Temporising an extradural haematoma by intraosseous needle craniostomy in the District General Hospital by non-neurosurgical doctors: A response

Editor,

I read with interest the case report by Durnford et al. ¹ where an intraosseous needle was used in an attempt to decompress an acute intracranial haematoma. Whilst this may prove to be of use in situations where emergent neurosurgery may be delayed, for example, due to the need for long distance inter-hospital transport, I would be grateful if the authors could confirm what regulatory processes were in place prior to them undertaking this novel surgical technique.

This is only the second report in the literature of this procedure, the other having been described by a similar authorship group. ² As part of Good Surgical Practice guidelines, the Royal College of Surgeons recommends that any new surgical technique, which is not part of established practice, be subject to rigorous governance processes. This may include: local ethics committee approval; registration with the Interventional Procedures Programme at the National Institute for Health and Care Excellence; ensuring that any equipment used complies with European standards; and that appropriate training is provided to ensure technical competence by the operator. It is not clear from the report what regulatory processes were in place when the procedure was undertaken. Whilst the procedure was attempted in an emergency setting as a last-ditch lifesaving intervention, this does not obviate the need for sound ethical practice. There have been recent cases where novel local management strategies have unwittingly fallen within the boundaries of what would better be described as research.^3,4

In addition, the illustrating figure in the article of the patient’s computed tomographic scan appears to show a subdural haematoma (possibly with a hyperacute element) in addition to some frontal intraparenchymal blood (presumably from a contusional injury), rather than the extradural suggested by the authors; however, this may be an artefactual effect caused by viewing a single image slice.

I believe it is important for the readership of the journal to recognise that this novel technique is not part of standard practice at the present time. Future efforts should be directed at the formal investigation of the utility of the procedure (and the associated risks) within an established governance framework, rather than being undertaken ad hoc in critically injured patients.