ion of tem poralis m u scle,
416417, 416f417f
posit ion ing an d prep arat ion , 413, 413f
skin in cision , 414, 414f
subcu t an eous abdom in al bon e ap ret rieval, 418, 418f
subcu t an eous dissect ion , 415, 415f
tem poralis t ran sp osit ion , 420, 420f
postoperat ive m an agem en t
m edicat ion , 422
m on itoring, 422
radiograph ic im aging, 422, 422f
preprocedu re con siderat ion s
m edicat ion , 412
operat ive eld preparat ion , 412
radiograph ic im aging, 412, 412f
special con siderat ion s, 422
bon e ap storage, in abdom in al fat layer, 54, 63, 63f
ap ret rieval after, 418, 418f
bony debridem en t , for com bat inju ries, 391, 391f
brain debridem en t , for com bat inju ries, 394, 394f
brain decom p ression , for cerebellar in farct ion , 85, 85f
brain t issue oxygen ten sion m on itoring
closu re, 116
in d icat ion s for, 101, 458
Inde x
postop erat ive m an agem en t
m edicat ion , 190
m on itoring, 190
preprocedure con siderat ion s
m edicat ion , 179
radiograph ic im aging, 179, 180f
special con siderat ion s, 195196
C1 lateral m ass screw s, for p ediat ric cer vical spin e inju r y, 479,
479f
C2 pars screw, for pediat ric cer vical spin e inju r y, 480
C2 pedicle screw, for pediat ric cer vical spin e injur y, 480, 480f
C2 translam inar screw, for pediatric cervical spine injury, 481, 481f
calvarial recon st ruct ion , after depressed sku ll fract u re elevat ion ,
98, 98f
carot id arter y, TCVI of
en dovascu lar m an agem en t , 138, 141f
in dicat ion s for su rger y, 133134, 134f
proxim al an d dist al con t rol, 149, 149f
repair of ar terial inju r y, 150, 150f
su rgical dissect ion , 148, 148f
carot id-cavern ou s st u la (CCF), t raum at ic, 135136
cau da equin a syn drom e
closu re, 309
in dicat ion s for su rger y, 302
operat ive proced ure
lum bar diskectom y, 308, 308f
lum bar lam in ectom y, 307, 307f
posit ion ing, 304, 304f
skin in cision , 305, 305f
su bperiosteal dissect ion , 306, 306f
postoperat ive m an agem en t , 309
preprocedu re con siderat ion s
Foley cath eter placem en t , 303
m edicat ion , 302
operat ive eld p reparat ion , 303
radiograph ic im aging, 302, 303f
special con siderat ion s, t im ing of su rger y, 309
cavern ous sin us syn drom e, t rau m at ic st u la cau sing, 135136
CCF. See carot id-cavern ou s st ula
cerebellar st roke or h em orrh age
closing, 88
in dicat ion s for su rger y, 73
in t racerebral, 312328
operat ive proced ure
bony exposu re, 79, 79f
bur h ole placem en t , 80, 80f
cran iectom y, 81, 81f
decom pression of in farcted brain , 85, 85f
du ral closure, 87, 87f
du ral opening, 83, 83f
epidural h em atom a evacu at ion , 82, 82f
h em ost asis, 86, 86f
in t racerebellar h em atom a evacuat ion , 84, 84f
posit ion ing, 76, 76f
skin in cision , 77, 77f
su bcu tan eou s dissect ion , 78, 78f
postoperat ive m an agem en t
m edicat ion , 89
m on itoring, 89
radiograph ic im aging, 88f, 89
ven t ricu lostom y, 88
493
494
Inde x
cerebral edem a, during decom pressive cran iectom y, 71
cerebrospin al uid (CSF)
com bat-associated leak of, 398, 400f
pen et rat ing h ead inju ries w ith leak of, 119120, 132
t rau m at ic rhin orrh ea of. See t rau m at ic CSF rh in orrh ea rep air
cerebrovascular injur y, t rau m at ic. See t raum at ic cerebrovascular
inju r y
cer vical bu rst fract ures
closing, 212
in d icat ion s for su rger y, 197, 197t, 198f199f, 200
in it ial evaluat ion of, 200
m ech an ism s of inju r y, 197, 198f199f
m edical m an agem en t of, 200
operat ive p rocedure, 197t, 200201
allograft placem en t , 210, 210f
an terior locking p late placem en t , 211, 211f
corp ectom y, 209, 209f
deep cer vical invest ing fascia iden t i cat ion , 205, 205f
diskectom y, 208, 208f
incision an d subp lat ysm al dissect ion , 204, 204f
om ohyoid iden t i cat ion , 204, 204f
posit ion ing, 203, 203f
prevertebral fascia iden t i cat ion , 206, 206f
self-ret ain ing ret ractor p lacem en t , 207, 207f
postoperat ive m an agem en t
m edicat ion , 212
m on itoring, 212
radiograph ic im aging, 212, 212f
prep rocedure con siderat ion s
op erat ive eld preparat ion , 201
radiograph ic im aging, 201, 202f
special con siderat ion s, 212
cer vical collar, for pediat ric cer vical sp in e injur y, 490
cer vical epidu ral spin al cord com p ression , su rgical app roach es
to, 291
cer vical facet d islocat ion
an terior approach op erat ive p rocedure, 225f
closing, 234
diskectom y, 230, 230f
graft placem en t an d fu sion , 232, 232f
op en ing, 227, 227f
plat ing, 233, 233f
posit ion ing, 226, 226f
