Analysis of the neuro-physical benefits of surgically elevating depressed skull fractures in patients who have sustained non-missile traumatic head injuries at the Chris Hani Baragwanath Academic Hospital.

Abstract

This study reports on 30 patients who presented with traumatic (non missile) depressed skull fractures with resultant neuro-physical deficits admitted to the neurosurgical unit at the Chris Hani Baragwanath Academic Hospital for treatment. The 30 patients included in this study underwent formal surgical elevation and debridement of their fractures within 48 hours of injury at the Chris Hani Baragwanath Academic Hospital theatre. The surgical procedures were undertaken by five neurosurgical registrars all with similar neurosurgical experience within our department.

The total number of 30 patients included 2 subsets of patients. Group A (n=11) being patients with isolated depressed skull fractures and no other intracranial injuries. Group B (n=19) included patients with depressed skull fractures and concomitant intracranial injuries.

The mechanism of injury varied amongst patients. Twenty-two patients were assaulted. Six patients were involved in motor vehicle accidents (MVA). Two patients were involved in pedestrian vehicle accidents (PVA).

Clinically, 11 patients had compound injuries and 19 patients had closed injuries. Seven patients had dural tears noticed at the time of operation. All patients presented with neuro physical deficits consistent with the site of injury on the skull vault.

All patients presented with the depth of depression of the fracture greater than the width of the skull table on radiological imaging. Nineteen patients presented with associated bleeds namely, extradural hematomas (n=7), subdural hematomas (n=4), cerebral contusions (n=5) and intracerebral haemorrhages (n=4). vi

A pre- and post-operative comparison of the neuro-physical deficits of the enrolled patients was made. Radiological and clinical factors associated with the injury have also been assessed for a possible causal relationship to clinical outcomes.

Analyses of the data revealed that post-operatively, patients with isolated skull fractures were more likely to have improvements in motor function than patients with depressed skull fractures with an associated haemorrhage (p value = 0.21). The degree of improvement in motor function based objectively on the Medical Research Council (MRC) motor scale was also higher in the group of patients with isolated skull fracture as compared to the group of patients with depressed skull fractures with an associated haemorrhage (p value = 0.30).

Younger age (p value = 0.12), shorter time to surgery (p value = 0.66) and open injuries (p value = 0.45) were regarded as good prognostic markers for post-operative improvements in motor function.

The results indicated a predilection for post-operative functional motor improvements in the upper limb as opposed to the lower limb. The average degree of motor neurological improvement as measured by the MRC motor scale was slightly greater in the upper limb by 0.86 points as compared to the lower limb group (p value = 0.07).