Decompressive surgery in acute head injuries: where should it be performed?
BACKGROUND
In Norway, most patients with severe head injuries are transported to, and operated in, the neurosurgical unit of the regional university hospital. However, some patients are still occasionally operated on in county central hospitals by orthopedic or general surgeons who do not have neurosurgical expertise. The aim was to analyze this surgical activity outside the neurosurgical units.


METHODS
Data were collected from two sources: a nation-wide survey and the records of all patients with a severe head injury occurring within Vestfold county (1987-1996).


RESULTS
The Norwegian county central hospitals perform each only 2.5 to 3 surgical evacuations of intracranial hematomas per year. In Vestfold county, a total of 161 patients were hospitalized alive with an acute severe head injury. One third of the patients (54 patients) underwent decompressive surgery, mostly evacuations of intracranial hematomas. The patients operated on in the central hospital had a significantly worse outcome than the patients who were transferred to and operated on in the neurosurgical unit of the regional hospital. Only patients with extracerebral hematomas were operated on in the central hospital. Patients with an extradural (epidural) hematoma had a better outcome than patients with an acute subdural hematoma. Based on the surgery records and preoperative and postoperative computed tomographic scans, one third of the operations (10 operations) in the central hospital were classified retrospectively as inadequate, because the hematoma was not evacuated or found or because the surgeons did not achieve control of the perioperative bleeding. The overall mortality rate was 29.8%.


CONCLUSIONS
The present study indicates that, in Norway and countries with a similar hospital system, it must be difficult for general and orthopedic surgeons to achieve and maintain the skills required for emergency operations in patients with acute severe head injuries. Thus, it is probably to the patients' benefit to improve the general hospitals' competency and speed in the detection of candidates for surgical decompression, and stress the importance of these patients being transferred without unnecessary delay to a neurosurgical unit.
Wester
T
T
Department of Orthopaedic Surgery, Vestfold County Central Hospital, Tønsberg, Norway.
Fevang
L T
LT
Wester
K
K
D000208:Acute Disease; D000328:Adult; D000368:Aged; D001930:Brain Injuries / Q000401:mortality / Q000601:surgery*; D019299:Decompression, Surgical; D004630:Emergencies; D005260:Female; D006407:Hematoma, Epidural, Cranial / Q000601:surgery; D006408:Hematoma, Subdural / Q000601:surgery; D017052:Hospital Mortality; D006766:Hospitals, County / Q000706:statistics & numerical data; D006785:Hospitals, University / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000592:standards / Q000706:statistics & numerical data; D009664:Norway / Q000453:epidemiology; D010360:Patient Transfer; D011787:Quality of Health Care; D015996:Survival Rate; D016896:Treatment Outcome