J Neurol Surg A Cent Eur Neurosurg 2024; 85(02): 147-154
DOI: 10.1055/a-1994-9330
Original Article

Variations in the Neurosurgical Management of Depressed Skull Fractures in Adults: An International Cross-Sectional Survey

Amir Suliman
1   Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
1   Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
2   Department of Neurosurgery, Gandak Hospital, Birgunj, Nepal
Damian Holliman
1   Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
› Author Affiliations
Funding None.


Background Depressed skull fractures have been well described since antiquity, yet its management remains controversial. Contentious issues include the use of prophylactic antibiotics and antiepileptics, the role of nonoperative management, and the replacement/removal of bone fragments. Our objective was to explore the management patterns of closed and open depressed skull fractures across the world.

Methods A 23-item, web-based survey was distributed electronically to the members of national neurosurgical associations, and on social media platforms. The survey was open for data collection from December 2020 to April 2021.

Results A total of 218 respondents completed the survey, representing 56 countries.With regard to open fractures, most respondents (85.8%) treated less than 50 cases annually. Most respondents (79.4%) offered prophylactic antibiotics to all patients with open fractures, with significant geographical variation (p < 0.001). Less than half of the respondents (48.2%) offered prophylactic antiepileptics. Almost all respondents (>90%) reported the following indications as important for surgical management: (1) grossly contaminated wound, (2) dural penetration, (3) depth of depression, and (4) underlying contusion/hematoma with mass effect. Most respondents treated less than 50 cases of closed depressed skull fractures annually. Most European respondents (81.7%) did not offer prophylactic antiepileptics in comparison to most Asian respondents (52.7%; p < 0.001). Depth of depression, an underlying hematoma/contusion with mass effect, and dural penetration were the most important surgical indications.

Conclusions There remains a great degree of uncertainty in the management strategies employed across the world in treating depressed fractures, and future work should involve multinational randomized trials.

Publication History

Received: 08 March 2022

Accepted: 05 December 2022

Accepted Manuscript online:
08 December 2022

Article published online:
01 May 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
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