OT notes · Neurosurgery

Emergency craniotomy / burr holes for acute extradural or subdural haematoma

Usual anaesthesia
General anaesthesia with endotracheal intubation
Position
Supine, head turned to the opposite side on a horseshoe or doughnut head rest, shoulder roll under the operative side, head end raised (reverse Trendelenburg)
Setting
emergency

Operative note template for emergency craniotomy (or burr holes enlarged into a craniectomy) to evacuate an acute traumatic extradural or subdural haematoma, with a filled example for a right temporal extradural haematoma from the middle meningeal artery.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • death or persistent coma despite surgery
  • re-collection of the haematoma needing a second operation
  • new haematoma on the same or opposite side
  • brain swelling needing the bone flap to be left out (craniectomy)
  • seizures
  • wound or bone flap infection, meningitis
  • CSF leak
  • weakness, speech or memory problems

Pre-operative details for this operation

  1. Mode and time of injury
  2. GCS and pupilsE V M at admission and just before surgery; pupil size and reaction each side; lucid interval?
  3. Focal deficitside and power
  4. CT findingstype (EDH / SDH), side, site, maximum thickness in mm, volume in ml, midline shift in mm, cisterns, fracture, other lesions
  5. Indication for surgeryEDH: volume 30 ml or more; or under 30 ml with thickness 15 mm or more, midline shift 5 mm or more, GCS 8 or less or focal motor deficit; GCS 8 or less with anisocoria; effaced cisterns; falling GCS. SDH: thickness 10 mm or more or shift 5 mm or more; or smaller with GCS fall of 2 or more, asymmetric or fixed dilated pupils, or ICP 20 mmHg or more
  6. Other injuries and haemodynamic statuscervical spine cleared or in collar; chest, abdomen, limbs
  7. Coagulation and bloodINR, platelets, antiplatelet / anticoagulant use and reversal given; units cross-matched
  8. Antiepileptic starteddrug, dose, time
  9. Side marked and confirmed with CTRightLeft

Anaesthesia and position

  1. AnaesthesiaGeneral, oral ETT to opposite sideGeneral, tracheostomy / other
  2. Head supportHorseshoe head restDoughnutPin fixation
  3. Positionsupine, head turned, shoulder roll, reverse Trendelenburg; prone for posterior fossa
  4. Lines and catheterarterial line, central line, Foley
  5. Skin preparationPovidone-iodineChlorhexidine / alcohol (iodine allergy)area shaved
  6. Local infiltrationlignocaine 1% with adrenaline 1:100,000, volume

Operative findings

  1. HaematomaExtraduralSubduralBothclot and liquid blood; estimated volume
  2. Skull fracturesite, linear / depressed
  3. Source of bleedingMiddle meningeal arteryBone edge / diploeVenous sinusCortical vein / bridging veinContusionNot found
  4. Duraintact / torn; tense or slack after evacuation
  5. BrainSlack, pulsatileSwollenContused (site)

Procedure (steps)

  1. Skin incisionReverse question mark (trauma flap)Linear / smaller incisionstart at zygomatic arch about 1 cm in front of tragus; kept off the midline
  2. Scalp haemostasisRaney clipsCautery
  3. Musculocutaneous flapscalp and temporalis raised together; flap protected with counted swabs
  4. Burr holesnumber and sites; drill used (hand drill / pneumatic / electric); at least 1-2 cm off the midline
  5. Dura stripped from bonePenfield dissector; bone wax to edges
  6. Bone flapCraniotome with footplateGigli sawBurr hole enlarged with rongeur (craniectomy)size in cm; flap kept in antibiotic saline
  7. Temporal base decompressionNot neededBone nibbled down to the temporal floor
  8. Extradural haematoma evacuatedsuction, irrigation, forceps; volume
  9. Bleeding controlledBipolar to vesselBone wax to foramen spinosum / bone edgeGelatin sponge / oxidised cellulose
  10. Dura openedNot openedSmall durotomy to exclude SDHCurvilinear / cruciate / stellateNo. 11 blade, scissors; dural edges held with 4-0 braided nylon stay sutures
  11. Subdural haematoma evacuatedirrigation and suction, perimeter explored; source found and coagulated or not
  12. Haemostasis confirmedValsalva by anaesthetist; clear irrigation
  13. Dural closurePrimary, 4-0 braided nylonDuraplasty (graft: pericranium / fascia / substitute)Left open with onlay (craniectomy)
  14. Dural tack-up suturesperipheral holes; central tack through the bone flap

