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192 Craniocerebral and Spinal Trauma

Table 30.1: Paediatric (Adelaide) Scale.
Normal score Normal eye Score Normal motor Score Normal verbal Score Total
at age opening response response
0–6 months Spontaneous 4 Flexion 3 Cries 2 9
6–12 months Spontaneous 4 Localises 4 Vocalises 3 11
1–2 years Spontaneous 4 Localises 4 Words 4 12
2–5 years Spontaneous 4 Obeys 5 Words 4 13

nerve deficits may require surgical decompression and corticosteroid.
Growing skull fractures are peculiar and are characterised by a
pulsatile scalp swelling overlying an enlarged bony defect with an
associated underlying leptomeningeal cyst. They are repaired via cyst
drainage, dura graft, and autologous skull graft.
Haematomas
Subgaleal haematomas can be very massive in children to the extent of
inducing hypovolaemic shock.
Prompt recognition and evacuation of epidural haematomas via a
craniotomy leads to a good and rapid neurological recovery.
Acute subdural haematomas carry a high mortality. The
recommended surgery is craniotomy and evacuation. Chronic subdural
haematomas are approached via burr-hole evacuation.
Intraparenchymal haemorrhage may be large enough to cause
neurologic deficit or midline shift, and surgical evacuation is indicated
in such children as they tend to recover from neurologic deficits.
Intraventricular haematoma is managed with external ventricular
drainage.
Figure 30.3: Skull x-ray showing intraventricular pneumocephalus.
Penetrating injuries
Positioning In the presence of a protruding penetrating foreign body, the offending
Elevation of the head of the bed to 15–30 degrees, when not contrain- object should not be removed instantaneously. Following clinical evalu-
dicated, optimises arterial flow and venous drainage. ation, a plain radiograph in two views and a brain CT scan should be
Oxygenation requested. Appropriate consultation should be sought, such as from an
Oxygenation leads to improved cerebral oxygenation and a reduction ophthalmologist for orbitocranial injuries. Appropriate broad spectrum
in cerebral oedema. antibiotics and tetanus prophylaxis are to be instituted. The aim of
Mannitol surgery is removal of the foreign body in a controlled condition in the
14
Mannitol is very effective and can be life saving. It reduces blood vis- operating room. In the absence of a retained foreign body, the goal
cosity and acts as an osmotic diuretic. It is given only after adequate of surgery is to debride the tract and repair the dura and bony defects.
volume resuscitation. The dose is 0.5–1g/kg body weight over 20 min- Basic Neurosurgical Procedures
utes (bolus). However, because of its rebound effect, it should be admin- Burr-hole evacuation of chronic subdural haematoma
istered only when the patient is being prepared for an indicated surgery.
Controlled hyperventilation 1. The patient is positioned supine, head turned laterally and elevated
Hyperventilation has a very rapid effect and is aimed at reducing the 15 degrees, with shoulder support.
PaCO to about 40 mm Hg. Lowering the PaCO further is associated with 2. The site of surgery is shaved and cleaned, and the patient is then
2 2
a risk of cerebral vasoconstriction, leading to cerebral ischaemic injury. draped.
Surgery 3. A vertical incision is made over the site of the haematoma.
Intracranial haematomas in children are treated more aggressively. 4. Usually, the first burr hole is temporal, 2.5 cm above the zygomatic
Specific head injuries arch, just anterior to the ear.
Scalp injuries 5. Scalp bleeding is controlled with cautery and self-retaining mastoid
In young children, blood loss from scalp laceration can lead to shock retractors.
and should be promptly controlled. Scalp loss is managed with skin 6. The periosteum is incised and retracted.
grafts or rotational flaps. 6
Skull fractures 7. A burr hole is made with a drill.
Linear, diastatic, and stellate fractures occur from focal contact forces. 8. The dura is coagulated and incised in a cruciate fashion with a size
They may occur over a venous sinus with resultant tear haemorrhage. 11 blade.
A CT scan is advised in the setting of stellate fractures due to the high 9. The haematoma is evacuated with gentle suction and irrigation,
incidence of underlying contusion. taking care not to injure any bridging vessels. Any bleeding point is
Ping-pong fractures are managed most often nonoperatively because controlled with bipolar cautery.
they often resolve spontaneously.
10. The subdural space is irrigated with normal saline.
Depressed skull fractures are treated with elevation when indicated.
Fractures at the base of the skull are common in children, but 11. A subdural drain may be left in place for 24–48 hours.
cerebrospinal fluid (CSF) leaks often resolve spontaneously. Persistent 12. The incision is closed.
leaks, however, require surgical intervention. Accompanying cranial