Emergent craniotomy in rural and regional settings: recommendations from a tertiary neurosurgery unit: diagnosis and surgical decision‐making

Abstract

Largely attributed to the tyranny of distance, timely transfer of patients with major traumatic brain injuries (TBI) from rural or regional hospitals to metropolitan trauma centres is not always feasible. This has warranted emergent craniotomies to be undertaken by non‐neurosurgeons at their local hospitals with previous acceptable results reported in regional Australia. Our institution endorses this ongoing potentially life‐saving practice when necessary and emphasize the need for neurosurgical units to provide ongoing TBI education to peripheral hospitals. In this first of a two‐part narrative review, the authors describe the recommended diagnostic pathway for patients with a suspected TBI presenting to rural or regional hospitals and discuss local surgical management options in the presence or absence of a CT scanner.

General surgeon performed emergency craniotomies in regional Queensland hospitals: a 20‐year state‐wide study on patient outcomes

“…Traumatic brain injuries account for up to 50% of trauma related deaths and remain a leading cause of disability 1,2 . When a craniotomy or craniectomy is indicated, early intervention is paramount to improving patient outcomes, with the consensus suggesting that a maximum of 4 h from presentation to decompression is associated with a reduction in mortality 1–4 .…”

“…The longstanding absence of a neurosurgical service in Darwin with consequent longstanding practice of general surgeon performed craniotomies is something of an anomaly in the Australian setting and therefore those results may not be applicable to lower volume centres 7 . Although recent opinion pieces continue to advocate for this practice, there is currently no relevant data to support such recommendations 1 . To our knowledge there have been no reports of clinical or radiological results for non‐neurosurgeon craniotomies performed in other regions of rural and regional Australia.…”

Craniotomy Simulator with Force Myography and Machine Learning-Based Skills Assessment

“…During a craniotomy procedure, dural tear or rupture can have several adverse consequences, such as cerebrospinal fluid (CSF) leak, infection, hematoma, or brain herniation [ 3 , 4 ]. Furthermore, patients suffering from traumatic head injuries in rural areas require immediate surgical intervention even in the absence of neurosurgeons [ 5 ]. Therefore, competent training of craniotomy procedures in a safe and repeatable environment is essential for neurosurgeons as well as community general surgeons [ 6 , 7 ].…”

Head injury management in rural and regional settings

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In this issue of the journal Raman et al 1 in their article 'Emergent Craniotomy in rural and regionasettings: recommendations from a tertiary unit: diagnosis and surgical decision making' provide advice for non-neurosurgeons in rural and remote locations confronted by a patient with a head injury who is deteriorating from a potential intracranial clot.In 1976, an epidemiological study of neurotrauma in New South Wales, South Australia and the Australian Capital Territory, initiated by the Neurosurgical Society of Australasia (NSA) demonstrated the importance of pre-hospital management and difficulties specific to the Australian setting, namely long distances and sparse rural facilities. Two thirds of all neurotrauma deaths occurred pre-hospital and a high percentage of these were due to rural and remote accidents.

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“…In this issue of the journal Raman et al 1 in their article ‘Emergent Craniotomy in rural and regionasettings: recommendations from a tertiary unit: diagnosis and surgical decision making’ provide advice for non‐neurosurgeons in rural and remote locations confronted by a patient with a head injury who is deteriorating from a potential intracranial clot.…”