CRANIAL SURGERY

CRANIOTOMY

Definition

Craniotomy and/or craniectomy performed (separate procedures).
- Craniotomy means “cranium opened, something removed, cranium closed.”
- Craniectomy means “cranium opened and left open.”

Form

[X] Form 1
[ ] Form 2

Source

Abstraction (acute record)

Details

Craniectomy is coded yes when bone flap is removed and not replaced during initial surgery.

The guidelines below should be followed when considering burr holes:

When a burr hole is drilled, the patient is left with a 1 cm diameter hole. Removing a small disc of bone is not equivalent to removing the cranium or any part of the cranium. A burr hole to put in an ICP monitor is neither a craniotomy nor craniectomy, simply placement of a monitor.

Situations where a chronic subdural is drained or washed out through a burr hole should be counted as a craniotomy. It is the removal of the chronic subdural that is the key part, because the goal is to remove something (the liquefied old blood).

An EVD (External Ventricular Drain) should not be counted as a craniotomy.

Variables

Form Type	Variable	ID	Question	History
Form 1	Craniotomy	421	Craniotomy/Craniectomy:	2003-01-01 - Variable Added

Codes and Values

ID	Code	Description
421	1	Neither Craniotomy Nor Craniectomy
421	2	Craniotomy
421	3	Craniectomy
421	4	Both: Separate Procedures
421	66	Variable Did Not Exist
421	99	Unknown

History

Date	Description
2004-04-01	Added DEFINITION : that burrhole washout is coded as craniotomy.
2007-01-01	Added NOTE : that when bone flap is removed and not replaced during initial surgery code Craniectomy as yes
2011-04-01	Added DEFINITION : craniotomy means "cranium opened, something removed, cranium closed." Craniectomy means "cranium opened and left open."
2015-01-01	Added NOTE : to not count an EVD (External Ventricular Drain) as a craniotomy.