Variations in the neurosurgical management of depressed skull fractures in adults: An international cross-sectional survey

Background and Study Aims
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 non-operative 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.

Material and 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-April 2021. Statistical calculations were performed with SPSS v22 (IBM).

Results
A total of 218 respondents completed the survey, representing 56 countries.
With regards 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 (48.2%) offered prophylactic antiepileptics. Almost all (>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/haematoma 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 haematoma/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 multi-national randomised trials.