title: Decompressive craniectomy and cranioplasty: experience and outcomes in deployed UK military personnel.
abstract: OBJECTIVE
  In recent conflicts, many UK personnel sustained head injuries requiring damage-control surgery and aeromedical transfer to the UK. This study aims to examine indications, complications and outcomes of UK military casualties undergoing craniectomy and cranioplasty from conflicts in Afghanistan and Iraq.
  
  
  METHODS
  The UK military Joint Theatre Trauma Registry (JTTR) was searched for all UK survivors in Afghanistan and Iraq between 2004 and 2014 requiring craniectomy and cranioplasty resulting from trauma.
  
  
  RESULTS
  Fourteen decompressive craniectomies and cranioplasties were performed with blast and gunshot wounds equally responsible for head injury. Ten survivors (71%) had an Injury Severity Score (ISS) of 75, normally designated as 'unsurvivable'. Most were operated on the day of injury. Seventy-one percent received a reverse question mark incision and 7% received a bicoronal incision. Seventy-nine percent had bone flaps discarded. Overall infection rate was 43%. Acinetobacter spp was the causative organism in 50% of cases. Median Glasgow Outcome Scale (GOS) at final follow-up was 4. All casualties had a GOS score greater than 3.
  
  
  CONCLUSIONS
  Timely neurosurgical intervention is imperative for military personnel given high survival rates in those sustaining what are designated 'un-survivable' injuries. Early decompression facilitates safe aeromedical evacuation of casualties. Excellent outcomes validate the UK military trauma system and the stepwise performance gains throughout recent conflicts however trauma registers most evolving to have specific relevance to military casualties. In high-energy trauma with contamination and soft-tissue destruction, surgery should be conducted with regard for future soft tissue reconstruction. Bone flaps should be discarded and cranioplasty performed according to local preference. Facilities receiving military casualties should have specialist microbiological input mindful of the difficulties treating unusual microbes.
authors.affiliation: a The Computational, Cognitive and Clinical Neuroimaging Laboratory (C3NL) , The Hammersmith Hospital , London , UK ;|b Academic Department of Military Surgery and Trauma (ADMST) , Royal Centre for Defence Medicine (RCDM), Medical Directorate, Joint Medical Command, ICT Centre , Birmingham , UK ;
authors.forename: S A G
authors.initials: SA
authors.lastname: Roberts
authors.affiliation: c National Institute for Health Research (NIHR) , Surgical Reconstruction & Microbiology Research Centre (SRMRC) , Birmingham , UK ;
authors.forename: E
authors.initials: E
authors.lastname: Toman
authors.affiliation: c National Institute for Health Research (NIHR) , Surgical Reconstruction & Microbiology Research Centre (SRMRC) , Birmingham , UK ;
authors.forename: A
authors.initials: A
authors.lastname: Belli
authors.affiliation: b Academic Department of Military Surgery and Trauma (ADMST) , Royal Centre for Defence Medicine (RCDM), Medical Directorate, Joint Medical Command, ICT Centre , Birmingham , UK ;|d The Rurul Clinical School, University of Queensland , Australia.
authors.forename: M J
authors.initials: MJ
authors.lastname: Midwinter
mesh_terms: D000293:Adolescent; D000328:Adult; D055826:Afghan Campaign 2001-; D001753:Blast Injuries / Q000601:surgery; D006259:Craniocerebral Trauma / Q000601:surgery; D003399:Craniotomy / Q000379:methods*; D056424:Decompressive Craniectomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D023261:Glasgow Outcome Scale; D006801:Humans; D054542:Iraq War, 2003-2011; D008297:Male; D008889:Military Personnel / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013524:Surgical Flaps; D013530:Surgical Wound Infection / Q000453:epidemiology; D016019:Survival Analysis; D016896:Treatment Outcome; D006113:United Kingdom; D014948:Wounds, Gunshot / Q000601:surgery; D055815:Young Adult
keywords: Decompressive craniectomy; complications; cranioplasty; military; operative experience; outcomes