Surgical treatment of complex traumatic frontobasal lesions: personal experience in 74 patients

The author's personal series included 148 patients who sustained traumatic frontobasal injuries and were treated between 1986 and 1999. Included in this study are 74 of 148 patients with acute injuries and complex frontobasal lesions involving the frontal sinus, the cribriform/ethmoid roof complex, one or both orbital roofs, and the planum sphenoidale.

Surgery was delayed for up to 4 weeks postinjury in most patients (67 cases), whereas 17 with space-occupying hematomas and perforating injuries required early surgery. In 30 patients additional surgery was required to treat maxillofacial fractures, which was performed as a one-stage procedure together with the neurosurgical operation. The author performed a standard bifrontal craniotomy in which an intradural or combined intradural-extradural approach was used in all cases. Four patients developed ascending meningitis in the preoperative period. As a result of surgical treatment one patient died, another two patients suffered from permanent defects, and three suffered from transitory neurological worsening. In two patients recurrence of a cerebrospinal fluid fistula occurred within a 3-month period posttreatment but was successfully obliterated during reoperation. In the author's experience the intradural approach is comparable in terms of the morbidity, mortality, and success rates with extracranial approaches; additionally the intradural approach provides full visualization of the intracranial lesion. Useful olfactory nerve function can only be preserved if both olfactory nerves are left intact and not crushed during initial injury; this occurred in only five patients in this series.

If possible, surgical treatment of more complex lesions should be delayed until the 2nd or 3rd week following traumatic injury. With antibiotic prophylaxis the risk that ascending meningitis will occur prior to surgery is low. If the patient is systemically stable and brain swelling has resolved, even extensive one-stage neurosurgical/maxillofacial procedures are well tolerated.