redu ct ion , 231, 231f
spin al colum n exposure, 228, 228f
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 ,
229f
closed reduct ion , 215
exam in at ion , 214
indicat ion s for su rger y, 214
op erat ive m anagem en t
approach , 215
tech n iqu es, 215
posterior approach operat ive p rocedu re, 216f
closing, 225
decom pression an d redu ct ion , 220, 220f
fusion preparat ion , 221, 221f
posit ion ing, 217, 217f
posterolateral fusion , 224, 224f
rod placem en t , 223, 223f
screw placem en t , 222, 222f
subcut an eous dissect ion , 218219, 218f, 219f
Inde x
pin site m an agem en t , 177
radiograph ic im aging, 176f, 177
preprocedu re con siderat ion s
m edicat ion , 170
operat ive eld p reparat ion , 170
radiograph ic im aging, 170, 171f
special con siderat ion s, 177
com bat-associated pen et rat ing sp in e inju r y (PSI)
closu re, 410
in dicat ion s for su rger y, 398, 399f, 400f, 401f
operat ive tech n iqu e
decom pression , 408, 408f
dissect ion , 406, 406f
du ral explorat ion /repair, 409, 409f
in st ru m en t at ion /fu sion, 410
lam in ectom y, 407, 407f
posit ion ing, 404405, 404f405f
postoperat ive m an agem en t , 410
preprocedu re con siderat ion s
an esth esia issu es, 403
associated inju ries, 402
equ ipm en t/set-u p, 402403
in it ial evaluat ion , 402
in it ial m edical m an agem en t , 402
n eurom on itoring, 403
prepping/in cision , 403
radiograph ic im aging, 402
t act ical scen ario, 402
com bat cran ial operat ion s
closing, 396
in dicat ion s for, 386
operat ive proced ure
bony debridem en t , 391, 391f
brain debridem en t , 394, 394f
h em icran iectom y, 393, 393f
pericran ial graft , 395, 395f
posit ion ing an d p reparat ion , 388, 388f
scalp in cision , 392, 392f
skull base recon st ru ct ion , 395, 395f
soft t issue debridem en t , 390, 390f
urgen t h em ost asis, 389, 389f
postoperat ive m an agem en t
m edicat ion , 396
m on itoring, 396
radiograph ic im aging, 396, 396f
preprocedu re con siderat ion s
con su ltat ion /team w ork, 386
m edicat ion s, 387
operat ive eld p reparat ion , 387
radiograph ic im aging, 386, 387f
special con siderat ion s, 397
com pression fract u res
th oracic, 239
th oracolum bar, 266
com puted tom ograp hy (CT)
bon e ap replacem en t , 412, 412f, 422, 422f
cerebellar st roke or h em orrh age, 7374, 75f, 88f, 89
cerebral con t u sion s, 33, 33f, 51, 51f
cer vical bu rst fract ures, 201
cer vical facet dislocat ion , 215, 234
closed sp in al t ract ion , 170, 171f
com bat-associated pen et rat ing sp in e inju r y, 402
com bat cran ial op erat ion s, 386, 387f, 396, 396f
CSDH, 1617, 17f, 18f, 18t, 30, 30f, 31f
d ecom pressive cran iectom y, 5354, 54f, 70, 71f
d epressed sku ll fract u re elevat ion , 90, 91f, 99, 99f
epidu ral h em atom a, 2, 3f, 14, 15f
fron t al sin u s inju ries, 444, 445f, 456
ICH, 312, 312f, 320, 320f, 327, 327f, 328f
in t racran ial in fect ion , 331, 332f, 347, 347f
invasive n eu rom on itoring, 116, 117f
odon toid fract u res, 179, 180f
p ediat ric cer vical sp in e inju r y, 471, 472f
p ediat ric TBI, 459, 459f
p it u it ar y ap oplexy, 370, 371f
sp in al epid u ral com pression , 288, 290f
su bd u ral h em atom a, 2, 3f, 14, 15f
su boccipit al t raum a, 7374, 75f, 88f, 89
su rgical debridem en t of p en et rat ing h ead inju ries, 120, 121f,
131, 131f
th oracic fract u res, 239
th oracolu m bar fract ures, 267, 267f
t rau m at ic CSF rh in orrh ea repair, 444, 445f, 456
ven ou s sin us injuries, 153, 154f, 168, 168f
ven t ricu lar sh u n t m alfu n ct ion , 350, 350f, 368, 368f
com p u ted tom ograp hy angiogram (CTA)
com bat-associated p en et rat ing sp in e inju r y, 402
ICH, 312, 313f, 320, 320f
TCVI, 136137, 136f, 151
com p u ted tom ograp hy ven ography (CTV), ven ou s sin u s injuries,
153, 154f, 168, 168f
corpectom y
for cer vical burst fract u res, 209, 209f
for th oracic fract u res, 251f
corpectom y an d diskectom y, 254, 254f
d rilling, 253, 253f
p edicle screw s, 256, 256f
rem oval of facet com plex, 252, 252f
rib h ead t rap door osteotom y, 255, 255f
cor t icosteroids. See steroids
costot ran sversectom y, for th oracic fract ures, 264
cran ial bon e ap rep lacem en t . See bon e ap replacem en t
cran ial fract u re, d epressed. See depressed sku ll fract ure elevat ion
cran iectom y
for allop last ic cran ioplast y. See bifron t al cran iectom y;
u n ilateral cran iectom y
for cerebellar stroke or hem orrhage or suboccipital traum a, 81, 81f
d ecom pressive. See decom pressive cran iectom y
for dep ressed sku ll fract u re elevat ion , 95, 95f
