Day 59 (Oct 23)

Tobias spent a restful night in the neuro acute care unit (NAC).  He was given the first dose of oxycodone at 9:45 and another 10 mg six hours later.  When I arrived in the morning he was sleeping comfortable with no signs of stress or storming.  One of the nurse at the station where I need to sign in and pick up a daily name tag was the same nurse who received Tobias into his room last night.  She only spent an hour with Tobias since it was so close to shift change, but she remembered my name and volunteered that she had heard from the rehab hospital that they were looking to transfer him back to their care tomorrow.  I've learned to take these advice with a grain of salt, since many of them get changed before they are realized.  It would be a good thing for Tobias to go back to the rehab hospital tomorrow, if only as evidence that his cranioplasty (CP) went extremely well.  All evidence points toward a successful outcome.  He doesn't appear to be in pain and he has been a responsive as the few days before the procedure.  Today he was able to move his thumb for me and he mouthed "yes" and "no" several times.  He is still not fully conscious and doesn't respond at all for most of my attempts, but it is good for my soul when he does respond.  Today has been more about sleep than interaction.  I facetimed with his mom, sister and grandma and I played for him the videos from family and friends.  He was dozing half-heartedly at the time, but opened both eyes intently on the iPad when I played the videos for him.

I was surprised at his condition when I saw him after the operation yesterday.  In a good way.  I had expected to see him looking roughed up akin to his plight after the craniectomy and blood clot removal, but he looked healthy and rested.  His color was/is good and his face isn't contorted in a grimace of pain.  I'm glad of it, no doubt, but I expected this to be a heavier burden to bear and that the strain would show on Tobias' appearance.  So far, so good.  Fingers crossed.  The other surprise was that his head was not shorn.  I expect that a narrow band was shaved along the incision line, but there is a wide, white bandage covering the sutures so I can't see if that was spared the razor as well.  

I asked some questions of the neurosurgeon, but much of what follows comes from my research to understand how the procedure will be carried out.  It may not have been followed exactly like this, but it will have been close.

The procedure to put Tobias' cranium securely back in place is called a cranioplasty (CP).  Since August 27th, Tobias has only had a flap of skin covering his brain on the right top portion of his head.  He has had to wear a special helmet to protect this compromised portion of his brain when he was doing anything, except for lying securely in his bed.  The bone removal saved his life because it allowed his brain to swell beyond its normal confines.  Left intact, the skull who have forced the swelling to increase pressure within the brain itself and irreparably damaged parts of the brain that support life-critical functions.  Week by week the puffed out right side of Tobias' head receded and resulted in a concave depression where the bone was removed.  Once the swelling had completed receded the neurosurgeon determined that it was time to put Tobias back together.  Putting the skull back in place creates above all, more safety for the patient, but it also allows the brain to function in its "normal" environment again.  The cerebrospinal fluid (csf) can support the brain as it did before and the pressure on the brain returns to its natural levels.  We have heard from several involved parties that this return to normalcy results in a much faster rehabilitation.  The neurosurgeon and several studies that I found claim, however, that there is no demonstrable relationship between CP and accelerated rehabilitation.

When the anesthesiologist wheeled Tobias and his bed away from us yesterday, he took Tobias to an operating room where he was anesthetized and then his trache was replaced with a cuffed version that inflates to block anything from accidently draining into his lungs.  Tobias' head was secured in a three-pin vice to ensure that he wouldn't be able to move at all.  The skin along the upcoming incision is prepared with an antiseptic and the skin is cut taking care not to penetrate through the dura, a tough membrane covering and protecting the brain.  The skin is peeled back to allow for the bone to be replaced and the bone is reset like a jigsaw puzzle or a dish that has broken cleanly into two pieces.  I was told that it is common, and was also done in Tobias' case, that a CT scan is performed before the surgery so that a current image of the brain is available to ensure correct placement of the cranium.  I was told by several non-surgical sources (therapists, nurses) that "superglue" is used to hold the bone in place and that the joint is stronger than the surrounding bone.  I also read online that screws or devices similar to "butterfly keys" used in woodworking can also used to secure the bone flap back in place.  The skin is set back in place and sutures are used to hold the skin together.  I was also told that metal staples are used to support the sutures.  I haven't been able to see the sutures or the stables due to the bandage covering Tobias' scalp.  A shallow drain, called a Jackson-Pratt drain, is inserted to allow blood to exit the wound for two to five days.  The Jackson-Pratt drain is used as a surface drain in this case and can be managed by the NAC nurses.  The drain is a small plastic tube that inserts into a grenade shaped plastic pouch.  The pouch can be squeezed and will naturally return to its normal shape thereby applying suction pressure on the plastic tube and drawing blood away from the wound.

Aside from the general anesthesia risks, the biggest risks from CP are infection, blood clots, bleeding and seizures.  Tobias is doing well so far and the nursing staff and doctors continue to monitor his condition.  I take it as a good sign that they are planning on moving him back to the rehab hospital so soon.

Hope over fear.