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Specific Considerations in Primary Surgery of Nervous System

Medical Science Publication No. 4, Volume 1



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 treatment was delayed, and débridement was inadequate or not definitive. Infection with consequent morbidity and morality was common. With the advent of neurosurgical teams within the zone of operations these complications fell to the level generally existing at the close of World War II.

I do not intend to discuss the minutiae of neurosurgical technic. Nor will we cover the care of peripheral nerve injuries, for beyond proper notation of the fact that such injury exists there is no specific treatment indicated at the time of wounding.

Patients having wounds of the brain do not usually present a problem on preoperative blood volume replacement. If associated injuries cause a need for blood this should be administered as indicated without regard to the presence of brain damage. The patient in deep coma may well receive benefit from a tracheotomy if tracheobronchial respiratory embarrassment arises, that is usually sufficient indication that one should be performed. With or without a tracheotomy the unconscious patient should be maintained in the "coma position." This is a lateral recumbent position with the ventral aspect of the head and body inclined slightly toward the supporting surface. Vomitus, mucus and blood will tend to run from the mouth instead of being aspirated and thus pneumonia, lung abscess or drowning is prevented.

X-rays of the skull are essential aids in planning the surgical attack. These give information regarding the size, number and position of bone fragments within the brain. The path, position, size and, to some extent, the effects of the missile may be ascertained. General anesthesia with an 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.


istered. If the aid of a skillful anesthetist is not available it is better to use local anesthesia as the straining which occurs in a stormy induction may cause further damage or even death.

The operation on the wounded brain is essentially a débridement which also includes scalp, skull and dura. Great care must be taken to remove all bone fragments, hair, blood and nonviable brain. The removal of the missile is not always essential and is generally contraindicated if to do so would impose a new neurological deficit.

The use of lighted retractors and other instruments is generally advocated in the search for foreign bodies and bone fragments. Personally, I found that palpation with the index finger was advantageous and resulted in more thorough identification and removal, with less operative trauma.

The skull is a rigid box containing substances which are of relatively similar density. The shock effects of a missile may cause laceration of the brain or its vessels distant to the point of impact, and the possibility of such an occurrence must always be kept in mind.

The exposed brain is easily contaminated by bacteria. Its response is to swell and extrude out of the cranial defect. This impedes venous return from the affected area, which causes further swelling. A cyclic phenomenon is thus set up which may lead to death or massive tissue destruction. Therefore, a major departure from the usual débridement concept is forced upon us by the nature of the tissue and its reaction to trauma and infection. Following débridement, the brain is covered and protected by primary wound closure. Fortunately the scalp is highly vascular and, if properly trimmed to the level of viable tissue, will readily heal.

The dura must be closed to prevent scar formations between scalp and brain and to defeat bacterial invasion. Often a graft is needed. This may be 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 was accomplished with galea, etc., showed that a significant increase of wound disruptions resulted when fascia lata was used.

Postoperatively the coma position with frequent changes from side to side should be maintained if indicated. Fluid and electrolyte administration is essential, and the "dehydration treatment" has no place in the care of these men. If coma continues, tube feeding with a high-protein and high-caloric formula simplifies the maintenance of metabolism.

Patients who have injuries to the spine and spinal cord require specific care as soon as they are first seen. A normal anatomical posi-


tion is generally best for transportation, face down if at all possible. Jostling and jouncing are to be avoided. A catheter should be inserted in the bladder and the indicated blood and fluids administered. Combined wounds are common in this group and transportation to a neurosurgical team or surgery directed toward the spinal cord are both subordinate to lifesaving surgery for the associated wounds which are usually of the abdomen or chest. Alternate face-down and face-up positioning must be started within a few hours after wounding to prevent formation of decubiti. This can be accomplished by sandwiching the patient between prepared litters or by use of the Stryker frame. The latter has proved practical as a piece of forward equipment and as a means of transportation via air, water or land. It also requires fewer people to manipulate than the improvised arrangements.

Débridement is carried out thoroughly and extensive decompression of the cord performed. The dura is closed or left open as circumstances dictate. Here again, primary wound closure is performed if the wound path is 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. At the forward level, no attempt is made to institute tidal drainage, and suprapubic cystostomy is done only when bladder wounding forces this step.

Penicillin and streptomycin are administered routinely in both brain and spinal cord injuries. Crystalline penicillin is used intravenously preoperatively and immediately postoperatively. Other antibiotics are used if indicated but none are applied directly to the wound area.

Neurosurgical Teams

We have sketched out the basic principles involved in the primary surgical care of war wounds of the brain and spinal cord. Equally important and requiring much planning are the aspects of patient transportation, location of a neurosurgical team, composition of the team, its organic equipment and 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 rough handling should be stressed. Helicopter ambulance service is preferable when the tactical situation permits. Postoperatively, the patients should be moved, by air if possible, to a base zone center as soon as their condition permits movement. The forward unit cannot afford to become overloaded with long-term cases.


The forward unit providing primary definitive neurosurgical care needs to 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 and a higher mortality rate.

The hospital to which a neurosurgical team is attached should be of the evacuation type, for this is large enough to absorb the postoperative care of the patients, to aid in the preparation of sterile supplies, and accommodate the team itself without undue strain. This may not be practical and 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, miniature hospitals, 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 procedures per day under optimum conditions for a period of several days. With the exception of special equipment, most of the necessary medical supplies can be drawn from the hospital to which the unit is attached. The neurosurgical group should not be considered a permanent attachment to a hospital but rather a mobile specialty unit. To aid in this function, sufficient organic transportation 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 be arrived at by estimating the expected or observed number of casualties. Approximately 10 percent of the seriously wounded men have damage of the brain or spinal cord. Teams, or parts of teams, may have to be moved as needed 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 should be carried out so that the unit members will become efficient in their functions. Our neurosurgeons must be trained to operate with simplicity and speed and have the opportunity to guide their teams in their proposed duties. We do not shirk residency training to accomplish peacetime surgical competence. We cannot afford to be delinquent in such training to prepare for the surgical treatment of war wounds.