I WAS prepared for the blood but the most shocking thing about watching brain surgery was seeing the surgical drapes being stapled to the patient’s face. But surgeon Peter Hutchinson dismisses my concern that the tiny holes might bother the patient when she wakes up: “That’s nothing compared with the massive hole we’re about to make in her head.”
I am at Addenbrooke’s Hospital in Cambridge, UK, to learn about craniectomy, a procedure that involves removing a large part of someone’s skull, to relieve the pressure inside. There are no official tallies but it’s thought that several hundred surgeries take place in the UK every year on people with head injuries or who have had a stroke. Once the brain is given room to swell, the pressure drops and the scalp is sewn back into place. The skull fragment can be stored in a freezer or kept sterile inside the patient’s abdomen for weeks or months before it is reattached.
The operation I’m witnessing is part of a randomised trial to compare the effectiveness of craniectomy with that of drugs alone to bring the pressure down. It will involve 400 people with head injuries, half of whom will get the surgery.
This is needed as craniectomy has a long and chequered history. Human remains suggest it was done with stone tools in Peru a thousand years ago, a practise known as trepanning, perhaps for similar reasons as today. As a modern surgical procedure, though, it has fallen in and out of favour over the last few decades. Whether you would be sent for surgery today depends on how safe your surgeon thinks it is.
There are concerns that while it may save people’s lives, it might make it more likely that someone will end up in avegetative state. The number of people in this state is rising in most Western countries, as more people survive serious injuries thanks to medical advances. But some are concerned that craniectomy is contributing.
The problem with the procedure is that such a brutal assault could be doing more harm than good. One risk is infection, caused by bacteria on the patient’s skin entering the wound. Hence the need to anchor the drapes so firmly in place to ensure the skin stays covered up.
Another risk is nicking a major blood vessel. I see how this fear affects the surgical team when I observe a second operation. The patient needs a circle of skull removed that overlies a major artery. The team members joke about how, if things go wrong, they will need to change their socks – because of the ensuing torrent of blood. The banter stops as they start to ease the skull away from the brain, gently severing recalcitrant tissue. With the skull removed, they step back to look at the blood vessel almost reverently, then delicately cover it with gauze.
The man’s brain throbs before our eyes with each beat of his heart. Hurt it, and he could awake unable to speak or move – or he might not wake at all.
Hutchinson has spent years planning this trial and convincing colleagues at other hospitals to take part. But he insists he doesn’t care what the outcome is, merely that we finally learn if we should use this controversial procedure. “I’m not passionate about the operation, I’m passionate about the trial,” he says. “We need answers.”