Closure, drains and dressing

  1. Bone flapReplaced with titanium plates and screwsNot replaced (reason; where stored)
  2. DrainNoneSubgalealExtraduraltype, exit by separate stab, secured with nylon, suction or gravity
  3. Temporalis muscle and fasciasuture, e.g. braided absorbable 0
  4. Galeainterrupted inverted braided absorbable 2-0
  5. SkinNylonStaples
  6. Dressingtype; head bandage

Specimens and implants

  1. Cranial fixationnumber of plates and screws, size, make, lot number; sticker pasted
  2. Dural substitutetype, size, make, lot number
  3. Haemostatic agents left ingelatin sponge / oxidised cellulose
  4. Bone flap (if not replaced)how and where stored, labelled

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Neuro checksGCS, pupils and limb power at least hourly in ICU / HDU
  2. Positionhead end raised; head neutral
  3. Drainoutput every 4 hours for the first 8 hours, then every shift; plan removal on POD 1 if output low
  4. Antibioticcontinue for 24 hours
  5. Antiepilepticdrug and dose; total 7 days
  6. Coagulationrepeat INR / platelets; correct if deranged
  7. CT headtiming; earlier if GCS falls or a pupil dilates
  8. Wounddressing off after 24 hours; sutures or staples out on day 10 to 14
  9. If bone flap left outwrite that the flap is out, on which side, and where and how the flap is stored

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. R.M., 24 years, fell from a two-wheeler without a helmet. Brief loss of consciousness, then talked, then drowsy. CT: right temporal extradural haematoma with an overlying fracture.

Case details

Date: 03/09/2026. Emergency. OT 5.

Injury 19:30. Admitted 21:00. CT 21:15. Decision 21:25. In OT 21:50. Incision 22:15. Closure completed 23:50.

Surgeon: Dr A. (2nd-year resident, MCh Neurosurgery). Assistant: Dr B. Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

GCS at admission E3 V5 M6 = 14, pupils 3 mm equal. At 21:20 GCS E2 V3 M5 = 10, right pupil 5 mm sluggish, left 3 mm reacting. Left upper limb power 4/5.

CT head 21:15: right temporal biconvex extradural haematoma, maximum thickness 22 mm, volume about 45 ml, midline shift 7 mm to the left. Linear fracture of the right temporal squama. Basal cisterns partly effaced. No other lesion.

Indication: EDH over 30 ml with falling GCS and a dilating right pupil.

Cervical spine CT normal, collar removed. Chest and abdomen: no injury on eFAST. Pulse 64/min, BP 150/90 mmHg.

No antiplatelet or anticoagulant. INR 1.1, platelets 2.4 lakh/cumm. Blood group O positive, 2 units cross-matched.

Antiepileptic loading dose given in emergency (drug and dose on the drug chart).

Consent: patient drowsy, so procedure-specific consent taken from the father, Mr. S.M., in Hindi, including death, re-bleeding, seizures and leaving the bone out. Right side marked and checked against the CT.

WHO checklist sign in and time out done. Cephalosporin IV within 1 hour before incision (drug and dose on the anaesthesia chart).

Anaesthesia and position

General anaesthesia, oral ETT taped to the left. Right radial arterial line, Foley catheter.

Supine on horseshoe, head turned to the left, roll under right shoulder, head end up. Head shaved. Painted with povidone-iodine and draped with room for a drain exit.

Incision line infiltrated with 10 ml lignocaine 1% with adrenaline 1:100,000.

Procedure

Right reverse question-mark incision from the zygomatic arch 1 cm in front of the tragus, curving behind the pinna to the frontal hairline, 3 cm off the midline. Raney clips to scalp edges.

Scalp and temporalis raised together as one flap and held with fish hooks over counted swabs.

Findings: linear fracture of the temporal squama. Three burr holes with pneumatic drill around the haematoma. Clot seen at once under the first burr hole.

Dura stripped with Penfield No. 3. Holes joined with craniotome with footplate. Bone flap 8 x 7 cm lifted and kept in antibiotic saline. Temporal bone nibbled down towards the floor with a rongeur.

Extradural haematoma, clot with some liquid blood, about 50 ml, removed with suction and irrigation.

Source: torn anterior branch of the middle meningeal artery near the fracture, coagulated with bipolar. Bone edges waxed. Gelatin sponge over oozing dura.

Dura intact. Small durotomy with No. 11 blade: no subdural blood. Closed with 4-0 braided nylon.

Valsalva by anaesthetist: no bleeding. Brain slack and pulsatile through the dura.

Peripheral dural tack-up sutures with 4-0 braided nylon through small drill holes. Central tack through two holes in the bone flap.

Closure

Bone flap replaced with three titanium plates and six screws. Central tack tied.

Subgaleal round drain through a separate stab, secured with nylon, on bulb suction.