for ICH. See m idlin e su boccipit al cran iectom y
p ediat ric, 458, 460461
for p en et rat ing h ead injuries, 119120
cran iop last y
alloplast ic. See allop last ic cran iop last y
au tologou s, 424
p ediat ric, 458
cran iostom y. See t w ist drill cran iostom y
cran iotom y
for cerebral con t usion
bicoron al ap p roach , 39, 39f
m od i ed pterion al ap p roach , 47, 47f
for CSDH, 16
bu r h ole p lacem en t , 20, 20f
closing, 25
495
496
Inde x
cran iotom y (cont inued)
drain p lacem en t , 24, 24f
du ral op en ing, 21, 21f
h em atom a evacu at ion , 22f, 23
posit ion ing, 19, 19f
skin incision , 19, 19f
for decom pressive h em icran iectom y
bifron t al, 67, 67f
fron totem poropariet al, 59, 59f
for ep idu ral or su bdu ral h em atom a, 7, 7f
for ICH. See fron t al cran iotom y
for in t racerebral abscess, 343, 343f
pediat ric, 458, 460, 465, 465f
for p en et rat ing h ead inju ries, 119120, 126, 126f
for ven ou s sin u s inju ries
an terior on e-th ird superior sagit t al sin u s, 157, 157f
posterior t w o-th irds su perior sagit tal sin u s, torcu lar
h eroph ili, an d dom in an t t ran sverse sin u s, 164, 164f
CSDH. See ch ron ic su bdural h em atom a
CSF. See cerebrospin al uid
CT. See com pu ted tom ography
CTA. See com p uted tom ography angiogram
CTV. See com pu ted tom ography ven ograp hy
D
DC. See decom pressive cran iectom y
d ebridem en t . See surgical debridem en t of pen et rat ing h ead
inju ries
d ecom pressive cran iectom y (DC)
bifron t al operat ive procedure
closing, 70
cran iotom y, 67, 67f
du ral open ing, 68, 68f
du raplast y, 69, 69f
in cision plann ing, 65, 65f
posit ion ing, 64, 64f
subcu t an eous dissect ion , 66, 66f
fron t ot e m p orop ar iet al h e m icran ie ctom y op e rat ive
p roced u re
bon e ap elevat ion , 59, 59f
bon e ap storage, 63, 63f
bur h ole placem en t , 58, 58f
closing, 70
du ral open ing, 61, 61f
du raplast y, 62, 62f
posit ion ing, 55, 55f
skin in cision , 56, 56f
subcu t an eous dissect ion , 57, 57f
tem poral cran iectom y re n em en t , 60, 60f
in d icat ion s for, 53, 458
pediat ric, 458, 460461
postoperat ive m an agem en t
m edicat ion , 70
m onitoring, 70
radiograph ic im aging, 70, 71f
preprocedu re con siderat ion s
m edicat ion , 54
operat ive eld preparat ion , 54
radiograph ic im aging, 5354, 54f
special con siderat ion s, 71
Den is classi cat ion , 266
Inde x
open ing of
for cerebellar st roke or h em orrh age, 83, 83f
for cerebral con t u sion s, 40, 40f, 48, 48f
for CSDH, 21, 21f
for decom pressive h em icran iectom y, 61, 61f, 68, 68f
for epidu ral or su bdu ral h em atom a, 9, 9f
for ICH, 317, 317f, 325, 325f
for in t racran ial in fect ion , 341, 341f
for in t racran ial m on itoring, 108, 108f
for suboccip ital t rau m a, 83, 83f
for surgical debridem en t of pen et rat ing h ead inju ries, 127,
127f
tearing of, depressed skull fract ures w ith , 96, 96f
du ral venous sin u s inju r y. See ven ou s sin u s inju ries
duraplast y
for decom pressive h em icran iectom y
bifron t al, 69, 69f
fron totem poropariet al, 62, 62f
for surgical debridem en t of pen et rat ing h ead inju ries, 130,
130f
E
EDH. See epidural h em atom a
en dovascu lar m an agem en t
of ext racran ial blu n t TCVI, 137138, 139f
of ext racran ial pen et rat ing TCVI, 138, 141f
epidural abscess, 330
closu re, 347
in dicat ion s for su rger y, 331
operat ive proced ure
abscess rem oval, 340, 340f
bon e ap elevat ion , 339, 339f
in cision , 336, 336f
pericran ial ap h ar vest , 337, 337f
posit ion ing, 334335, 334f335f
t e m p or alis d ivision a n d b u r h ole p lace m e n t , 3 3 8 ,
338f
postop erat ive m an agem en t
fu r th er m an agem en t , 348
m edicat ion , 347
m on itoring, 347
radiograph ic im aging, 347, 347f
preprocedure con siderat ion s
m edicat ion , 333
operat ive eld p rep arat ion , 333
radiograph ic im aging, 331, 332f
special con siderat ion s, 348
sp in al. See sp in al epid u ral abscess
epidural h em atom a (EDH)
cerebellar st roke or h em orrh age w ith , 73, 73f, 82, 82f
in dicat ion s for su rger y, 2, 458
operat ive proced ure
bon e ap replacem en t , 12, 12f
closing, 14
cran iotom y, 7, 7f
drain placem en t , 13, 13f
h em atom a evacu at ion , 8, 8f
posit ion ing, 4, 4f
skin in cision , 5, 5f
su bcu tan eous dissect ion , 6, 6f
pediat ric, 458, 460
497
498
Inde x
ext racran ial pen et rat ing TCVI (cont inued)
repair of arterial inju r y, 150, 150f
skin in cision , 146, 146f
postoperat ive m an agem en t
m edicat ion , 151
m on itoring, 151
