Fig. 19. Third Stage in the Formation of an Osteoplastic Flap. The dural flap turned down and the brain exposed. Note the relation of the scalp, bone, and dural incisions to one another.
The dura is now separated from the bone along the line of the two vertical incisions, and the visceral blade of de Vilbiss’s forceps insinuated beneath the bone, starting at one trephine-hole and working downwards to the lower limit of the incision. It is essential that the operator should be satisfied with the ‘morcellement’ of small portions of bone at each bite of the instrument. At the lower end of each of the vertical incisions the forceps is directed inwards for 1⁄4 to 1⁄2 inch so as to weaken the base of the flap.
To lift up the osteoplastic flap, a stout elevator or spatula is introduced beneath the bone at its upper part, leverage applied, and, as soon as sufficient elevation has been attained, the dura mater carefully separated from the whole of the under aspect of the flap. The flap is then grasped at its upper part with both hands and, with a quick but forcible jerk, broken across at its base, the assistant at the same time aiding the correct linear fracture of the bone by a flat spatula applied to the outer aspect of the base of the flap. Insomuch as the flap is most usually framed in the parieto-temporal region—for the exposure of the motor area—the base of the flap, being formed from the squamous portion of the temporal bone, is comparatively weak. Fracture is then readily obtained. Under other circumstances the base may be sufficiently weakened by the application of the de Vilbiss forceps or by the use of the Gigli saw.
The bone-flap is thrown back and enveloped in gauze. Its basal region is examined for a possible injury to meningeal vessels. In the event of such complications the bleeding vessel is clipped, ligatured, or underrun. Possibly some branch of the anterior division of the middle meningeal artery, running in an osseous canal, may require to be controlled by foraminal occlusion—with a wooden match, bone peg, cotton-wool, or aseptic wax.
In comparing the relative advantages and disadvantages of craniectomy and craniotomy, although there are certain definite contra-indications to the latter method, yet craniotomy should always be carried out when the surgeon desires to expose a large surface area of brain, more especially in the exposure of a tumour diagnosed to lie in relation to the motor cortex. Even if the operator should be unsuccessful in his exploration, or, if finding the tumour, should deem it irremovable, the dura can be sewn up and the bone-flap replaced, resting on its bevelled edge, with little defect in the skull and a normal surface contour.
The three main disadvantages to craniotomy are as follows:—(1) the operation can seldom be done under much less than thirty minutes; (2) there is some slight risk of complication through injury to the middle meningeal artery; and (3) the dura mater may be so adherent to the bone as to be torn in the process of flap-elevation. Time, however, is usually of little importance; bleeding from the middle meningeal artery may be controlled, and dural lesions may be avoided by careful technique. In general, the advantages of osteoplastic resection greatly outweigh the disadvantages.
The more definite contra-indications to the formation of the bone-flap are as follows:—
1. This operation is unnecessarily severe in most cases of intracranial hæmorrhage, e. g. from the middle meningeal artery. It is also usually impracticable by reason of the associated damage to the bones of the vault and base.
2. It is contra-indicated in operations conducted for the exposure of the Gasserian ganglion, its root and its branches (trigeminal neuralgia). In these operations it is essential that the operator should get down as low as possible towards the base of the skull.
3. It is contra-indicated in operations conducted in the cerebellar region. Even after cerebellar exposure by craniectomy, the surgeon is working in a sufficiently confined space. The presence of a bone-flap only adds further difficulty and complication. Added to this is the fact that the thin wall of the cerebellar fossa is not adapted to osteoplastic flap-formation.