Facial injury should be considered separately as soft tissue and hard tissue injuries. Diagnosis between them is very important to obtain good results for appropriate treatment. Soft tissue includes facial nerve branches in the cheek, a parotid duct in the cheek injury, and lacrimal draining system in the medial canthal region. Basic planning of the treatment is respective primary repair of the injured tissue. Rarely reconstruction using autogenous ductal tissue such as a vein should be considered for the tissue defect. Topical management of the scar on the face is challenging for the proper plastic surgical suturing technique. Layer to layer suture is also fundamental technique for general sugery. W shaped scar plasty for the visible scar is important procedure for facial aesthetics.
Conversely, facial bone injury is of particular importance in precise diagnosis and its prognosis for the treatment. Basic diagnosis includes pulpation, inspection, and roetogenographic and CT scans. Treatment protocol consists of precise reduction and repositioning as much as possible with rigid osteosynthesis. Delayed treatment of the facial bone injury becomes more difficult, because of consequent atrophy and shrinkage of the soft tissue around the injured bone. Malunited fracture induces unpredictable deformity, which requires definitive plastic surgical reconstruction using basic autogenous bone and or cartilage as well as soft tissue, such as fat, fascia, or muscle tissue. Functional as well as aesthetic reconstruction are required for the treatment of old fractures. Fundamental diagnostic procedure and proper treatment is described in this report.
Over the past decade, imaging technologies have been successfully developed and many imaging modalities have emerged in the clinical field. In this article, the symposium entitled “Brain imaging in traumatic brain injury” held in the 32nd annual meeting of the Japan Society of Neurotraumatology is reviewed and recent advancement of neuroimaging in head trauma is discussed. In the symposium, six investigators presented the role and the usefulness of their imaging modalities including morphological imaging using CT angiography and 3-tesla MRI, functional imaging using diffusion tensor imaging, blood flow imaging using SPECT, and molecular imaging using PET in the acute or chronic stage after traumatic brain injury (TBI). They demonstrated that the use of modern imaging tools could improve early recognition of primary damage and understanding the underlying mechanisms of secondary damage after TBI.
CT scanning is the most important imaging technique for acute TBI, giving rapid information and being part of a general trauma work up in an emergency situation. Guidelines for CT scanning in minor head injury have been proposed, however, a recent validation study has failed to show the cost-effectiveness. MRI is an imaging technique for evaluating the full extent of brain injury. Information on brain injury especially diffuse axonal injury is obtained by several MRI sequences such as fluid-attenuated inversion recovery, T2*-weighted imaging and diffusion-weighted imaging. Diffusion tensor imaging is able to show long tract damage and has been reported to correlate with prognosis. Several techniques are suited to studying cerebral blood flow and metabolism, including single photon emission CT (SPECT) and positron emission tomography (PET). Each imaging modality has merits and demerits and should be used complementary to each other. There are several molecular imaging techniques available in TBI, which may give us more information about the injury and prognosis for recovery.
The new classification of head injury for trauma surgeons and for neurosurgeons was proposed by the working group of the Japanese Association of the Surgical Trauma (JAST) and the Japan Neurotrauma Society (JNTS). The classification was established by the combination of the classification of head injury by Gennarelli and the concept of the Japanese advanced trauma evaluation and care (JATEC), and the guidelines for the treatment and management of severe head injury by JNTS. The classification defines the severity of skull injury, focal brain injury, and diffuse brain injury according to the findings of neurology and CT imaging on admission. The case with the impending herniation signs by neurology and by CT imaging is defined as severe, and has to be treated by neurosurgeon and/or in neurosurgical ICU.
This new classification will be used both by the trauma surgeon working in the emergency room and by the neurosurgeon in the neurointensive care unit or in the operating room.
Objectives: Recently, it has misgivings about traumatic brain injury (TBI) parting of neurosurgeons. Standard guidelines for management of severe TBI were announced in 2000 by the Japan Society of Neurotraumatology. The purpose of this study was to understand the situation regarding the system of neurotrauma treatment in Japan.
Method: A questionnaire regarding management of severe TBI was sent to each specialist training medical center of the Japan Neurosurgical Society (384 facilities). Answers were obtained by mail from 233 medical centers (60.7%).