radiograph ic im aging, 151
prep rocedure con siderat ion s, 137
special con siderat ion s, 151
F
facetectom y, for th oracolum bar fract u res, 272273, 272f
facet fusion , for th oracolu m bar fract u res, 281, 281f
facet join t dislocat ion . See cer vical facet dislocat ion
facet s, an atom y of, 237
brin sealan t applicat ion , for fron t al sin u s su rger y, 454, 454f
exion -dist ract ion fract ures
th oracic, 239
th oracolu m bar, 266
uoroscopy, for p it uit ar y apoplexy, 373374, 373f, 374f
foreign body rem oval, for in t racran ial p en et rat ing injur y, 144,
144f
fract ure-dislocat ion inju r y
th oracic spin e, 239
th oracolu m bar, 266
fract ure elevat ion . See depressed skull fract u re elevat ion
fron tal cran iotom y, for su praten torial ICH
cran iotom y, 316, 316f
dural open ing, 317, 317f
hem atom a evacuat ion , 318319, 318f, 319f
posit ion ing an d skin in cision , 314, 314f
subcu t an eous dissect ion , 315, 315f
fron tal lobe con t usion . See cerebral con t usion s
fron tal lobectom y, for cerebral con t usion , 42, 42f
fron t al sin u s cran ializat ion , after in t racran ial in fect ion , 344,
344f
fron tal sin u s inju ries
closing, 456
in d icat ion s for su rger y, 444
operat ive p rocedure
bicoron al in cision, 446, 446f
cran ial bon e ap replacem en t , 455, 455f
brin sealan t ap plicat ion , 454, 454f
fragm en t rem oval an d cat alogu ing, 448, 448f
fron ton asal du ct packing, 452, 452f
fron ton asal du ct paten cy con rm at ion , 449, 449f
pericran ial ap elevat ion an d rot at ion , 453, 453f
posterior t able rem oval, 450, 450f
sin us m ucosa bu rn ing, 451, 451f
subperiosteal dissect ion , 447, 447f
postoperat ive m an agem en t , 456
prep rocedure con siderat ion s, 444, 445f
special con siderat ion s, 456
fron totem poropariet al decom p ressive h em icran iectom y, 53
bon e ap elevat ion , 59, 59f
bon e ap storage, 63, 63f
bur h ole placem en t , 58, 58f
closing, 70
du ral open ing, 61, 61f
du raplast y, 62, 62f
pediat ric, 462
posit ion ing, 55, 55f
Inde x
h alo vest t ract ion , 170, 172, 176f
h ead injuries
pen et rat ing. See pen et rat ing h ead inju ries
TBI. See t raum at ic brain injur y
TCVI. See t raum at ic cerebrovascular injur y
h em atom a evacu at ion
CSDH, 22f, 23
epidural, 8, 8f, 82, 82f
ICH
in fraten torial, 326, 326f
su praten torial, 318319, 318f, 319f
in t racerebellar, 84, 84f
spin al epidu ral, 294, 294f
su bdu ral, 10, 10f
h em icran iectom y
for com bat h ead inju ries, 393, 393f
decom pressive. See fron totem poropariet al decom p ressive
h em icran iectom y
h em orrh age
cerebellar. See cerebellar st roke or h em orrh age
in t racerebral. See in t racerebral h em orrh age
ven ou s sin u s injuries w ith , 153
h ep arin , for TCVI, 137
hyd roceph alus, after decom p ressive cran iectom y, 70
hyd roxyap at ite cem en t com pou n d , for alloplast ic cran iop last y,
438f, 439, 442
I
ICA. See in tern al carot id arter y
ICH. See in t racerebral h em orrh age
ICP m on itoring. See in t racran ial pressu re m on itoring
in fect ion
epidural. See epidu ral abscess
in t racran ial. See in t racran ial in fect ion
pen et rat ing h ead inju ries w ith , 119120, 132
sh un t , 351
sp in al. See sp in al ep idu ral abscess
in fraten torial ICH
closing, 327
in dicat ions for surger y, 320
m idlin e suboccip it al cran iectom y operat ive procedu re
cran iectom y, 323324, 323f324f
du ral open ing, 325, 325f
h em atom a evacuat ion , 326, 326f
posit ion ing, 321, 321f
skin in cision an d su bcu t an eou s dissect ion , 322, 322f
postop erat ive m an agem en t , 327, 327f, 328f
preprocedu re con sid erat ion s
in it ial m an agem en t , 320
m edicat ion , 320
operat ive eld preparat ion , 320
radiograph ic im aging, 320, 320f
special con siderat ion s, 327329
in tern al carot id arter y (ICA), TCVI of
en dovascular m an agem en t , 138, 141f
in dicat ions for surger y, 133134
in terspin ou s w iring arth rod esis, for pediat ric cer vical sp in e
injur y, 487, 487f
in t racerebellar h em atom a, 73, 73f, 84, 84f
in t racerebral abscess, 330
closu re, 347
in dicat ions for surger y, 331
499
500
Inde x
in t racran ial in fect ion (cont inued)
special con siderat ion s, 348
t ypes of, 330
in t racranial p en et rat ing TCVI
in d icat ion s for surger y, 136
m an agem en t , 142, 144, 144f
algorith m for, 143f
postoperat ive m an agem en t
m edicat ion , 151
m on itoring, 151
radiograph ic im aging, 151
preprocedu re con siderat ion s, 137
special con siderat ion s, 151
