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Official Publication of Orofacial Chronicle, India

www.jhnps.weebly.com

EDITORIAL
PUSHING FRONTIERS IN NEUROTRAUMA... EMERGING
FROM THE SHADOWS OF A CENTURY OLD SURGERY
I ype Cherian
Prof and Chair, Department of Neurosurgery,
COMS Bharatpur, Nepal.

Cite this article: Iype Cherian, Pushing frontiers in neurotrauma. Emerging from the
shadows of a century old surgery: Journal of head & neck physicians and surgeons Vol 2
Issue 1 2014: Pg 4-6

We have come a long way in neurosurgery from letting spirits out of the cranial
cavity ... All subspecialties of Neurosurgery has taken advantage of the advances
in technology, and has been providing excellent results..Better Pre op care, better
imaging, magnification, coaxial lighting, and other tools in surgery, navigation and
so much more help is available to the lucky Neurosurgeons of today...and the
results are far better as well..
However, one branch where none of these advancements have peeped into is
Neurotrauma. Head injury is still operated by surgically naive residents worldwide,
and the advancements have been mostly in non operative management.... I would
not discount the merits of so called non operative management, but would also like
to point out that the surgical option is over 110 years old and has no finesse or
skills associated with all the other branches of Neurosurgery. You just cannot
compare both....And funnily enough, this is one place Neurosurgeons seem to
willingly fail...

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Is this because, no senior consultant in Neurosurgery, with enough expertise and
skills want to go and operate on trauma at funny times in the midnight..?Or is it the
dread of that "malignant brain swelling" which nobody can handle and therefore let
the resident do it..? Is this the becoming of us Neurosurgeons who were brave to
combat near hundred percent mortality when we started off a century ago.....? Are
we following the same legacy of people who sweated blood to improve the
specialty and who embraced innovations like microscope, endoscope and
navigation to improve the results... Or did we just forget the biggest killer, head
injuries.. And developed pseudo contempt for it?
With this in the background, we started applying microsurgical principles to
trauma and after 1000 cases; we believe that the so called malignant brain
swelling, "brain mushroom" and so many other dreadful things that we hear from
the residents is an overblown myth... Of course if you do not know how to drive a
car, you cannot obviously drive a race car. It is not fair on the residents to operate
on a condition which is more difficult than clipping most aneurysms or doing most
skull base tumors. People who have witnessed the cases in our center and who
have done cisternostomy on their own will be our witnesses..
We also proposed that the brain swelling which shows up is because the CSF goes
into the brain through Virchow Robin spaces and the brain swells up like a
sponge..This was heavily contested and laughed at, but after Iliff's and
Nedergaards's landmark paper proving that there is abundant transport between
subarachnoid spaces and parenchyma through Virchow Robin spaces, people have
been more kind..
Cisternostomy changes the way brain trauma is done.. It brings trauma
neurosurgery at par with the rest of the branches, if not better... Unless somebody
knows how to open cisterns in a swollen brain and drill anterior clinoid and
posterior clinoid process, they are not fully trained in Cisternostomy.. Residents
who see Cisternostomy daily are much more confident in handling other
pathology, especially vascular and skullbase and also develop finesse rather than
having the urge to just close anything which is seemingly out of control.. A trauma
-swollen brain is probably the most out- of- control thing you would encounter
only next to the wife who found you out with your girlfriend..!!

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Having said this, if the GCS is 3-4 and the pupils are dilated and if there are
radiological evidence of infarction, Cisternostomy may not be of much
help..Which is stating the obvious. But for other cases of severe head injury, it is
time that we changed...
Decompressive hemicraniectomy has been around for too long a time.. It is a
shame that we still follow variants of it and most of the so called "trauma
surgeons" are more of "Medical surgeons".. It is time that finesse and innovations
and technique came to trauma surgery.. We believe Cisternostomy will usher a
new age in trauma Neurosurgery.

Acknowledgments- Nil
Conflict of Interest-Nil
Support-Nil
Correspondence Addresses:
Dr. I ype Cherian,
Prof and Chair,
Department of Neurosurgery,
COMS Bharatpur, Nepal.
Correspondence - drrajucherian@gmail.com