Double concentric craniotomy for a craniocerebral penetrating nail. Case report and technical note

Craniocerebral penetrating injuries from nail-gun accidents are rare and usually are discovered immediately after the trauma. Several surgical procedures have been described to extract a foreign body that is infixed in the skull and has penetrated the surrounding structures; blind extraction, craniectomy, and craniotomy.

We report the case of a 25-year-old ex-carpenter who presented with jacksonian seizure at the left limb. Plain radiography of the skull revealed the unexpected presence of a nail hammered in the right parietal bone, penetrating the underlying structures of the frontoparietal area up to a depth of 3 cm. The patient was operated on; a small craniotomy (1 x 1 cm) just around the head of the nail, and a concentric larger frontoparietal bone flap, involving the first craniotomy, were performed. The larger bone flap was elevated first, whereas the small bone flap with the nail infixed was carefully elevated along the axis of the nail, under direct vision of the nail tract.

Double concentric craniotomy is the only technique that permits the removal of a foreign body that has penetrated both the skull and the brain, under direct vision, without transmitting any undue forces to the underlying structures. With this technique, control of bleeding can also be easily achieved.