Medical Science Publication No. 4, Volume 1
SPECIFIC CONSIDERATIONS IN PRIMARY SURGERYOF NERVOUS SYSTEM*
LIEUTENANT COLONELGEORGE J. HAYES, MC
Basic Principles
The Korean war has demonstrated again that which needs no further demonstration.There is no substitute for prompt, definitive treatment of missile wounds.This is true of wounds of the nervous system. Early in the war treatmentwas delayed, and débridement was inadequate or not definitive. Infectionwith consequent morbidity and morality was common. With the advent of neurosurgicalteams within the zone of operations these complications fell to the levelgenerally existing at the close of World War II.
I do not intend to discuss the minutiae of neurosurgical technic. Norwill we cover the care of peripheral nerve injuries, for beyond propernotation of the fact that such injury exists there is no specific treatmentindicated at the time of wounding.
Patients having wounds of the brain do not usually present a problemon preoperative blood volume replacement. If associated injuries causea need for blood this should be administered as indicated without regardto the presence of brain damage. The patient in deep coma may well receivebenefit from a tracheotomy if tracheobronchial respiratory embarrassmentarises, that is usually sufficient indication that one should be performed.With or without a tracheotomy the unconscious patient should be maintainedin the "coma position." This is a lateral recumbent positionwith the ventral aspect of the head and body inclined slightly toward thesupporting surface. Vomitus, mucus and blood will tend to run from themouth instead of being aspirated and thus pneumonia, lung abscess or drowningis prevented.
X-rays of the skull are essential aids in planning the surgical attack.These give information regarding the size, number and position of bonefragments within the brain. The path, position, size and, to some extent,the effects of the missile may be ascertained. General anesthesia withan endotracheal tube should be smoothly and quickly admin-
*Presented 22 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.
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istered. If the aid of a skillful anesthetist is not available it isbetter to use local anesthesia as the straining which occurs in a stormyinduction may cause further damage or even death.
The operation on the wounded brain is essentially a débridementwhich also includes scalp, skull and dura. Great care must be taken toremove all bone fragments, hair, blood and nonviable brain. The removalof the missile is not always essential and is generally contraindicatedif to do so would impose a new neurological deficit.
The use of lighted retractors and other instruments is generally advocatedin the search for foreign bodies and bone fragments. Personally, I foundthat palpation with the index finger was advantageous and resulted in morethorough identification and removal, with less operative trauma.
The skull is a rigid box containing substances which are of relativelysimilar density. The shock effects of a missile may cause laceration ofthe brain or its vessels distant to the point of impact, and the possibilityof such an occurrence must always be kept in mind.
The exposed brain is easily contaminated by bacteria. Its response isto swell and extrude out of the cranial defect. This impedes venous returnfrom the affected area, which causes further swelling. A cyclic phenomenonis thus set up which may lead to death or massive tissue destruction. Therefore,a major departure from the usual débridement concept is forced uponus by the nature of the tissue and its reaction to trauma and infection.Following débridement, the brain is covered and protected by primarywound closure. Fortunately the scalp is highly vascular and, if properlytrimmed to the level of viable tissue, will readily heal.
The dura must be closed to prevent scar formations between scalp andbrain and to defeat bacterial invasion. Often a graft is needed. This maybe obtained from the adjacent periosteum, galea or muscle fascia.
The routine use of fascia lata has been advocated as a dural graft source.A comparison between cases so treated and those in which dural repair wasaccomplished with galea, etc., showed that a significant increase of wounddisruptions resulted when fascia lata was used.
Postoperatively the coma position with frequent changes from side toside should be maintained if indicated. Fluid and electrolyte administrationis essential, and the "dehydration treatment" has no place inthe care of these men. If coma continues, tube feeding with a high-proteinand high-caloric formula simplifies the maintenance of metabolism.
