Neurosurgery
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We performed a biomechanical comparison of several C1 to C2 fixation techniques including crossed laminar (intralaminar) screw fixation, anterior C1 to C2 transarticular screw fixation, C1 to 2 pedicle screw fixation, and posterior C1 to C2 transarticular screw fixation. ⋯ All four screw fixation techniques limit motion at the C1 to 2 articulation. The addition of cable fixation improves resistance to flexion and extension for posterior transarticular screw fixation.
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An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patient's Glasgow Coma Scale (GCS) score. All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring. A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg. ⋯ If surgical evacuation of an acute SDH in a comatose patient (GCS < 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.
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An epidural hematoma (EDH) greater than 30 cm3 should be surgically evacuated regardless of the patient's Glasgow Coma Scale (GCS) score. An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial computed tomographic (CT) scanning and close neurological observation in a neurosurgical center. ⋯ There are insufficient data to support one surgical treatment method. However, craniotomy provides a more complete evacuation of the hematoma.