Introduction

The U.S. Military has deployed combat assets throughout the world.  As such, catastrophic injuries can and do occur in austere environments with limited or no resources.  It is understood that the standard of care for the treatment of severe traumatic brain injury includes the direct evaluation and treatment by a trained neurological surgeon.1,2  Because there are not enough neurosurgical assets to support all missions, and because timely critical care air transport of severely brain injured servicemen and women is not always available depending on the location, and because severe and catastrophic brain injury can be rapidly fatal, the U.S. Military has recognized the occasional need for certain non-neurosurgeons (usually general surgeons) to perform cranial procedures far forward.3  Data from the DoD Trauma Registry demonstrate that craniectomy procedures have been documented at Role 2 surgical facilities in Iraq and Afghanistan 36 times, with indeterminate success.  There is some precedent for this practice within the literature,2,5-6 including reference to the need for this practice as early as World War II.7  This concept is addressed to a certain extent in the treatise on War Surgery from the International Committee of the Red Cross.8  In the aforementioned references, there is tacit acknowledgement that neurosurgical procedures are possible in austere locations with appropriate training and resources.  With this in mind, it has become the responsibility of the U.S. Military neurosurgical community to ensure that our deployed servicemen and women receive the best care possible from non-neurosurgical colleagues. The purpose of this clinical practice guideline is therefore to provide specific and tailored guidelines for the performance of cranial procedures by non-neurosurgeons.  The document has been developed jointly by the neurosurgical departments of all three services to support the non-neurosurgeon faced with this difficult situation. 

This CPG was developed by consensus opinion from the Joint Trauma System, neurosurgical members of the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS), Joint Military Committee and the AANS/CNS Section of Neurotrauma.  This document has been reviewed by and is supported by the Defense and Veterans Brain Injury Center.