in t racranial p ressu re (ICP) m on itoring
closu re, 116
in d icat ion s for, 101, 458
m on itor p lacem en t op erat ive procedu re
bolt-t ype m on itor variat ion , 107, 107f
cath eter t un n elling an d secu ring, 110, 110f
EVD variat ion , 109, 109f
in t raparen chym al probe variat ion , 111, 111f
open ing of du ra an d leptom en inges, 108, 108f
posit ion ing, 104, 104f
skin in cision , 105, 105f
t w ist drill cran iostom y, 106, 106f
pediat ric, 458, 459
postoperat ive m an agem en t
fu rth er m an agem en t , 116
m edicat ion , 116
m onitoring, 116
radiograph ic im aging, 116, 117f
preprocedu re con siderat ion s
coagulat ion param eters, 101
equip m en t availabilit y, 102
m edicat ion , 102
operat ive eld preparat ion , 102, 102f103f
radiograph ic im aging, 101
special con siderat ion s, 118
invasive n eurom on itoring
closu re, 116
in d icat ion s for, 101, 458
in t racran ial m on itor placem en t op erat ive procedu re
bolt-t ype m onitor variat ion , 107, 107f
brain t issue oxygen m on itor variat ion , 112
cath eter t un n elling an d secu ring, 110, 110f
cerebral blood ow m on itor variat ion , 112
EVD variat ion , 109, 109f
in t raparen chym al probe variat ion , 111, 111f
m icrod ialysis cath eter variat ion , 112
open ing of du ra an d leptom en inges, 108, 108f
posit ion ing, 104, 104f
skin in cision , 105, 105f
t w ist drill cran iostom y, 106, 106f
pediat ric, 458, 459
postoperat ive m an agem en t
fu rth er m an agem en t , 116118
m edicat ion , 116
m onitoring, 116
radiograph ic im aging, 116, 117f
preprocedu re con siderat ion s
coagulat ion param eters, 101
equip m en t availabilit y, 102
Inde x
lobectom y, for cerebral con t u sion
an terior fron t al, 42, 42f
an terior tem poral, 50, 50f
lum bar epidural spinal cord compression, surgical approaches to, 291
M
Magerl tech n ique. See C1-C2 t ran sart icu lar screw
m agn et ic reson an ce angiogram (MRA), TCVI, 136137, 136f
m agn et ic reson an ce im aging (MRI)
cauda equin a syn drom e, 302, 303f
cerebellar st roke or h em orrh age or su boccip it al t rau m a,
7374, 75f
cer vical burst fract u res, 201, 202f
cer vical facet dislocat ion , 215
closed spin al t ract ion , 170
com bat-associated p en et rat ing sp ine inju r y, 402
CSDH, 17, 18t
decom pressive cran iectom y, 54
in t racran ial in fect ion , 331, 332f, 347, 347f
pediat ric TBI, 459
pit u it ar y apoplexy, 370, 372f
spin al epidu ral com p ression , 288, 289f
su rgical debridem en t of pen et rat ing h ead injuries, 120
th oracic fract u res, 239
th oracolum bar fract ures, 267
ven t ricular sh u n t m alfu n ct ion , 350, 350f
MCA. See m iddle cerebral ar ter y
m et ast at ic epidu ral spin al cord com pression (MESCC)
an esth esia, 289290
closu re, 300
et iologies of, 287
in ciden ce of, 286
in dicat ion s for su rger y, 288
path ophysiology of, 287
posterior an d p osterolateral p osit ion ing an d in cision , 292, 292f
postop erat ive m an agem en t
adjuvan t t reat m en ts, 300
m edicat ion , 300
m on itoring, 300
radiograph ic im aging, 300
preprocedu re con sid erat ion s
m edicat ion , 288
radiograph ic im aging, 288, 289f, 290f
presen t at ion of, 287
special con siderat ion s, 300301
surgical approach es
an terior, 291
gen eral prin ciples, 290291
posterior, 291
t ran spedicu lar ap p roach operat ive procedure
lam in ectom y, 297, 297f
lateral an d ven t ral t um or rem oval, 299, 299f
pedicu lectom y, 298, 298f
m ethylp redn isolon e, for SCI, 215, 267, 302
m icrodialysis cath eter m on itoring
closu re, 116
in dicat ion s for, 101, 458
operat ive procedu re
bolt-t ype m on itor variat ion , 107, 107f
m icrodialysis cath eter variat ion , 112
open ing of du ra an d leptom en inges, 108, 108f
posit ion ing, 104, 104f
501
502
Inde x
occlusion , t rau m at ic vascular. See vascular occlusion
odon toid fract ures
C1- C2 lateral m ass fu sion w ith polyaxial screw s an d rods
operat ive procedu re
C1 screw t rajector y an d p lacem en t , 193, 193f
C2 screw t rajector y an d p lacem en t , 194, 194f
closing, 195
n al con st ruct , 195, 195f
posit ion ing an d surgical site prep arat ion , 191, 191f
t issue dissect ion an d exp osure, 192, 192f
C1- C2 t ran sart icular screw op erat ive procedu re
closing, 190
n al con st ruct , 190, 190f
posit ion ing, 186, 186f
screw t rajector y an d placem en t , 189, 189f
surgical site prep arat ion , 187, 187f
t issue dissect ion an d exp osure, 188, 188f
in d icat ion s for surger y, 179
odon toid screw operat ive p rocedure
