Delayed repair of open depressed skull fracture

Abstract

Introduction: Elevation and repair of an open depressed skull fracture is often thought of as an emergency procedure. Common indications for emergent elevation of a depressed skull fracture have been dural tear, seizure, gross contamination or mass effect from bone or a sizable underlying intracerebral hematoma. As treatment of head injury moves towards management of cerebral perfusion pressure (CPP) rather than intracranial pressure (ICP), we sought a way to maximize CPP in the initial treatment of head-injured patients with depressed skull fractures that would eventually require surgery by delaying surgery, when possible, until after the initial period of elevated ICP.

Methods: Over a 12-month period, 7 patients (all male, ages 1-15 years) were admitted to our institution with the diagnosis of open depressed skull fracture without significant mass effect requiring urgent decompression. All had significant head trauma with altered mental status and a Glasgow Coma Score of 3-12. Patients were treated with antibiotic prophylaxis (nafcillin, ceftriaxone, metronidazole), seizure prophylaxis (phenytoin) and underwent CPP management in an intensive care unit setting as indicated by intracranial pressure monitoring or clinical assessment. Length of medical management of CPP ranged from 4 to 12 days. Upon stabilization of CPP, patients were operated for repair of their dural, bone and scalp injuries.

Results: All 7 patients treated in the above manner suffered no ill effects from their delayed surgery: there was no meningitis, no late seizures, and no cerebrospinal fluid leak. Complications attributable to delay were not present at follow-up ranging from 12 to 24 months.

Conclusions: We have delayed surgery for repair of open depressed skull fractures in order to maximize medical management of CPP in the setting of acute trauma. Among other considerations, the risk of intraoperative hypotension occurring at a time of acutely raised ICP was avoided by this delay. We conclude that there is a role, in this specifically defined subset of head trauma patients, for delayed surgical repair of open depressed skull fractures.