Craniectomy is the surgical removal of a portion of skull (cranium), leaving an opening in the skull that may be left open

or covered with synthetic material. This procedure is often used to remove tumors in the rear of the brain (cerebellum) and to relieve brain swelling. A craniectomy also allows surgical treatment of diseases that affect the cranial nerves supplying sensation and movement to the structures of the head and neck. The procedure is classified as an emergency if pressure within the skull (intracranial pressure), usually from bleeding within the brain or its coverings, has increased to a dangerous level.

Reason for Procedure Craniectomy is most commonly performed to remove a tumor or hematoma, a collection of blood and blood clots, from beneath the skull. A hematoma beneath the skull takes up space, compresses the brain, and decreases the flow of blood and oxygen to brain tissue. If not removed promptly, hematomas often cause permanent brain damage. Hematomas found between the skull and outer covering of the brain (dura mater) are called epidural hematomas and are often arterial in origin. When found between the outer and middle coverings of the brain, they are called subdural hematomas and are often venous in origin.

Craniectomy performed at the base of the skull is called suboccipital craniectomy. This approach allows exploration of the lower back portion of the brain (posterior fossa) and surgical treatment of diseases affecting certain cranial nerves. Through a suboccipital craniectomy, the fifth cranial nerve (trigeminal nerve) can be decompressed or deliberately cut in order to treat severe facial pain (trigeminal neuralgia). The ninth cranial nerve (glossopharyngeal nerve) can be cut to treat severe pain originating in the throat and spreading to the ear (glossopharyngeal neuralgia). A suboccipital craniectomy may also be used to remove tumors (acoustic neuromas) from the hearing (auditory) canal, or to cut a portion of the eighth cranial nerve (the vestibular branch of the vestibulocochlear nerve) when surgically treating Mnire's disease, a chronic condition of the inner ear. How procedure is done

Craniectomy is done in the operating room under general anesthesia. An incision is made in the scalp above the location of the hematoma, abscess, or other condition to be treated while the tissues are held open with small retractors. A bone flap is not turned. Instead, one or more small holes (burr holes) are drilled into the skull with a special drill. The edges of the burr holes are chipped away (rongeur) to enlarge the opening. If a larger opening is needed, a circular saw or a router blade craniotome may be used to connect the burr holes. The circular piece of bone is then removed, exposing a larger work surface for the surgeon.

The collection of blood, clots, or bloody fluid is suctioned out. To control vascular bleeding, the blood vessel is burned (cauterized) or clamped with clips. The brain is irrigated with saline irrigating solution until the return runs clear. A drain may be placed under the skull or dura mater and brought to the outside through a puncture hole in the scalp. The bone is not replaced, although under some circumstances, the long gap is filled with an acrylic material molded in the shape of the skull. The incision is closed and the wound is covered with a sterile dressing. Prognosis Predicted outcome after a craniectomy depends upon the underlying condition, the success of the surgical procedure performed through this approach, and the number and severity of postoperative complications. Individuals who suffer permanent brain damage from bleeding, infection, or increased intracranial pressure may have decreased cognitive ability. They may not be able to perform tasks they could before surgery. In some cases, the impairment can be severe enough to require permanent disability. Individuals with acoustic neuromas removed through a suboccipital craniectomy may experience permanent hearing loss and incapacitating balance problems. Rehabilitation Rehabilitative therapy for individuals who have undergone a craniectomy is aimed at restoring the functions required for activities of daily living. Therapy may range in intensity from minimal to long-term chronic rehabilitative care depending on the nature and severity of the injury or disease that necessitated treatment through a craniectomy approach.

Individuals undergoing craniectomy to treat disorders of the cranial nerves have outpatient rehabilitation plans geared toward the effects of injury to the cranial nerves, such as difficulties in hearing, swallowing, maintaining balance, and using the muscles of facial expression. Such therapy continues until maximum restoration of function or adjustment to loss of function is attained and could take several weeks to several months.

Certain individuals may require psychological counseling to help them adjust to chronic pain or the loss of mental or physical function. Complications Complications of surgery performed through a craniectomy approach include bleeding, swelling of brain tissue resulting in nerve cell damage, wound infection, cranial nerve damage, leakage of the fluid covering the brain (cerebrospinal fluid), and postoperative headache. Air that enters a vein (venous air embolism) can form an air bubble, block off a small vessel, and cause a stroke. Complications of general anesthesia include allergic reaction to the anesthetic agent (anaphylaxis), decreased respiratory rate or effort, airway obstruction, and partial or complete collapse of the lung (atelectasis). A rare but often fatal complication of general anesthesia is a rapid rise in body temperature (malignant hyperthermia). Treatment After a craniectomy, the risk of brain injury is increased, particularly after the patient heals and becomes mobile again. Therefore, special measures must be taken to protect the brain, such as a helmet or a temporary implant in the skull. When the patient has healed sufficiently, the opening in the skull is usually closed with a cranioplasty. If possible, the original skull fragment is preserved after the craniectomy in anticipation of the cranioplasty. Instruments:

Quantity Name 2 Jansen Retractor

Description Blunt 3x3 Blades

Size 4"

2 1 1 1 4 2 2 12 2 2 6 6 18 18 1 1 2 1 1 1 1 1 1 1 1

Weitlaner Retractor Scalpel Handle #3 Scalpel Handle #4 Scalpel Handle #7 Solid Bar Handle For Gigli Saw Adson (Ewald) Dressing Forceps Adson Tissue Forceps Backhaus Towel Clamp Cushing Brain Forceps Cushing Brain Forceps Ruskin Rongeur Foerster Sponge Forceps Halsted Mosquito Forceps Halsted Mosquito Forceps Luer Bone Rongeur Stille-Liston Bone Forceps Mayo-Hegar Nh Gigli Saw Wire Gigli Saw Wire Operating Scissors Mayo-Stille Dissecting Scissors Mayo-Stille Dissecting Scissors Metzenbaum Dissecting Scissors Taylor Dural Scissors Cover for Instrument Tray

Blunt 3x4 Teeth

6-1/2"

Pack of 2 Serrated 1x2 Teeth Delicate Serrated Delicate 1x2 Teeth Straight Serrated Straight Curved Curved 8mm x 10mm Bite Curved Double Action Serrated 4-3/4" 4-3/4" 5-1/4" 7" 7" 7-1/4" 9-1/2" 5" 5" 7" 10-1/2" 7" 12" 20" Straight Sharp/Blunt Straight Curved Curved w/ Probe Tip 6" 6-3/4" 6-3/4" 7" 5-1/2"