cer vical dissect ion an d en t r y site prep arat ion , 182183,
182f183f
closing, 185
com pleted con st ruct , 185, 185f
posit ion ing, 181, 181f
screw t rajector y an d placem en t , 184, 184f
postoperat ive m an agem en t
m edicat ion , 185, 190, 195
m onitoring, 185, 190, 195
preprocedu re con siderat ion s
m edicat ion , 179
radiograph ic im aging, 179, 180f
special con siderat ion s, 195196
op en cran ial fract ures, 90, 99
orth oses
for cer vical spin e inju ries, 490
for th oracic fract ures, 238
P
p aren chym al brain m on itors. See invasive n eu rom on itoring
p aren chym al injur y, p en et rat ing h ead inju ries w ith , 128129,
128f129f
p ediat ric cer vical spin e inju r y
an esth esia, 472
atlan toaxial arth rodesis, 470, 482
Brooks an d Jen kin s tech n iqu e, 482, 482f
Gallie tech n iqu e, 483, 483f
Harm s p osterior C1- C2 fu sion w ith p olyaxial screw an d rod
xat ion , 486, 486f
posterior C1-C2 t ran sart icular screw xat ion , 484485, 484f
closing, 489
in d icat ion s for su rger y, 470, 473, 482, 487
occipitocer vical xat ion
ar th rodesis. See occipitocer vical ar th rodesis
C1 lateral m ass screw s, 479, 479f
C2 pars screw, 480
C2 pedicle screw, 480, 480f
C2 t ran slam in ar screw, 481, 481f
plate, 479
posit ion ing based on ap proach
an terior cer vical, 472473
posterior cer vical, 473
Inde x
pericallosal bran ch an eu r ysm s, 135
pericran ial ap
elevat ion an d rot at ion of, 453, 453f
h ar vest of, 337, 337f
pericran ial graft , for com bat injuries, 395, 395f
pet rocavern ou s segm en t an eur ysm s, 135
pit u it ar y apoplexy
in dicat ion s for su rger y, 370
operat ive proced ure
abdom in al fat graft , 383, 383f
draping an d operat ing m icroscope, 375, 375f
du ral in cision an d pit u it ar y t um or resect ion ,
380, 380f
uoroscopy, 373374, 373f, 374f
h em ost asis an d closu re, 382, 382f
m u cosal ap, 376, 376f
posit ion ing, 373, 373f
sella exposu re, 378379, 378f379f
sella oor recon st ru ct ion , 381, 381f
sph en oid bon e iden t i cat ion , 377, 377f
postop erat ive m an agem en t , 384
preprocedure con siderat ion s
m edicat ion , 371
operat ive eld p rep arat ion , 371
radiographic im aging, 370, 371f, 372f
special con siderat ion s, 384
PMMA. See polym ethylm eth acr ylate
polyeth ereth erketon e (PEEK), for allop last ic cran iop last y, 436f,
439, 442443
polym ethylm eth acr ylate (PMMA), for alloplast ic cran ioplast y,
438f, 439, 442
porou s polyethylen e, for alloplast ic cran ioplast y, 436f, 439,
442443, 442f
posterior sp in al decom p ression
for th oracic fract ures, 241f, 242f
lam in ectom y, 246, 246f
ligam en t rem oval, 247, 247f
pedicle screw en t r y poin t , 248, 248f
pedicle screw placem en t , 249, 249f
posit ion ing an d localizat ion , 243, 243f
rod placem en t , 250, 250f
skin , su bcut an eous, an d su bperiosteal dissect ion , 244, 244f
spin ou s process rem oval, 245, 245f
for th oracolum bar fract ures
bon e graft ing, 276, 276f
closu re, 284
decom pression , 271, 271f
exposure, 270, 270f
facetectom y an d pedicle can n ulat ion , 272273, 272f
percut an eous. See percu t an eou s posterior spin al
decom pression
posit ion ing, 269, 269f
rod placem en t , 275, 275f
t ap ping an d screw p lacem en t , 274, 274f
posterior sp in al fusion , 216f
operat ive proced ure
closing, 225
decom pression an d redu ct ion , 220, 220f
fu sion preparat ion , 221, 221f
posit ion ing, 217, 217f
posterolateral fu sion , 224, 224f
503
504
Inde x
radiograp h ic im aging (cont inued)
odon toid fract ures, preprocedu re, 179, 180f
pediat ric cer vical sp in e inju r y
postoperat ive, 489, 489f
preprocedure, 471, 472f
pediat ric TBI, preprocedu re, 459, 459f
pit u it ar y apoplexy, prep rocedu re, 370, 371f, 372f
SjVO2 m on itor p osit ion veri cat ion , 115, 115f
spin al epidural com pression
postoperat ive, 300
preprocedure, 288, 289f, 290f
suboccipit al t raum a
postoperat ive, 88f, 89
preoperat ive, 7374, 75f
surgical d ebridem en t of pen et rat ing h ead inju ries
postoperat ive, 131, 131f
preoperat ive, 120, 121f
t rau m at ic cerebrovascu lar inju r y (TCVI)
postoperat ive, 151
preoperat ive, 136137, 136f
th oracic fract ures
postoperat ive, 262, 262f, 263f
preprocedure, 238239
th oracolu m bar fract u res
postoperat ive, 284, 284f
preprocedure, 267, 267f
t rau m at ic CSF rh in orrh ea rep air
postoperat ive, 456
preprocedure, 444, 445f
ven ous sin us injuries
postoperat ive, 168, 168f
preoperat ive, 153, 154f
ven t ricular sh un t m alfun ct ion
postoperat ive, 368, 368f
preprocedure, 350, 350f, 351f
