Uniformed Services University of Health Sciences, USA.
Neurosurg Focus. 2010 May;28(5):E1. doi: 10.3171/2010.2.FOCUS1022.
Decompressive craniectomy has defined this era of damage-control wartime neurosurgery. Injuries that in previous conflicts were treated in an expectant manner are now aggressively decompressed at the far-forward Combat Support Hospital and transferred to Walter Reed Army Medical Center (WRAMC) and National Naval Medical Center (NNMC) in Bethesda for definitive care. The purpose of this paper is to examine the baseline characteristics of those injured warriors who received decompressive craniectomies. The importance of this procedure will be emphasized and guidance provided to current and future neurosurgeons deployed in theater.
The authors retrospectively searched a database for all soldiers injured in Operations Iraqi Freedom and Enduring Freedom between April 2003 and October 2008 at WRAMC and NNMC. Criteria for inclusion in this study included either a closed or penetrating head injury suffered during combat operations in either Iraq or Afghanistan with subsequent neurosurgical evaluation at NNMC or WRAMC. Exclusion criteria included all cases in which primary demographic data could not be verified. Primary outcome data included the type and mechanism of injury, Glasgow Coma Scale (GCS) score and injury severity score (ISS) at admission, and Glasgow Outcome Scale (GOS) score at discharge, 6 months, and 1-2 years.
Four hundred eight patients presented with head injury during the study period. In this population, a total of 188 decompressive craniectomies were performed (154 for penetrating head injury, 22 for closed head injury, and 12 for unknown injury mechanism). Patients who underwent decompressive craniectomies in the combat theater had significantly lower initial GCS scores (7.7 +/- 4.2 vs 10.8 +/- 4.0, p < 0.05) and higher ISSs (32.5 +/- 9.4 vs 26.8 +/- 11.8, p < 0.05) than those who did not. When comparing the GOS scores at hospital discharge, 6 months, and 1-2 years after discharge, those receiving decompressive craniectomies had significantly lower scores (3.0 +/- 0.9 vs 3.7 +/- 0.9, 3.5 +/- 1.2 vs 4.0 +/- 1.0, and 3.7 +/- 1.2 vs 4.4 +/- 0.9, respectively) than those who did not undergo decompressive craniectomies. That said, intragroup analysis indicated consistent improvement for those with craniectomy with time, allowing them, on average, to participate in and improve from rehabilitation (p < 0.05). Overall, 83% of those for whom follow-up data are available achieved a 1-year GOS score of greater than 3.
This study of the provision of early decompressive craniectomy in a military population that sustained severe penetrating and closed head injuries represents one of the largest to date in both the civilian and military literature. The findings suggest that patients who undergo decompressive craniectomy had worse injuries than those receiving craniotomy and, while not achieving the same outcomes as those with a lesser injury, did improve with time. The authors recommend hemicraniectomy for damage control to protect patients from the effects of brain swelling during the long overseas transport to their definitive care, and it should be conducted with foresight concerning future complications and reconstructive surgical procedures.
去骨瓣减压术定义了这个损伤控制战伤神经外科时代。在以前的冲突中，以前采用保守治疗的损伤现在在远前方的战斗支援医院积极减压，并转移到沃尔特·里德陆军医学中心（WRAMC）和贝塞斯达的海军医疗中心（NNMC）进行确定性治疗。本文的目的是研究接受去骨瓣减压术的受伤战士的基线特征。将强调这一程序的重要性，并为当前和未来在战区部署的神经外科医生提供指导。
作者回顾性地在 WRAMC 和 NNMC 数据库中搜索了 2003 年 4 月至 2008 年 10 月期间在伊拉克自由行动和持久自由行动中受伤的所有士兵。纳入本研究的标准包括在伊拉克或阿富汗的战斗行动中遭受的闭合性或穿透性头部损伤，并随后在 NNMC 或 WRAMC 进行神经外科评估。排除标准包括无法核实所有主要人口统计学数据的病例。主要结局数据包括 NNMC 或 WRAMC 就诊时的损伤类型和机制、入院时的格拉斯哥昏迷量表（GCS）评分和损伤严重程度评分（ISS），以及出院时、6 个月和 1-2 年时的格拉斯哥结局量表（GOS）评分。
在研究期间，408 名患者因头部受伤就诊。在这一人群中，共进行了 188 例去骨瓣减压术（154 例穿透性头部损伤，22 例闭合性头部损伤，12 例损伤机制不明）。在战区接受去骨瓣减压术的患者入院时的初始 GCS 评分明显较低（7.7 +/- 4.2 对 10.8 +/- 4.0，p < 0.05），ISS 较高（32.5 +/- 9.4 对 26.8 +/- 11.8，p < 0.05）。当比较出院时、6 个月和 1-2 年后的 GOS 评分时，接受去骨瓣减压术的患者明显低于未接受去骨瓣减压术的患者（3.0 +/- 0.9 对 3.7 +/- 0.9，3.5 +/- 1.2 对 4.0 +/- 1.0，3.7 +/- 1.2 对 4.4 +/- 0.9）。也就是说，组内分析表明，接受去骨瓣减压术的患者随着时间的推移有持续改善，使他们平均能够参与并从康复中受益（p < 0.05）。总体而言，83%有随访数据的患者在 1 年内的 GOS 评分大于 3。
本研究对在严重穿透性和闭合性头部损伤的军事人群中早期实施去骨瓣减压术进行了研究，这是迄今为止在民用和军事文献中规模最大的研究之一。研究结果表明，接受去骨瓣减压术的患者比接受开颅术的患者损伤更严重，虽然与损伤较轻的患者相比，结果并不理想，但随着时间的推移，他们确实有所改善。作者建议进行半颅脑切除术以进行损伤控制，以防止患者在长途海外转运到确定性治疗期间出现脑肿胀的影响，并且应该预见到未来的并发症和重建手术。
