KEY WORDS
Cervical spine injury - replantation - scalp avulsion
INTRODUCTION
Total scalp avulsions are rare but serious injuries owing to the rich blood supply,
the patient runs a risk of massive blood loss. At the same time, total scalp avulsions
also pose a significant cosmetic disability. Scalp avulsion injuries are associated
with cervical spine injury, although not very common. Miller et al. in 1976 did the first successful scalp replant. Replant is the best choice for achieving
the best result cosmetically.[[1]]
This article aimed at highlighting the lesson learnt during a replantation of scalp
with cervical spine injury.
CASE REPORT
A 38-year-old female was brought to the emergency department with a total scalp avulsion
injury which happened 8 h ago. She complained of pain in the head and neck. She was
conscious, oriented and vitals were stable when she arrived to casualty. The avulsed
scalp was brought with an ice pack which was inspected and found to involve bilateral
eyebrows, the root of the nose and total scalp [[Figure 1]]. The scalp dressing was opened in the operation theatre. There were no neurological
deficits, but tenderness was noted on the cervical spine.
Figure 1: Frontal view showing complete scalp avulsion involving bilateral eyebrows
Head and cervical spine computed tomography scan was done and which had shown doubtful
instability in the subaxial cervical spine at C4-5 level [[Figure 2]]. Magnetic resonance imaging (MRI) could not be performed due to progressively prolonging
ischemia time of the scalp and also the active bleed, which required immediate attention.
Hence, discussion with neurosurgeon, plastic surgeons and anaesthesiologist concluded
at the procedure, targeting at minimally mobilising the neck. This decision was also
taken considering the absence of neurological deficit, lateral mass and facetal fractures,
which provided clue towards the probable lesser degree of trauma to the cervical spine.
The decision was made to do the replantation with hard cervical collar in situ and post-operative MRI spine. The patient was anaesthetised with intubating laryngeal
mask airway (LMA) with cervical collar in situ. The horseshoe stand was placed for better access to the posterior scalp, and anterior
part of the collar was removed and cut a bit upper lateral part. Initial haemoglobin
was 11.5 g % with packed cell volume 38%.
Figure 2: Cervical spine computed tomography showing suspected C4-5 instability
With two-team approach, the bench dissection was started. Bilateral superficial temporal
artery and vein, bilateral supraorbital vein and left supratrochlear vein were identified.
The post-auricular and occipital vessels were not dissected as it was not intended
to do the anastomosis of these vessels. The other team dissected on patient simultaneously.
The scalp was placed and inset was done in post-auricular region bilaterally. The
occipital area inset was not possible. Quilting sutures were placed at vertex with
3-0 Vicryl®. The right superficial temporal artery and vein, bilateral supraorbital
veins and left supratrochlear veins were anastomosed. The left superficial temporal
artery and vein were anastomosed with vein graft. The scalp started to bleed once
anastomosis of artery was done. It was difficult to achieve haemostasis on the posterior
scalp. Intraoperative blood loss was significant and the patient received 2 units
packed red blood cells, four fresh-frozen plasma along with crystalloids. The procedure
time was 9 h.
Post-operative day 1: The haemoglobin dropped to 6.6 g%, which was corrected with
2 units packed red blood cells and was maintained around 10 g%. The patient was extubated
uneventfully. On post-operative day 3: MRI of cervical spine was done and showed no
evidence of the cervical spine injury. Hence, hard cervical collar was removed. On
post-operative day 15, the patient was taken to the operation theatre and necrosed
left occipital area was debrided along with the left eyebrow area. Vacuum-assisted
closure (VAC) dressing was done. There was progressive necrosis of scalp in occipital
extending to the parietal area due to infection. The patient was taken to the operation
room, the scalp was debrided and split-thickness skin graft (STSG) with VAC was done
on day 27. The scalp and STSG settled with minimal raw area which healed with dressing
[[Figures 3]
[4]].
Figure 3: Frontal view
Figure 4: Posterior view extended loss at right parietooccipital and left parietal region with
island of scalp surviving
DISCUSSION
Total scalp avulsion injury is an emergency situation. Apart from having other life-threatening
injuries, isolated total scalp avulsion patients may present with haemorrhagic shock.[[2]] Zhang et al. reported 9.4% of cases with scalp avulsion injuries have a cervical spine injury.
The cervical spine injury is an emergency and may require surgical stabilisation or
conservative management depending on the severity of the injury.[[3]] The incidence of cervical spine injury associated with clinically significant head
injury is 4%–8%.[[4]]
In the situation where the patient is having cervical spine injury with total scalp
avulsion injury is a challenge for the plastic surgeon. The decision of doing anatomical
replantation is controversial[[5]] and few authors have mentioned it as a contraindication.[[6]] Xu et al. did ectopic implantation of avulsed scalp to forearm with cervical spine injury
as they considered it as contraindication.[[6]] Sanger et al. did ectopic replantation to abdomen in a similar situation as they mention it was
technically impossible. The ectopic replant will require multiple stages, other problems
such as limited vessels for anastomosis, maintaining the position of scalp without
causing shearing or kink in vessels.[[5]] Zhang et al. have done five composite grafts and one microvascular replantation. They have used
cervical protection in the form of cervical collar, cervical traction and halo fixation
depending on the extent of injury.[[3]]
Anaesthesia in cervical injury is a challenge, especially in emergency situations.
Saini et al. and Komatsu et al. concluded that a blind tracheal intubation through intubating LMA is a possible
option for airway management in patients with a semi-rigid cervical collar with an
overall success rate of 85%.[[7]
[8]]
Although single artery and vein is enough to perfuse the whole scalp,[[9]
[10]
[11]] most of the authors have done as many vessels as possible.[[8]
[12]
[13]
[14]] Quilting sutures are important not only to prevent the minor shearing forces on
anastomosis[[9]] but we also found it to be useful in obliterating a potential dead space and preventing
hematoma collection which can lead to flap failure.[[10]] Intraoperative blood loss is significant if proper care is not taken in doing haemostasis.
It is usually difficult once revascularised as scalp is very vascular and vessels
do not collapse once cut.[[15]] We used low-molecular-weight heparin as post-operative anticoagulation as routine,
in case of thrombogenic individuals, we use unfractionated heparin with close monitoring
of international normalised ratio.[[16]] The occipital area necrosis is significant problem and multiple reasons have been
discussed, most authors are of the opinion that it is the distal most part and least
vascular or increased risk of venous congestion.[[9]
[10]
[12]
[13]
[14]] The other obvious reason is pressure necrosis due to immobilisation. Koul et al. used halo frame to prevent pressure necrosis.[[17]] In our patient, apart from this reason, we think the posterior inset was not done
and significant area was left open for infection to set in. The hematoma formation
in occipital region is another factor.
CONCLUSION
Lessons learnt in the whole journey to replace like with like i.e., replantation,
If the patient is fit for GA then:
-
It is possible to do anatomical replant of avulsed scalp with cervical spine injury
if the anterior and lateral vessels are available for anastomosis
-
Hard cervical collar and immobilization will not allow posterior access to do inset
and anastomosis. The raw area left open has to be addressed as early as possible to
prevent the infection
-
The proper clipping or haemostasis of all possible vessels on the specimen and patient
is important to prevent heamatoma and blood loss. As manipulating the neck may lead
to disastrous complications; hence, limitations and precautions have to be kept in
mind.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form, the patient has given her consent for her images and other clinical information
to be reported in the journal. The patient understands that name and initial will
not be published and due efforts will be made to conceal identity, but anonymity cannot
be guaranteed.
Financial support and sponsorship
Nil.