reperfu sion , of TCVI, 137138
rib h ead t rap door osteotom y, for th oracic fract u res, 255, 255f
ribs, an atom y of, 237
S
SCI. See spin al cord inju r y
SCIWORA. See spin al cord inju ries w ith ou t radiograph ic
abn orm alit y
SDH. See su bdural h em atom a
SEA. See spin al epidu ral abscess
SEH. See spin al epidu ral h em atom a
sella
exposu re of, 378379, 378f379f
reconst ruct ion of, 381, 381f
sh un togram , for VS m alfun ct ion , 350351
sh un t revision , for VS m alfu n ct ion
distal cath eter revision , 360364, 360f, 361f, 362f, 363f, 364f
externalizing of dist al cath eter, 366, 366f
posit ion ing an d prep arat ion, 353, 353f
skin incision an d w ou n d dissect ion , 354355, 354f355f
valve an d distal cath eter evalu at ion , 359, 359f
ven t ricular cath eter p lacem en t , 358, 358f
ven t ricular cath eter p lacem en t an d t u n n elling for extern al
drain age, 365, 365f
ven t ricular cath eter reser voir evalu at ion , 356, 356f
ven t ricular cath eter revision , 357, 357f
w ou nd closure, 365, 367, 367f
Inde x
spin al epidu ral com p ression , m etast at ic. See m etast at ic epidu ral
spin al cord com pression
spin al epidu ral h em atom a (SEH)
an esth esia, 289290
closu re, 300
et iologies of, 286
in ciden ce of, 286
in dicat ion s for su rger y, 287
path ophysiology of, 287
posterior and p osterolateral posit ion ing an d incision , 292, 292f
postoperat ive m an agem en t
adjuvan t t reat m en t s, 300
m edicat ion , 300
m on itoring, 300
radiograph ic im aging, 300
preprocedu re con siderat ion s
m edicat ion , 288
radiograph ic im aging, 288, 289f, 290f
presen t at ion of, 287
special con siderat ion s, 300
su rgical approach es
an terior, 291
gen eral prin ciples, 290291
posterior, 291
th oracic lam in ectom y op erat ive proced ure
h em atom a rem oval, 294, 294f
lam in ectom y, 293, 293f
spin al fract ures
cer vical. See cer vical bu rst fract ures
th oracic. See th oracic fract ures
th oracolum bar. See th oracolu m bar fract u res
spin al fusion
an terior. See an terior sp in al fu sion
posterior. See posterior spin al fu sion
spin al inju r y
com bat-associated. See com bat-associated pen et rat ing spin e
injur y
pediat ric. See p ediat ric cer vical spin e injur y
spin al t ract ion , closed. See closed sp in al t ract ion
spin ou s process rem oval, for th oracic fract ures, 245, 245f
sten t ing
of ext racran ial blu n t TCVI, 137138, 139f
of ext racran ial pen et rat ing TCVI, 138, 141f
steroid s
for CSDH, 31
for in t racran ial in fect ion , 333
for SCI, 215, 239, 267, 302, 471
st roke
cerebellar. See cerebellar st roke or h em orrh age
decom pressive cran iectom y for. See decom pressive
cran iectom y
spon t an eou s ICH cau sing. See in t racerebral h em orrh age
su baxial cer vical posterior arth rodesis, 470, 487
in terspin ou s w iring arth rodesis, 487, 487f
posterior arth rodesis w ith lateral m ass screw xat ion , 488,
488f
su bdural em pyem a, 330
closu re, 347
in dicat ion s for su rger y, 331
operat ive procedu re
bon e ap elevat ion , 339, 339f
du ral closure, 344, 344f
505
506
Inde x
su boccipit al t rau m a (cont inued)
preprocedu re con siderat ion s
m edicat ion , 74
operat ive eld preparat ion , 74
posit ion ing, 74
radiograph ic im aging, 7374, 75f
ven t riculostom y, 74, 77, 77f
su perior sagit t al sin u s inju ries
an terior on e-th ird op erat ive procedu re
cran iotom y, 157, 157f
gen eral con siderat ion s, 154
posit ion ing, 155, 155f
sin us in terposit ion graft , 161, 161f
sin us ligat ion , 159, 159f
sin us patch , 160, 160f
skin in cision , 156, 156f
t am pon ade, 158, 158f
closing, 165
depressed skull fract u re elevat ion w ith , 97, 97f
in d icat ion s for su rger y, 153
posterior t w o-third s operat ive procedu re
cran iotom y, 164, 164f
direct rep air, 165, 165f
gen eral con siderat ion s, 154
posit ion ing, 162, 162f
sin us in terposit ion graft , 167
sin us patch , 166, 166f
skin in cision , 163, 163f
t am pon ade, 165
postoperat ive m an agem en t
m edicat ion , 168
m onitoring, 168
radiograph ic im aging, 168, 168f
preprocedu re con siderat ion s
m edicat ion , 153
operat ive eld preparat ion , 153154
radiograph ic im aging, 153, 154f
special con siderat ion s, 168
su ppu rat ive in t racran ial th rom boph lebit is, 348
su praten torial ICH
closing, 320
fron tal cran iotom y operat ive procedu re
cran iotom y, 316, 316f
du ral open ing, 317, 317f
h em atom a evacu at ion , 318319, 318f, 319f
posit ion ing an d skin in cision , 314, 314f
