Emergency burr hole craniostomy for traumatic brain injury in austere environments: a practical guide for non-neurosurgeons

Traumatic brain injury (TBI) is a leading cause of mortality and morbidity, particularly in austere environments where neurosurgical expertise is scarce. TBI causing extra-axial haemorrhage can lead to intracranial hypertension and herniation. Emergency burr hole craniostomy is a critical intervention for managing extra-axial haematomas in patients with deteriorating neurological status. The need for non-neurosurgeons to be capable of this procedure has been reinforced by experience from the Russo-Ukrainian war and by planning assumptions for Large-Scale Combat Operations, in which contested airspace, prolonged casualty care and a finite NATO military neurosurgical workforce make timely transfer to neurosurgical care unreliable. This article provides a detailed practical guide for non-neurosurgeons, such as general surgeons and emergency physicians, to perform these procedures in resource-constrained settings without imaging or electric power. It is explicitly aligned with the US Joint Trauma System Clinical Practice Guideline ‘Emergency Life-Saving Cranial Procedures by Non-Neurosurgeons in Deployed Setting’, the Brain Trauma Foundation Guidelines and the NATO Committee of the Chiefs of Military Medical Services (COMEDS) Medical Action Plan. Drawing on extensive experience in austere surgical environments, we describe the clinical assessment, step-by-step technique and the structured training pathway required to ensure safe and effective intervention. The objective is to empower non-specialist surgeons to act decisively, stabilising patients and bridging them to definitive care, thereby improving outcomes in settings with limited resources.