Reply from authors to letter on Temporising an extradural haematoma by intraosseous needle craniostomy in the District General Hospital by non-neurosurgical doctors - a case report

We are grateful to Dr Wiles for his comments and are pleased that this report has provoked interest and discussion of new strategies in the emergency management of a group of patients in extremis. ¹ Our primary principle at all stages has been to have our patient’s interests as the paramount consideration – we have only attempted a technique where the individual circumstances meant that it seemed to be the most appropriate option at the time. After making this intervention, we felt it could be of interest to the wider medical community to learn of our experience, so that other clinicians could be aware of this potential treatment option under certain circumstances.

To be clear, this technique has not been used as part of a clinical trial, and we do not advocate it as standard practice. This is an off-label application of an approved device, where the relevant NICE guidance advises ‘balancing the risks and benefits to the patient’ and advises consideration of ethical and legal implications. We were satisfied that the balance of risks and benefits was reasonable in the cases presented and would welcome a broader discussion of ethical and legal implications involved. Perhaps, it is worth noting that the majority of emergency neurosurgery is performed without the benefit of Class 1 evidence, reflecting the difficulty of designing and implementing effective clinical trials in this area. We entirely agree that any future trial of this technique would need to be conducted in the context of standard ethical approvals.

Finally, we are grateful to Dr Wiles for highlighting the CT report which was indeed incorrect. The initial CT report at the referring hospital diagnosed an extradural haematoma, but further analysis of the images shows they are more in keeping with acute subdural haematoma. The authors regret that this was not made clear in the original manuscript.