subcu t an eous dissect ion , 315, 315f
in d icat ion s for su rger y, 312
postoperat ive m an agem en t , 327, 327f, 328f
preprocedu re con siderat ion s
in it ial m an agem en t , 313
m edicat ion , 313
operat ive eld preparat ion , 313
radiograph ic im aging, 312, 312f, 313f
special con siderat ion s, 327329
su rgical d ebridem en t of pen et rat ing h ead inju ries
closing, 131
in d icat ion s for, 119120
operat ive p rocedure
app roach to paren chym al inju r y, 128129, 128f129f
bur h ole placem en t , 125, 125f
Inde x
surgical approach es
an terior, 240
posterior, 240
posterolateral, 240
t ran spedicu lar corp ectom y op erat ive procedu re, 251f
corpectom y an d diskectom y, 254, 254f
drilling, 253, 253f
pedicle screw s, 256, 256f
rem oval of facet com p lex, 252, 252f
rib h ead t rap door osteotom y, 255, 255f
t ran sth oracic ver tebrectom y op erat ive p rocedure, 257f
dissect ion , 259, 259f
fu sion an d in st ru m en t at ion , 261, 261f
posit ion ing an d ap proach p lan n ing, 258, 258f
vertebrectom y, 260, 260f
th oracic sp in e, an atom y of, 237
th oracolum bar fract ures
classi cat ion , 266267, 267t
in dicat ion s for su rger y, 267
open operat ive procedure
bon e graft ing, 276, 276f
closu re, 284
decom pression , 271, 271f
exposure, 270, 270f
facetectom y an d ped icle can n u lat ion , 272273, 272f
posit ion ing, 269, 269f
rod placem en t , 275, 275f
t apping an d screw p lacem en t , 274, 274f
percutan eou s op erat ive procedu re
bon e t reph in e n eedle placem en t , 278279, 278f
closu re, 284
facet fusion , 281, 281f
guidew ire placem en t , 280, 280f
posit ion ing an d p edicle t arget ing, 277, 277f
rod placem en t an d deform it y correct ion , 283, 283f
screw placem en t , 282, 282f
postoperat ive m an agem en t
m edicat ion , 284
m on itoring, 284
radiograph ic im aging, 284, 284f
preprocedu re con siderat ion s
m edicat ion , 267
operat ive eld p reparat ion , 268
radiograph ic im aging, 267, 267f
su rgical m an agem en t , 267268
special con siderat ion s, 284
Th oracolu m bar Inju r y Classi cat ion an d Severit y Score (TCLIS),
266267, 267t
th oracoscopy, for th oracic fract u res, 240
th oracotom y, for th oracic fract ures, 240
t itan ium m esh , for alloplast ic cran iop last y, 437f, 439, 442443
t itan ium plate, for alloplast ic cran ioplast y, 437f, 439, 442443
torcular h erop h ili injuries
closing, 165
in dicat ion s for su rger y, 153
operat ive proced ure
cran iotom y, 164, 164f
direct repair, 165, 165f
gen eral con siderat ions, 154
posit ion ing, 162, 162f
sin u s in terposit ion graft , 167
507
508
Inde x
t rau m at ic CSF rh in orrh ea repair (cont inued)
sin us m u cosa bu rn ing, 451, 451f
subperiosteal dissect ion , 447, 447f
postoperat ive m an agem en t , 456
preprocedu re con siderat ion s, 444, 445f
special con siderat ion s, 456
t um or resect ion
pit u it ar y t u m ors, 380, 380f
spin al t um ors, 299, 299f
t w ist drill cran iostom y
for CSDH
cath eter placem en t , 28, 28f
closing, 29, 29f
drilling, 27, 27f
posit ion ing, 26, 26f
postoperat ive m an agem en t , 29, 30f
skin in cision , 26, 26f
for in t racran ial m on itoring, 106, 106f
U
u n ilateral cran iectom y, for allop last ic cran ioplast y
cran iectom y site preparat ion , 435, 435f
im plan t t ypes, 436f438f, 439
posit ion ing, 427, 427f
skin in cision , 429, 429f
subcu t an eous dissect ion , 430432, 430f, 431f432f
tem poral defect repair, 440, 440f
tem poralis m u scle dissect ion , 433434, 433f434f
tem poralis t ran sp osit ion , 441, 441f
V
VAI. See ver tebral arter y inju r y
vascular occlusion , t raum at ic
en dovascular m an agem en t of, 137, 139f
ind icat ion s for su rger y, 133134
VB. See vertebral body
ven ous air em bolism , ven ou s sin u s inju ries w ith , 153
ven ous sin us injuries
an terior on e-th ird sup erior sagit t al sin us op erat ive procedure
cran iotom y, 157, 157f
gen eral con siderat ion s, 154
posit ion ing, 155, 155f
sin us in terposit ion graft , 161, 161f
sin us ligat ion , 159, 159f
sin us patch , 160, 160f
skin in cision , 156, 156f
t am pon ade, 158, 158f
closing, 165
depressed skull fract u res cau sing, 90, 99
ind icat ion s for su rger y, 153
posterior t w o-th ird s sup erior sagit t al sin u s, torcular h eroph ili,
an d dom in an t t ran sverse sin u s op erat ive p roced u re
cran iotom y, 164, 164f
direct rep air, 165, 165f
gen eral con siderat ion s, 154
posit ion ing, 162, 162f
sin us in terposit ion graft , 167
sin us patch , 166, 166f
skin in cision , 163, 163f
t am pon ade, 165