THE CHARLESTON GAZETTE
06/18/2007
ERIC EYRE, ERICEYRE@WVGAZETTE.COM

It was a simple idea, but it took a brain surgeon to figure it out. About 10 years ago, Dr. John Schmidt and physician's assistant Larry Young were operating on a patient with a head injury at CAMC-General Hospital. They were unsure whether the patient's brain would swell, which would require them to cut out part of her skull to relieve pressure.

So they improvised. They used a router saw to remove a 6-inch piece of bone flap, then attached a titanium plate and hinge. The skull bone would flap open if the brain swelled.

The patient survived the surgery.

" We said, 'Maybe let's put in a hinge, and see if it swells,' and we've been doing it ever since," recalled Schmidt, a neurosurgeon affiliated with CAMC.

Schmidt has used the technique, which he calls "hinge craniotomy," on more than 30 people with severe brain swelling. Most are trauma patients with head injuries after motor vehicle accidents, falls and assaults. The hinge technique also works on people who suffer strokes and other brain injuries that cause swelling.

In September, Schmidt will publish an article about the technique in the Journal of Neurosurgery, the most prominent journal in the field. The publication's cover will feature an illustration of the hinge procedure.

" The technique is going to get national attention," said Dr. Bernardo Reyes, a CAMC clinical research scientist who helped Schmidt write the article. "It's huge exposure for him, CAMC and the state."

Schmidt used a fiberglass skull to explain the technique last week.

When someone's brain is injured, it can swell up to twice its normal size. "It rises like bread dough," Schmidt said.

The skull, however, prevents the brain from swelling. The intense pressure results in brain damage or death.

To relieve severe brain swelling, surgeons try medications first. If that doesn't work, they use a saw and cut out a bone flap on the side of the skull.

" This is the last thing you do before you say they're not going to make it," Schmidt said.

Surgeons next decide what to do with the bone. A common practice is to cut open the patient's belly, place the bone inside, and sew it back up. The belly provides a sterile environment.

Another option is to put the piece of skull in a freezer. Some surgeons throw the bone out, and later repair the skull with metal and plastic materials.

The conventional procedures require up to three additional surgeries.

Instead, Schmidt screws on three small titanium plates to the bone flap. He then hinges one of the plates to the skull, sews the patient's scalp back on and wraps the person's head in gauze. No protective helmet is needed.

The entire procedure lasts an hour and 40 minutes to three hours.

When the brain's swelling subsides, the bone flap simply drops back into place. A perfect fit. No additional surgery to repair the skull is required.

" It's a real simple idea. It's really bright, when you think about it," Reyes said. "It's like being an extremely trained mechanic."

Just over half of the people on whom Schmidt has used the technique have survived. The survival rate for patients undergoing the emergency surgical procedure is low.

" These are serious head injuries we're talking about," he said.

Conventional brain surgery and bone-flap removal sometimes leaves patients with skull deformities, which require additional surgery to correct.

Schmidt's hinge technique prevents the bone flap from sinking into the head, which might cause headaches, fatigue, memory problems and depression among patient's who survive the traditional surgery.

Schmidt has talked about the hinge technique at two neurosurgery conferences. However, he's unaware of doctors outside his practice - Neurological Services Inc. in Charleston - who have adopted the technique.

" It's a hopeful situation if people continue to try things like this as an alternative to throwing the bone flap away or putting it in the freezer," Schmidt said.

Reyes said the majority of patients who have their skulls opened because of severe brain injuries receive government-funded health insurance through Medicaid.

Reyes predicts that Schmidt's hinge technique will save hospitals and the government money by eliminating the need for additional surgeries in the operating room.

" If this starts to become standard, it could impact significantly the way we treat these patients worldwide," Reyes said. "It will improve care and save the taxpayers millions of dollars."

To contact staff writer Eric Eyre, use e-mail or call 348-4869.