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During the last 10 years, 41 patients with dural tear caused by anterior cranial fossa bone fracture were treated surgically. Those treated conservatively were not included in this series. The patients' mean age was 36 years. The average time of postoperative observation was 15 months. Traffic accidents, as well as wounds caused by missiles (shell fragments or bullets), blows, and falls were the mechanisms of injury. An autogenous graft, followed by homologous (lyodura) and most recently by heterologous (lyoplant; B. Braun Melsungen AG, Melsungen, Germany) implants, was used to repair the dural lacerations. Fibrin adhesive was used to seal the sutures inserted between graft and dural defect margins in a majority of cases. The following criteria are required for the best dural substitute: uncontaminated tissue, histologic similarity to the local dura mater, adaptability, quick rehidratation, waterproof closure and the dural margins fast healing, and tensile strength easily resisting cerebrospinal fluid pressurization in physiological and pathological conditions. To define the effects of different tissue that could meet the above-mentioned criteria, we have undertaken a mechanical testing of the dural substitutes' tensile strength followed by histologic examination, and comparison with the dura mater of the anterior fossa region. Finally, we have paid particular attention to the clinical results of these substitutes.

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Thirty-five patients with self-inflicted gunshot brain injury were admitted to our hospital during 1991-96. War conditions and availability of firearms influenced the increase in these injuries, nearly six times greater than in the previous 6-year peace time period (1985-90). Our management protocol consisted of radical debridement of the missile track and evacuation of haematomata. For in-driven bone fragments we followed a less radical approach, but, if a post-operative computed tomogram (CT) showed a cluster of retained bone fragments, we operated on this. Attention was paid to the development of intracranial infection performing in such cases a contrast enhanced brain computed tomography. Ten patients died early and 29 were managed operatively. Twelve survived, and were followed-up for up to 60 months. No case of suicide recidivism was noted. We conclude that patients with a Glasgow Coma score of 3 should not be considered for operation. Per-operatively ultrasonography was very helpful in localizing and extracting in-driven bone fragments. Post-operatively, a CT scan is needed to demonstrate retained bone fragments.

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Twenty-two patients with spinal injury were evaluated by plain radiography immediately after hospital admission. In 14 patients whose condition was stable, we performed computed tomography (CT) scanning through the involved segments. To provide better planning before neurosurgical management, we divided the vertebral column in thirds. According to this division, we concluded that these injuries are mostly extensive, severely damaging all three thirds of the vertebral column and accompanying neural structures in the majority of cases. The information acquired by Ct concerning bony fragments, bone destruction, dural tear, spinal cord and nerve root compression, and neural damage directly influenced the surgical management. All patients except one underwent surgery while associated injuries of other organs were given priority in management. Injuries of the thoracic and the lumbar spine were the most common ones, frequently found in association with lesions of nearby organs. Penetrating injuries with a dural lesion were present in the majority of cases, while spinal cord injury was obvious in some. They were all well visualized using spinal CT scanning. Our view is that the role of CT is essential in guiding surgical management of war missile injuries to the spine.

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During the war period 1991-1992 in Croatia, ten wounded children (16 years of age or younger) with war injuries to the brain were admitted to the Division of Neurosurgery, Osijek Clinical Hospital. Six of them had been wounded by shrapnel and four by pistol or rifle bullets. All but one were managed surgically (i.e. by craniotomy). The outcome was: as follows three children had a good recovery, four retained a moderate neurological deficit, and three died (injured by shrapnel). Five of the wounded (four injured by shrapnel and one by bullets) had associated injuries (fractures of the leg bones, eye lesion, amputation of the right leg) which influenced morbidity, and in one case mortality. Children wounded with shrapnel had brain edema on admission to hospital. Our experience indicates that the thermal effect from heated shrapnel, as well as velocity, mass, size and shape of the shrapnel, could be an additional factor for the development of severe brain edema.

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Between 1991 and 1994, 21 patients with war missile injuries of the spine and spinal cord were treated; there were 17 men and four women, with a mean age 30.7 years; 52.4 per cent were civilians. The wounds were caused by shells (54.6 per cent) and bullets (45.4 per cent). The thoracic and lumbar spines were most commonly injured, and the injuries were frequently associated with lesions of other organs (47.6 per cent). There was extensive initial neurological deficit (tetraplegia, paraplegia) in 47.6 per cent of cases in whom there was no postoperative neurological recovery. All patients were treated operatively and associated injuries of other organs received priority management. A decompressive laminectomy was performed in 80.9 per cent of patients. Penetrating injuries of the dura were recorded in 61.9 per cent, while the spinal cord was injured in 28.5 per cent of patients. The dural defect was reconstructed in these patients. There was a low incidence of postoperative complications (14.5 per cent) which emphasizes the importance of early surgery.

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OBJECTIVE: Spinal stability after surgery for war missile wound to the spine is addressed in this study. DESIGNS: A retrospective 4-year analysis of 21 patients. MATERIAL AND METHODS: The most common injuries were of the thoracic and lumbar spine. The injuries were frequently associated with the lesions of other organs. We registered extensive initial neurologic deficit in 47.6% of cases. All the patients were treated surgically. MEASUREMENTS AND MAIN RESULTS: A decompressive laminectomy was performed in 80.9% of cases. Internal stabilization after laminectomy was performed in only one patient in our series. None had clinical signs of instability. There were no radiologic signs of postoperative spinal instability found on mean follow-ups of 15 months. CONCLUSIONS: Wound debridement with or without removal of bony and foreign body fragments from the spinal canal was performed. A laminectomy is considered a method of choice. The spine was not stabilized in most patients because the facet joints were left intact.

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During the 4-year period (1991-1994) there were 127 consecutive patients with missile brain wound treated at the Division of Neurosurgery. They sustained brain injury in the region of east Slavonia, Baranya and north Bosnia, and were admitted mostly during the homeland defensive war in Croatia (1991-1992). Analysing the wounded, we divided them in two groups: "succumbed" (59 wounded) and "survivors" (68 wounded). We applied "less radical type of surgery", i.e. the patients were never re-operated only because of the retained single bone fragment. However, a retained cluster of bone fragments should be reoperated. The higher percentage of retained bone fragments (76.8%) is the result of precise visualization on the postoperative computed tomography (CT) scan. The last few cases have convinced us that the problem of the retained fragments could be solved by using an intraoprative ultrasonography. An intracranial (i.c.) infection (meningitis, abscess) occurred in 10 patients (10%), mostly among the patients who, besides the retained fragments, had cerebrospinal fluid (CSF) leak on the dehiscenced scalp wound. These cases should be reoperated soon after the CSF leak is visible on the dehiscenced wound. The overall mortality rate of 46.4% can be explained since our hospital was located close to the front-line, and some of severely wounded reached our hospital just in time to die. Excluding moribunds and those who died on the operating table (operated immediately after the admission), the mortality was 31.7%.

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