Patients who have injuries to the spine and spinal cord require specificcare as soon as they are first seen. A normal anatomical posi-
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tion is generally best for transportation, face down if at all possible.Jostling and jouncing are to be avoided. A catheter should be insertedin the bladder and the indicated blood and fluids administered. Combinedwounds are common in this group and transportation to a neurosurgical teamor surgery directed toward the spinal cord are both subordinate to lifesavingsurgery for the associated wounds which are usually of the abdomen or chest.Alternate face-down and face-up positioning must be started within a fewhours after wounding to prevent formation of decubiti. This can be accomplishedby sandwiching the patient between prepared litters or by use of the Strykerframe. The latter has proved practical as a piece of forward equipmentand as a means of transportation via air, water or land. It also requiresfewer people to manipulate than the improvised arrangements.
Débridement is carried out thoroughly and extensive decompressionof the cord performed. The dura is closed or left open as circumstancesdictate. Here again, primary wound closure is performed if the wound pathis included in the laminectomy incision. If the wound is not in this incision,it is secondarily closed in 5 days.
Continuous bladder drainage is provided via an urethral catheter. Atthe forward level, no attempt is made to institute tidal drainage, andsuprapubic cystostomy is done only when bladder wounding forces this step.
Penicillin and streptomycin are administered routinely in both brainand spinal cord injuries. Crystalline penicillin is used intravenouslypreoperatively and immediately postoperatively. Other antibiotics are usedif indicated but none are applied directly to the wound area.
Neurosurgical Teams
We have sketched out the basic principles involved in the primary surgicalcare of war wounds of the brain and spinal cord. Equally important andrequiring much planning are the aspects of patient transportation, locationof a neurosurgical team, composition of the team, its organic equipmentand the amount of surgery such a unit can be expected to accomplish.
Patient transportation will be discussed in detail by another speaker.However, the avoidance of aggravating the wound by trauma because of roughhandling should be stressed. Helicopter ambulance service is preferablewhen the tactical situation permits. Postoperatively, the patients shouldbe moved, by air if possible, to a base zone center as soon as their conditionpermits movement. The forward unit cannot afford to become overloaded withlong-term cases.
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The forward unit providing primary definitive neurosurgical care needsto be within at least 12 hours evacuation time from the source of patients.A longer time will be reflected by an increased number of infections anda higher mortality rate.
The hospital to which a neurosurgical team is attached should be ofthe evacuation type, for this is large enough to absorb the postoperativecare of the patients, to aid in the preparation of sterile supplies, andaccommodate the team itself without undue strain. This may not be practicaland the team will have to be placed with a MASH or other unit. In any event,to ever consider making these neurosurgical units self-sustaining, miniaturehospitals, is to invite waste of manpower and equipment.
A suggested team is as follows:
2 Neurosurgeons (both high C).
2 Surgical Nurses.
8 Corpsmen (Surgical Technicians).
1 Anesthetist C.
Such a team attached to a hospital will be able to do about 12 proceduresper day under optimum conditions for a period of several days. With theexception of special equipment, most of the necessary medical suppliescan be drawn from the hospital to which the unit is attached. The neurosurgicalgroup should not be considered a permanent attachment to a hospital butrather a mobile specialty unit. To aid in this function, sufficient organictransportation should be provided for equipment, housing and personnel.Shuttle movements are not practicable.
The number of teams to assign to a Corps or Army area will have to bearrived at by estimating the expected or observed number of casualties.Approximately 10 percent of the seriously wounded men have damage of thebrain or spinal cord. Teams, or parts of teams, may have to be moved asneeded to cover busy areas.
Ideally, these units should be organized and ready to move at all times,prior to the onset of hostilities. Realistic peacetime maneuvers shouldbe carried out so that the unit members will become efficient in theirfunctions. Our neurosurgeons must be trained to operate with simplicityand speed and have the opportunity to guide their teams in their proposedduties. We do not shirk residency training to accomplish peacetime surgicalcompetence. We cannot afford to be delinquent in such training to preparefor the surgical treatment of war wounds.
