Justifying the Need for Overpacking with Hemostatic Agents in Surgeries for Neurotrauma: Do We Underestimate the Risk of Secondary Brain Injury?

Neurotrauma surgical procedures, whether pertaining to traumatic brain injury, spinal cord trauma, or some other such significant neurological event, are often required to be dealt with delicately with respect to the surgical site itself and all physiological parameters related to the patient. Overpacking, in the parlance of neurotrauma surgery, involves a situation whereby a surgeon applies more material, technique, or interventions than is necessitated by the procedure.

The literature is mostly based on single-case reports and anecdotal experiences; thus, the need for a systematic approach has been felt. A proposed overpacking scoring system could classify the degree of usage of hemostatic agents and its correlation with postoperative complications such as the following:

• The excessive use of hemostatic agents can lead to increased ICP, and the unnecessary hemostatic material compressing the brain may increase intracranial hypertension.

• Postoperative brain compression and herniation: Packing-induced mass effect can alter brain compliance and lead to various compression syndromes.

• Delayed healing and foreign body reactions: Nonabsorbable materials can cause an inflammatory reaction and delay recovery.

• Surgical site infections: The hemostatic agents may also serve as a nidus of bacterial colonization and, therefore, increase infection risks.

• Another factor is the complexity of neurotrauma cases, as these surgeries often involve multiple specialists, each with their own perspective on what is necessary to achieve a successful outcome.

Overpacking with hemostatic agents like oxidized regenerated cellulose (e.g., Surgicel), absorbable gelatin sponge (e.g., Gelfoam), and gelatin-thrombin hemostatic matrix (e.g., Floseal) is a common neurosurgical procedure, particularly in tumor resections, trauma, and vascular procedures.[1] [2] [3] However, overuse may contribute to increased ICP, postoperative brain compression, delay of healing, and an increased risk of surgical site infections ([Fig. 1]). Although clinically important, there is no standardized way of quantifying overpacking. In these high-stakes settings, the pressure for urgent and decisive action can sometimes spur a tendency to overpack, a less obvious but nonetheless perilous mistake. Overpacking in this setting can take several forms: overpacking with packing material, injudicious application of surgical technique, or unwarranted postoperative interventions. While these measures may seem salutary at the time, they can actually compromise recovery and overall patient outcomes.

Fig. 1 Pathophysiological effects of overpacking in neurotrauma surgery.

Despite the obvious risks, there is no standardized system in neurosurgery for determining the degree of overpacking. Because precision is highly important in neurotrauma surgical procedures, this may be rather dangerous to a patient's recovery and successful results from such surgical procedures. This becomes very relevant in neurotrauma surgery, whereby decisions made intraoperatively are often very far-reaching in implications regarding both immediate and long-term survival and neurological outcomes.

Although there is a lot of progress in neurotrauma care and techniques to manage these cases, overpacking in neurosurgery is generally an underestimated problem with considerable clinical consequences. The root causes of overpacking usually come from surgeons' decision-making. In neurotrauma surgery, where every minute counts, surgeons are often compelled to spring into action with the aim of addressing the immediate concerns of trauma. The urgency inherent in dealing with life-threatening issues, there comes a time when, out of compulsion, overcompensation occurs, leading to unwarranted interventions or the use of materials. This is also likely because, without specific guidelines or uniform practices, surgeons may use their personal experiences or institutional routines, which make them overuse packing.

Furthermore, the possibility of overpacking can be reduced by encouraging a culture of collaboration and communication within the surgical team. Clear definitions of roles, responsibilities, and expectations will enable the surgical team to ensure that interventions are done only when necessary, with every step of the surgery performed with attention to minimum injury and maximum recovery for the patient. The prevention of overpacking in neurotrauma surgery must be balanced with precision, evidence-based decisions, and personalized care. The surgeons should have up-to-date knowledge about the current clinical guidelines and best practices for neurotrauma surgery; all interventional procedures and uses of materials must be supported by the condition and surgical needs of the patient.

In a multidisciplinary environment, different priorities or treatment approaches can lead to inconsistent decisions regarding the level of intervention or the use of materials. It is proposed that a more standardized approach to packing materials and techniques in neurotrauma surgery should be developed, decreasing practice variability and avoiding resource misuse. Protocols on the use of gauze and sponges, for example, and the guidelines on when and how to employ decompression techniques, can be elaborated against overpacking. Moreover, surgeons should be regularly trained in ICP management methods that favor noninvasive techniques and conservative approaches where appropriate.

Conflict of Interest

None declared.

• References

• 1 Schonauer C, Mastantuoni C, Somma T, de Falco R, Cappabianca P, Tessitore E. Topical hemostatic agents in neurosurgery, a comprehensive review: 15 years update. Neurosurg Rev 2022; 45 (02) 1217-1232
• 2 Spotnitz WD. Hemostats, sealants, and adhesives: a practical guide for the surgeon. Am Surg 2012; 78 (12) 1305-1321
• 3 Tompeck AJ, Gajdhar AUR, Dowling M. et al. A comprehensive review of topical hemostatic agents: the good, the bad, and the novel. J Trauma Acute Care Surg 2020; 88 (01) e1-e21

Publication History

Article published online:
29 April 2025