Neurosurg Focus
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Comparative Study
Cranioplasty complications following wartime decompressive craniectomy.
In support of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom-Afghanistan (OEF-A), military neurosurgeons in the combat theater are faced with the daunting task of stabilizing patients in such a way as to prevent irreversible neurological injury from cerebral edema while simultaneously allowing for prolonged transport stateside (5000-7000 miles). It is in this setting that decompressive craniectomy has become a mainstay of far-forward neurosurgical management of traumatic brain injury (TBI). As such, institutional experience with cranioplasty at the Walter Reed Army Medical Center (WRAMC) and the National Naval Medical Center (NNMC) has expanded concomitantly. Battlefield blast explosions create cavitary injury zones that often extend beyond the border of the exposed surface wound, and this situation has created unique reconstruction challenges not often seen in civilian TBI. The loss of both soft-tissue and skull base support along with the need for cranial vault reconstruction requires a multidisciplinary approach involving neurosurgery, plastics, oral-maxillofacial surgery, and ophthalmology. With this situation in mind, the authors of this paper endeavored to review the cranial reconstruction complications encountered in these combat-related injuries. ⋯ This study represents the largest to date in which cranioplasty and its complications have been evaluated in a trauma population that underwent decompressive craniectomy. The overall complication rate of 24% is consistent with rates reported in the literature (16-34%); however, the perioperative infection rate of 12% is higher than the rates reported in other studies. This difference is likely related to aspects of the initial injury pattern-such as skull base injury, orbitofacial fractures, sinus injuries, persistent fluid collection, and CSF leakage-which can predispose these patients to infection.
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Comparative Study
Multilevel cervical arthroplasty with artificial disc replacement.
In this study, the authors review the technique for inserting the Prestige ST in a contiguous multilevel cervical disc arthroplasty in patients with radiculopathy and myelopathy. They describe the preoperative planning, surgical technique, and their experience with 10 patients receiving a contiguous Prestige ST implant. They present contiguous multilevel cervical arthroplasty as an alternative to multilevel arthrodesis. ⋯ Multilevel cervical arthroplasty with the Prestige ST is a safe and effective alternative to fusion for the management of cervical radiculopathy and myelopathy.
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An international military campaign involving large numbers of troops is ongoing in Afghanistan. To support the military efforts in the conflict zone, a network of military medical services of varying levels has been established. The largest and busiest multinational military hospital in southern Afghanistan is located at Kandahar Air Field where the only neurosurgeon is based. This report outlines the contribution of multinational military health services and the workload of the neurosurgical service in Kandahar.
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Minimal-access transforaminal lumbar interbody fusion (TLIF) has gained popularity as a method of achieving interbody fusion via a posterior-only approach with the aim of minimizing injury to adjacent tissue. While many studies have reported successful outcomes, questions remain regarding the potential learning curve for successfully completing this procedure. The goal of this study, based on a single resident's experience at the only Accreditation Council for Graduate Medical Education-approved neurosurgical training center in the US military, was to determine if there is in fact a significant learning curve in performing a minimal-access TLIF. ⋯ In summary, minimal-access TLIF can be safely performed in a training environment without a significant complication rate due to the expected learning curve.
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Review Comparative Study
The evolution of the treatment of traumatic cerebrovascular injury during wartime.
The approach to traumatic craniocervical vascular injury has evolved significantly in recent years. Conflicts prior to Operations Iraqi and Enduring Freedom were characterized by minimal intervention in the setting of severe penetrating head injury, in large part due to limited far-forward resource availability. Consequently, sequelae of penetrating head injury like traumatic aneurysm formation remained poorly characterized with a paucity of pathophysiological descriptions. ⋯ As a result of the rapid field resuscitation and early cranial decompression, patients are surviving longer, which has led to diagnosis and treatment of entities that had previously gone undiagnosed. Therefore, in this paper the authors' purpose is to review their experience with severe traumatic brain injury complicated by injury to the craniocervical vasculature. Historical approaches will be reviewed, and the importance of modern endovascular techniques will be emphasized.