Prospective comparison of simple suturing and elevation debridement in compound depressed fractures with no significant mass effect

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

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.

A Prospective Comparative Evaluation of Surgery and Conservative Treatment for Compound Depressed Skull Fractures

OBJECTIVE

The Brain Trauma Foundation issued level III evidence guidelines for surgical management of compound depressed fractures. However, some patients undergo successful conservative treatment. This study compares these 2 treatment modalities.

METHODS

This prospective study included 67 patients with compound depressed skull fractures with surgical indications and a minimum follow-up of 6 months. Depressed fractures in front of the hairline (operated on for cosmetic reasons) and associated with significant intracranial injuries were excluded. Those who gave consent for surgery were included in the surgical group, and those who denied were included in the conservative group.

RESULTS

The surgical group had 38 patients and the conservative group had 29. Both groups were comparable in mean age, gender, Glasgow Coma Scale score, head injury severity, depth of fractures, and follow-up duration. Focal neurologic deficits were observed in 19 patients at presentation and were higher in the surgical group. Mean hospital stay was significantly shorter in the conservative group. Mean Glasgow Outcome Scale score at follow-up was statistically similar in both groups (P = 0.13). Focal neurologic deficits improved equally in both groups (P = 0.67). The severity of traumatic brain injury (P = 0.004) and the presence of focal neurologic deficits (P < 0.001) affected the neurologic outcomes. The age, gender, mode of treatment (surgery vs. conservative), surgical site infections, and seizures did not affect neurologic outcomes. The overall complication rates were similar among groups (P = 0.50). New-onset focal neurologic deficits, seizures, and infection rates were not significantly different among the groups (P = 0.98, P = 0.72, P = 0.69).

CONCLUSIONS

Conservative management has equivalent neurologic outcomes and complications compared with surgical management.

Head injury care in a low- and middle-income country tertiary trauma center: epidemiology, systemic lacunae, and possible leads

BACKGROUND

Although head injury (HI) from low- and middle-income countries (LMIC) heavily contributes to the global disease burden, studies are disproportionately less from this part of the world. Knowing the different epidemiological characteristics from high-income nations can target appropriate prevention strategies. This study aims to provide a comprehensive overview of the clinico-epidemiological data of HI patients, focusing on the existing challenges with possible solutions from a developing nation's perspective.

METHODS

This is a prospective, registry-based, observational study of HI in an Indian tertiary trauma-care center over 4 years. Various clinico-epidemiological parameters, risk factors, and imaging spectrum were analyzed in a multivariate model to identify the challenges faced by LMIC and discuss pragmatic solutions.

RESULTS

The study included a large-volume cohort of 14,888 patients. Notably, half of these patients belonged to mild HI, despite most were referred (90.3%) cases. Only one-third (30.8%) had severe HI. Less than a third reached us within 6 h of injury. Road traffic accidents (RTA) accounted for most injuries (61.1%), especially in the young (70.9%). Higher age, males, RTA, helmet non-usage, drunken driving, systemic injuries, and specific imaging features had an independent association with injury severity.

CONCLUSIONS

The study represents the much-needed, large-volume, epidemiological profile of HI from an LMIC, highlighting the suboptimal utilization of peripheral healthcare systems. Strengthening and integrating these facilities with the tertiary centers in a hub and enhanced spoke model, task sharing design, and efficient back-referrals promise effective neurotrauma care while avoiding overburden in the tertiary centers. Better implementation of road safety laws also has the potential to reduce the burden of HI.

The collateral fallout of COVID19 lockdown on patients with head injury from north-west India

BACKGROUND

The COVID19 lockdown has altered the dynamics of living. Its collateral fallout on head injury care has not been studied in detail, especially from low- and middle-income countries, possibly overwhelmed more than developed nations. Here, we analyze the effects of COVID19 restrictions on head injury patients in a high-volume Indian referral trauma center.

METHODS

From the prospective trauma registry, clinico-epidemiological and radiological parameters of patients managed during 190 days before and 190 days during COVID19 phases were studied. As an indicator of care, the inpatient mortality of patients with severe HI was also compared with appropriate statistical analyses.

RESULTS

Of the total 3372 patients, there were 83 head injury admissions per week before COVID19 restrictions, which decreased to 33 every week (60% drop) during the lock phases and stabilized at 46 per week during the unlock phases. COVID19 restrictions caused a significant increase in the proportion of patients arriving directly without resuscitation at peripheral centers and later than 6 h of injury. Though the most common mechanism was vehicular, a relative increase in the proportion of assaults was noted during COVID19. There was no change in the distribution of mild, moderate, and severe injuries. Despite a decrease in the percentage of patients with systemic illnesses, severe head injury mortality was significantly more during the lock phases than before COVID19 (59% vs. 47%, p = 0.02).

CONCLUSIONS

COVID19 restrictions have amplified the already delayed admission among patients of head injury from north-west India. The severe head injury mortality was significantly greater during lock phases than before COVID19, highlighting the collateral fallout of lockdown. Pandemic control measures in the future should not ignore the concerns of trauma emergency care.

COVID-19: changing patterns among neurosurgical patients from North India, efficacy of repeat testing, and inpatient prevalence

OBJECTIVE

COVID-19 has affected surgical practice globally. Treating neurosurgical patients with the restrictions imposed by the pandemic is challenging in institutions with shared patient areas. The present study was performed to assess the changing patterns of neurosurgical cases, the efficacy of repeated testing before surgery, and the prevalence of COVID-19 in asymptomatic neurosurgical inpatients.