Results: Initial treatment of TBI patients was the responsibility of the Department of Neurosurgery (NS) in 34% of the medical centers, the Emergency Department (EM) in 29%, and a combination of these departments in 36%. Surgery was performed by NS in 90% and EM in 4% of facilities and postoperative management by NS in 76% and EM in 11%. The guidelines were acknowledged by 94% of the medical centers, but only 72% of the centers used a protocol that conformed to the guidelines.
Conclusion: Neurosurgeons in Japan are positively involved in management of severe TBI. Many medical centers may find it difficult to conform to the guidelines because of a lack of neurosurgeons and equipment shortages. These problems can be addressed by consolidation of neurosurgeons in a centralized center in each region and improvement of the medical insurance system for enhancement of equipment.
Recently nationwide collapse of emergency medical system has become evident in Japan. In Osaka prefecture difficulty in emergency transportation has been frequently reported. We reviewed the movement of emergency patients in Osaka Mishima secondary medical territory and discussed inter-hospital cooperation of neurotrauma patients. In Takatsuki district the number of patients transported to secondary emergency medical institutes increased by 1.55 times in these 10 years. Too much burden made these hospitals to escape from emergency medical system. As a result emergency transportation to the tertiary medical center has been increasing. Despite we accepted 1.6 times more patients in 2007 compared with those in 1998; number of patients we had to refuse was greatest in 2007. The leading causes were requests of mild cases that did not need critical care and over-capacity of our institute. Trauma or disease of central nervous system is the most common cause of admission, constituting around 35% of all patients admitted. Among 413 in 2007 and 384 in 2008 of neurosurgical emergency cases, 191 and 164 were neurotrauma patients, respectively. Most stroke patients were transported from Mishima secondary medical area, whereas trauma patients were transported from wider districts. The average length of hospital stay was 12.6 days in 2007 and 14.8 days in 2008 for neurotrauma patients, which were longer than those of all patients. Patients arrived from out of Mishima medical territory tended to stay longer compared with those arrived from inside the territory. Osaka prefecture introduced Flet's Phone system to facilitate emergency transportation over a wide area in order to resolve transportation difficulties. To accept new patients, earlier discharge of patients is essential. It seems that this system will not work well as long as medical resources are insufficient. Reinforce of whole medical system is required to resolve the ongoing medical crisis.
The management of neurosurgical emergencies is associated with many problems in a depopulated area. The depopulated Tsugaru distinct has only 2 neurosurgical units and many patients have to be transferred from the district general hospital. Since 1989, telemedicine by using an image transfer system has been used to increase diagnostic accuracy and to achieve improved results in neurosurgical emergencies. In this report, we describe the usefulness of telemedicine for diagnosing and treating head injury.
An image transfer system was installed at our hospital and at 11 regional hospitals in the Tsugaru district. Between January 2005 and September 2008, 367 patients were admitted to our hospital, and consultations were performed for 160 head trauma patients using this system including 65 patients who were transferred from the district general hospital. We divided these patients into 3 groups: (1) those who were admitted directly in our hospital; (2) those who were administered telemedicine using an image transfer system; (3) those who had telephone consultation as well as an analysis of the diagnosis. Glasgow Coma Scale, treatment, the interval until surgery, Glasgow Outcome Scale at discharge, the average hospitalized admission and the place of discharge from hospital.
The number of mild cases in the group of patients who were admitted directly in our hospital was more than that of those receiving telemedicine or telephone consultation. This difference can be attributed to the fact that although the neurosurgeon or doctor initially diagnosed the patients, the mild cases were not transferred from the regional hospital. The interval until surgery was the shortest in the group diagnosed using telemedicine, because the neurosurgeon diagnosed the patient before transfer and was able to prepare for surgery prior to arrival. The Glasgow Outcome Scale scores of patients directly admitted in our hospital tended to be worse than those of the other groups, because our hospital is a tertiary medical care and many serious cases are transported elsewhere. However, the scores were not significantly different.
The image transfer system in telemedicine seems to be beneficial for reducing unnecessary transfers and for shortening the interval until surgery.