Sammendrag
ABSTRACT
Introduction: Developing public services for cranial neurosurgery is an urgent need in Cambodia. To empower a regional hospital with adequate cranial neurosurgical capacity for trauma care, the University Hospital of Northern Norway (UNN) conducted medical training in emergency cranial neurosurgery. A prospective, descriptive interventional cohort study was conducted from January 2015 to December 2016 to evaluate the teaching effect of this trauma training program.
Methods: A total of 235 patients with traumatic brain injury (TBI) who received emergency burr-hole trephination or craniotomy from the cohort study were included in the analysis. The primary outcome was Glasgow Outcome Score (GOS) ratings three months after the injury/incident. Other outcomes as wound infection after surgery and mortality at the last follow-up were also assessed. We comprehensively evaluated UNN's neurosurgical training program by looking at the neurosurgical practice patterns and the surgical outcomes. First, the population characteristics were compared by surgery types to infer the selecting patterns. We further explored the relationship between the surgery types and the identified patient characteristics by literature comparison to examine whether the identified patterns were consistent with common neurosurgical practices. Since there was an association between surgery type and trauma diagnosis, the literature was compared from two aspects: the selection of surgery types for different trauma diagnoses and the general characteristics of different trauma diagnoses. Finally, the surgical outcome was evaluated according to the trauma diagnoses. The independent risk factor was identified using binary logistic regression.
Results: In the study hospital, TBI patients who underwent emergency cranial neurosurgery were majorly young men (62.1% of patients under 35 years of age; 12.3% female vs. 87.7% male), with acute epidural hematoma (EDH) and acute subdural hematoma (SDH) as the most common diagnoses, and with long transfer delay (especially among patients who underwent burr-hole trephination). All patients diagnosed with chronic intracranial hematoma underwent burr-hole trephination, and almost all patients (99%) diagnosed with acute intracranial hematoma underwent craniotomy. The incidence of favorable outcomes (GOS 4-5) at three months after injury of chronic intracranial hematoma, acute SDH, acute EDH, and acute intracerebral hematoma were 96.2%, 89.2%, 93%, and 97.1%, respectively. The mortality rates at the last follow-up were 3.8%, 10.8%, 7%, and 2.9%, respectively. Patients in a vegetative state on the fifth day after surgery were all deceased before the last follow-up. The risk of postoperative infection (polytrauma-adjusted odds ratio [OR] = 10.93, 95% CI: 3.63–32.95) and unfavorable outcome at three months after injury (age-adjusted OR = 26.74, 95% CI: 8.02–89.13; time from injury to admission-adjusted OR = 26.35, 95% CI: 7.83–88.71) significantly increased in the group with preoperative Glasgow Coma Scale (GCS) < 7 compared to the group with preoperative GCS ≥ 7.
Conclusion: The patterns for selecting the emergency burr-hole trephination or craniotomy as surgical treatment were consistent with the common neurosurgical practices in other countries, including the United States. Based on the surgical outcomes, the emergency operations in the study hospital were acceptable. In general, the UNN’s training program in emergency cranial neurosurgery was successful in the study hospital. The findings suggested an association of GCS < 7 with the risk of wound infection after surgery and unfavorable outcomes three months after injury.
Keywords: low-resource settings; Neurosurgical capacity; Traumatic intracranial hematoma; Medical training; Cambodia