February 2, 2015
Written by Marty Susskind (class of 2014-2015)
Cranioplasty and Radius Fracture Repair
Today could easily be summed up with one powerful word; Brain! Sure I have seen them on T.V, movies, and textbooks but there is absolutely nothing like the real thing in this case. A human brain exposed commands the same kind of zoned-in visual awe that a campfire or the ocean waves do. For a neuro-nerd like myself this was a truly unforgettable day.
First, some advise to all OREXers, when you see “cranioplasty” written on the white board, choose it. In this case, the patient was a 35-year-old man who had suffered a traumatic brain injury in a car accident on New Years. The patient underwent a number of surgeries right after the accident including the removal of a large portion of his right skull (called a bone flap in surgical terms) in order to relieve pressure on his swollen brain. Significant brain hemorrhaging was detected by a CT-scan but the doctors decided not to go through with any lobotomy procedure. The hope was that the patient would instead regain some cognitive activity over a two-month span without his right skull putting pressure on his brain. Unfortunately the patient’s status had not improved significantly and the surgeons were pessimistic about his chances of recovery after this cranioplasty procedure.
The patient’s head had what could only be described as a huge chunk missing from it as he was brought into the room and prepped by the nurses. His hair was buzzed off with clippers and the site on his skull was carefully prepped with iodine. The nurse described the surgery site as “soft” because it was essentially just brain and muscle left under his skin. The “skull flap” was brought into the surgery room in a box sent from a tissue bank the night before. The surgeon told me that in most cases they would have put the piece of skull into the patient’s abdominal cavity for storage until this second surgery but they couldn’t in this case because the patient had also had his spleen removed after the accident and couldn’t handle the temporary implant. The sample was stored in a sort of anti-biotic solution on ice and so the surgeon (Dr. Castro-Manre) had to thaw it for roughly an hour and a half in saline before beginning the surgery. The patient was under anesthesia during this time and I took the opportunity to see another surgery (compound radius fracture) in the mean time.
This surgery was only about 1 hour long. A metal plate was drilled into the patient’s re-set radius with 8 screws to repair the fracture but the coolest part was the anatomy lesson I got from the doc. He tugged on all of the individual tendons in the open surgical site to show me how they moved their corresponding fingers! It was one of the coolest things I have ever seen; pull the string, watch the finger curl! We Orexers are pretty spoiled by the amazing surgeons/teachers in the O.R.
When the wrist surgery was finished and the patient was stitched back up, I went back into O.R. 1 for the cranioplasty and sure enough the bone flap had thawed and the operation was underway. The skin had already been opened by the time I walked in and a huge portion of brain was entirely exposed! The surgeons let me get right up against the surgical bed to see the entire operation. The peeled back skin and the skin around the exposed brain were lined with plastic clips, which were attached to the sterile covering so that only the operation site was exposed. The thick membrane above the brain called the dura mater (Latin for “tough mother”) was peeled back so new protective layers could be added to the patient’s brain. First a white Duragen implant like a lattice mesh was layered onto the brain like patches on a quilt. Then, a blue gel epoxy was squirted onto the patches. The gel instantly polymerized on the brain to mimic the fluid like layer that naturally blankets the human brain. At this point, the surgical site was an explosion of red, white, and blue. A patriotic mess. The next step was to put the two pieces of the patient’s skull flap back together into one. The surgeons used butterfly clips to bridge the breaks in the skull pieces and then screwed them together. They used 6 screws in three clips to re-assemble one continuous chunk of skull. They then screwed the fully assembled skull flap back into the open site in the patient’s head again using these butterfly clips and screws to connect it to the surrounding skull. The temporal muscle was then sewn back to the skull using the butterfly clips as a kind of scaffolding (crazy innovative!). Finally the plastic clips were removed from the surrounding skin and the flap was sewn back to the head. Roughly 30 staples were also used to close the patient back up.
In the end, one piece of skull right at the temple was left without repair so that any remaining pressure from swelling could be relieved during his hopeful rehabilitation. If he does indeed make a miracle comeback, he can always have that last piece of skull patched up in cosmetic surgery. Here’s hoping! Some tubing was also left through his skull so that it could be hooked up to an aspirator in the I.C.U. and relieve fluid pressure for the next few days.
The surgeon told me that the biggest concern was that the patient had been hypoxic for a long time after (maybe a half hour) the accident and his brain would probably never recover from hat. Apparently it is common for the heart to slow down drastically right after a traumatic brain injury. Another new thing learned in OREX…
Today was the first time I ever saw a human brain and the entire operation was one of the most intense things I have ever witnessed but it was also the first time I saw a surgery on a patient that will probably never recover. Today was a real reminder and eye opener that these bodies on these gurneys are patients, they are people, with families, and surgery is sometimes just as much about hope as technique. Again… here’s hoping!