The U.S. Military has deployed combat assets throughout the world. Catastrophic injuries can occur in austere environments with limited or no resources. The standard of care for the treatment of severe Traumatic Brain Injury (TBI) includes the direct evaluation and treatment by a trained neurological surgeon.1,2,3 Because severe TBI can be rapidly fatal, and neurosurgical assets as well as timely critical care air transport of severely brain injured Service Members are not always feasible or available, the U.S. Military has recognized the potential need for non-neurosurgeons (usually general/trauma surgeons) to perform cranial procedures in a far forward setting.4 Data from the DoD Trauma Registry demonstrate that craniectomy procedures have been documented at Role 2 surgical facilities in Iraq and Afghanistan at least 36 times, with indeterminate success. There is some precedent for this practice within the literature,5-8 including reference to the need for this practice as early as World War II.8 This concept is briefly addressed in the treatise on War Surgery from the International Committee of the Red Cross.9 We acknowledge that neurosurgical procedures are possible in austere locations with appropriate training and resources, yet fully recognize that “there is no substitution for a fully trained neurosurgeon in any health care system, whether military or civilian.” 3 It is the responsibility of the U.S. Military neurosurgical community to ensure that our deployed Service Members receive the best care possible from non-neurosurgical colleagues. The purpose of this Clinical Practice Guideline (CPG) is to provide specific and tailored guidelines for the performance of cranial procedures by non-neurosurgeons. The document has been developed jointly by the neurosurgeons 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 (JTS), 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.