Background
This Touch Surgery procedure demonstrates how to remove the bone flap and open the dura during a trauma craniotomy. The trauma craniotomy (TC) is an essential tool in the neurosurgeon’s armamentarium. Used in a variety of settings, an emergent decompression is used to evacuate a mass lesion or treat globally increased intracranial pressure secondary to cerebral edema. TC is used in life-threatening situations to prevent downward herniation of the brainstem through the foramen magnum. The three most common indications for TC include:
• Severe TBI
• Malignant edema following acute large vessel infarct
• Aneurysmal SAH [2]
In the setting of acute TBI, when an extra-axial mass lesion is present, emergent surgical removal of the cranium is recommended. These include epidural hematomas (EDH) and subdural hematomas (SDH), where significant midline shift occurs in an acutely decompensating patient. A standard unilateral question mark incision is made, the bone is removed with a pneumatic drill, and when present, the extra-axial compressive lesion is evacuated. Bone replacement is left to the surgeon’s discretion, and is often done if minimal subsequent parenchymal swelling is expected. In the setting of a high energy trauma, with traumatic subarachnoid hemorrhage and other small contusions, the bone is often left off in anticipation of future malignant edema, and replaced months later with a cranioplasty. The use of TC for intraparenchymal hematomas (IPH) and cerebral contusions is more controversial.