Harjinder Singh Bhatoe MS MCh
Lieut Col Army Medical Corps
Jitendar P Vij
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Craniospinal Missile Injuries
© 2003 Harjinder Singh Bhatoe
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 2003
9788180611803
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, A-14, Sector 60, Noida
5Foreword
Since ancient times, missile injuries of the head having of interest to surgeons especially those in the Armed Forces. With the development of more sophisticated weapons, with greater destructive and explosive effect, the mortality and morbidity of such injuries has greatly increased. The system of “triage” has stood the test of time for selecting those which can be saved. The life expectancy and reduced disability has improved with the development of antibiotics and better neurosurgical facilities. Even so, the key factor is early evacuation to a specialised centre. The morbidity and disabilities of the survivor also present a long term and sometimes a depressing outcome.
Missile wounds of spine, however, present a different scene. Unless accompanied with other associated serious trauma they are not fatal. Their brain functions remain normal. Here again, early and prompt evacuation to a specialised centre will help to reduce the effects of trauma. Appropriate surgery, when indicated, will stabilise such cases. The modern facilities of rehabilitation and appliances can allow such a patient to lead a useful and near normal life.
Lt Col Harjinder Singh Bhatoe has very diligently traced the historical perspective, pathophysiology and the controversies in the management of craniospinal missile injuries. He has included illustrative case histories appropriate for each topic. This makes the subject more interesting and clinically oriented. His book will be of interest to all levels of surgeons and neurosurgeons and will be of great benefit to young surgeons and medical officers specially those in peripheral hospitals and field situations.
Brig Mahendra Singh,VSM (Retd)
7Preface
Craniospinal missile injuries are being reported from all over the world. These injuries have traditionally been viewed with pessimism, and a grave outcome is often accepted with forebearance. The pessimistic outlook persists in spite of the exponentially rapid change in terms of head injury management in general. These injuries are seen infrequently in the course of neurosurgical practice and for an average neurosurgeon, they occur to the troops somewhere “out there in the field at the line of control”, or may be in civilian population in “UP and Bihar”. Neurosurgeons specially dedicated to trauma in field may not be the best role models and a young neurosurgeon-in-making would be more inclined to specialize in various fields of neurosurgery, like vascular, skull base, paediatric, stereotaxy and endoscopy. However, it must be remembered that with the increase in availability of firearms, increasing ethnic unrest, deteriorating law and order situations, neurosurgeons in services as well as those in practice may be called upon to treat a patient with missile injury to the brain or spinal cord. Even a cursory glance at the daily newspapers in any major city provides strong evidence that the problem is gradually increasing. The sufferers are often the young (and often, innocent), treatment costs are high in terms of money, technical manpower, and the outcome uncertain. This book aims to address the various aspects of these injuries, as seen in the Indian context, so that a neurosurgeon as well as a surgeon in the field or in a peripheral hospital, can be certain about the approach, scope of surgery and the likely outcome. No pretence is made about this book being a treatise on the subject. Far from that, it is essentially an overview of the subject, and an attempt to fill a gap in Indian neurotrauma scenario.
Harjinder Singh Bhatoe
9Acknowledgements
- Brig Mahendra Singh vsm, ms, (retd)
- Consultant Neurosurgeon and Past President
- Neurological Society of India
- Maj Gen S Venkataraman vsm, md, dm, (retd)
- Senior Consultant Neurologist
- Mata Chanan Devi Hospital
- New Delhi
- Prof S Mohanty mch
- Director, Institute of Medical Sciences
- Head of Department of Neurosurgery
- Banaras Hindu University
- Varanasi
- Col Prakash Singh mch
- Senior Adviser Neurosurgery
- Army Hospital (Research & Referral)
- Delhi Cantt
- Lt Col JD Mukherji md, dm
- Neurologist
- Army Hospital (Research & Referral)
- Delhi Cantt
advanced dressing station
CBF
cerebral blood flow
CMI
cranial missile injury
CPP
cerebral perfusion pressure
CT
computed tomography
FSC
forward surgical section
ICP
intracranial pressure
ISS
injury severity score
MABP
mean arterial blood pressure
MIS
missile injury of spine
MRI
magnetic resonance imaging
RAP
regimental aid post
VHIS
Vietnam head injury study
WHIS
war head injury severity score