METHODS

Cases of non–trauma-related neurosurgical patients treated at the Postgraduate Institute of Medical Education and Research (PGIMER) before and during the COVID-19 pandemic were reviewed. During the pandemic, all patients underwent a nasopharyngeal swab reverse transcription–polymerase chain reaction test to detect COVID-19 at admission. Patients who needed immediate intervention were surgically treated following a single COVID-19 test, while stable patients who initially tested negative for COVID-19 were subjected to repeated testing at least 5 days after the first test and within 48 hours prior to the planned surgery. The COVID-19 positivity rate was compared with the local period prevalence. The number of patients who tested positive at the second test, following a negative first test, was used to determine the probable number of people who could have become infected during the surgical procedure without second testing.

RESULTS

Of the total 1769 non–trauma-related neurosurgical patients included in this study, a mean of 337.2 patients underwent surgery per month before COVID-19, while a mean of 184.2 patients (54.6% of pre–COVID-19 capacity) underwent surgery per month during the pandemic period, when COVID-19 cases were on the rise in India. There was a significant increase in the proportion of patients undergoing surgery for a ruptured aneurysm, stroke, hydrocephalus, and cerebellar tumors, while the number of patients seeking surgery for chronic benign diseases declined. At the first COVID-19 test, 4 patients (0.48%) tested were found to have the disease, a proportion 3.7 times greater than that found in the local community. An additional 5 patients tested positive at the time of the second COVID-19 test, resulting in an overall inpatient period prevalence of 1%, in contrast to a 0.2% national cumulative caseload. It is possible that COVID-19 was prevented in approximately 67.4 people every month by using double testing.

CONCLUSIONS

COVID-19 has changed the pattern of neurosurgical procedures, with acute cases dominating the practice. Despite the fact that the pandemic has not yet reached its peak in India, COVID-19 has been detected 3.7 times more often in asymptomatic neurosurgical inpatients than in the local community, even with single testing. Double testing displays an incremental value by disclosing COVID-19 overall in 1 in 100 inpatients and thus averting its spread through neurosurgical services.

Cognitive, Behavioral, and Functional Impairments among Traumatic Brain Injury Survivors: Impact on Caregiver Burden

Background  The burden of cognitive, behavioral, and functional impairments after traumatic brain injury (TBI) is still not highlighted much, but its impact on caregivers is socio-economically relevant. The objectives of the study were to assess cognitive, behavioral, and functional impairments in patients of TBI and its impact on caregiver burden. Materials and Methods  A descriptive cross-sectional study was conducted using a total enumeration sampling technique. Mini-mental status examination, neuropsychiatric inventory and Rappaport's disability rating scale were used to assess patients' cognitive, behavioral, and functional impairments, respectively. Zarit Caregiver Burden Scale was executed to quantify the caregiver burden. Results  Fifty patients of TBI and their caregivers were enrolled. Among these, 24% had moderate cognitive impairments. Among behavioral symptoms, 40% had agitation, 24% had depression, 18% had anxiety, and 16% had irritability. Moderate functional disability was reported by 18% of the patients, while 2% reported severe functional disability. Moderate to severe caregiver burden was reported by 8% of caregivers. Patients' behavioral ( r = 0.507, p < 0.001), functional ( r = 0.473, p = 0.001), and cognitive ( r = -0.438, p = 0.001) impairments had significant correlations with caregiver burden. Conclusion  Patients develop cognitive, behavioral, and functional disability after TBI. The caregiver burden increases significantly with cognitive dysfunction, behavioral symptoms, and impaired functional status of patients. Therefore, appropriate support is to be provided to caregivers as well as patients.

Treatment of Traumatic Depressed Compound Skull Fractures

BACKGROUND

A skull fracture widely occurs in patients with traumatic brain injury, leading to intracranial hematoma, brain contusion, and intracranial infection. It also influences the prognosis and death of patients. This study aimed to discuss cases of patients with comminuted skull fractures.

METHODS

From October 2015 to December 2018, 38 patients with comminuted skull fractures were admitted to the hospital. All patients underwent three-dimensional reconstruction of computed tomography scan images. Digital subtraction angiography or magnetic resonance venography was performed to find out the venous sinus. The clinical findings of the patients were significant regarding gender, age, injury mechanism, location, admission Glasgow Coma Scale (GCS), combined epidural, subdural, cerebral contusion, intracranial pneumatosis, maximum depth of depression, admission to surgery, dural tear, post-operative cerebrospinal fluid leakage, post-operative infection, and Glasgow Outcome Scale (GOS) 3 months after surgery.

RESULTS

The incidence of traffic accidents, fall from a height, railway accidents, fall of an object, and chop injury was 60.5%, 18.4%, 13.2%, 5.3%, and 2.6%, respectively. Intra-operative dural trar negatively correlated with epidural hematoma, cerebral contusion, and subdural hematoma. Also, post-operative infection negatively correlated with intracranial pneumatosis, depth of fracture depression, and pre-operative cerebrospinal fluid leakage. No correlation was found between contusion, subdural hematoma, intracranial pneumatosis, depth of fracture depression, and post-operative infection. The GOS score positively correlated with age, pre-operative cerebrospinal fluid leakage, and admission GCS score.

CONCLUSIONS

A perfect pre-operative examination is a key to successful surgery. Further studies should be conducted to find out more effective treatments for traumatic comminuted skull fractures.