Temporalis muscle and fascia closed with polyglactin 910 (Vicryl) 0. Galea with interrupted inverted Vicryl 2-0. Skin with staples. Non-adherent gauze, pads and head bandage.

Specimens and implants

Implants: titanium cranial fixation system, make as per sticker, 3 two-hole plates and 6 screws, sizes as per sticker. Lot numbers on sticker; stickers pasted in the case sheet and OT implant register.

Gelatin sponge left over the dura. No specimen.

End of procedure

Estimated blood loss 350 ml. No transfusion.

Mop, needle and instrument count correct, including the swabs behind the scalp flap.

No intra-operative complications.

Extubated in OT. GCS E3 V4 M6 = 13, right pupil 3.5 mm reacting, left 3 mm reacting. Shifted to neurosurgery ICU. Pulse 82/min, BP 128/78 mmHg.

Post-op orders

Hourly GCS, pupils and limb power. Inform at once if GCS falls by 2 or more or a pupil dilates.

Head end raised. Drain output every 4 hours for 8 hours, then every shift.

Antibiotic for 24 hours. Antiepileptic to continue for 7 days in total.

Post-op CT head as planned by the consultant, or at once if GCS falls or a pupil dilates.

Drain removal on POD 1 if output low. Dressing off after 24 hours. Staples out on day 10 to 14.

Signature

Dr A., MCh resident (year 2), Neurosurgery. Reg. no. ________. 04/09/2026, 00:10.

Must document for this operation

  • GCS and pupils at admission and just before surgery, with times. Outcome and the decision to operate are judged against the neurological state, and the next doctor needs a baseline to spot deterioration.
  • CT measurements: thickness, volume, midline shift, cisterns. These are the accepted thresholds for surgery, and they justify the operation in an audit or in court.
  • Side of the haematoma and that the marked side was checked against the CT. Operating on the wrong side is wrong-site surgery, which hospitals must take steps to prevent (NABH COP.14(d)).
  • Source of bleeding found or not found, and how it was controlled. If the haematoma comes back, the surgeon at re-operation needs to know where to look.
  • Whether the dura was opened and what was under it. An unrecorded subdural collection or contusion changes the post-op plan and the prognosis.
  • Bone flap replaced or not, and how it was stored if not replaced. The ward staff must protect a head without bone, and the flap will be needed for cranioplasty.
  • Cranial plates, screws and dural substitute with lot numbers. Needed for implant recall and when planning a later cranioplasty or MRI.

Common mistakes in these notes

  • Writing 'EDH evacuated' with no side, site, volume or source of bleeding.
  • Recording GCS as a total only, without E, V and M and without pupil findings.
  • Not recording the time of injury, CT and decision, so delay cannot be judged.
  • Not stating whether the dura was opened.
  • Leaving out the bone flap status, drain type and implant stickers.
  • Not recording who gave consent when the patient could not.

Indian practice and paperwork

  • When the patient cannot consent, record who gave consent and their relationship. Consent must be in a language they understand and taken by the person doing the operation. (NABH 5th ed., PRE.4(c) and (e))
  • If the bone flap is left out or another procedure is added that was not in the consent, write whether it was needed to save life and could not wait (Samira Kohli v. Dr Prabha Manchanda, Supreme Court, 2008). ((2008) 2 SCC 1)
  • The batch and serial number of implants (cranial plates, screws, dural substitute) must be recorded in the patient's record, the OT master logbook and the discharge summary. (NABH 5th ed., MOM.10(d))
  • Write the name of every anaesthetist in the note. A hospital was held negligent when the operation notes did not name the anaesthetist. (Thomas J. Indian J Urol 2009;25(3):384-8)

Sources

  • Ullman JS, Raksin PB, eds. Atlas of Emergency Neurosurgery. Thieme; 2015, Ch 1, Surgery for epidural and subdural hematomas (Timmons SD), pp. 2-15.
  • Demetriades D, Inaba K, Velmahos G, eds. Atlas of Surgical Techniques in Trauma. Cambridge University Press; 2015, Ch 6, Evacuation of acute epidural and subdural hematomas (Zada G, Matsushima K), pp. 87-108.
  • Atlas of Emergency Neurosurgery (Thieme 2015), Ch 1, pp. 2 and 14: preoperative cephalosporin; seizure prophylaxis for 7 days; lidocaine 1% with epinephrine 1:100,000 for infiltration; antibiotics for 24 hours after surgery; drain checks every 4 hours for 8 hours; sutures out day 10-14. Surgical thresholds taken from Bullock MR et al., Neurosurgery 2006;58:S7-S15 and S16-S24, as cited in the chapter.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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