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Quantifying the discrepancy between pre-operative suspicion and intra-operative confirmation of a dural breach in patients with skull fractures post assault

Background: Skull fractures are associated with a dural breach and are regarded as Neurosurgical emergencies to prevent potentially devastating infective complications. We aimed to quantify the discrepancy between pre-operative suspicion and intra-operative confirmation of a dural breach in 246 patients admitted over a 2 year period with skull fractures post assault. 
Materials and Methods: Retrospective data analysis of all patients that were admitted to the neurosurgical wards at our institution with skull fractures post assault from January 2015-December 2016 was performed. Medical charts were analyzed for pre-operative suspicion of a dural breach including the evidence for this suspicion, and operative confirmation of a dural breach. Management included simple suturing and antibiotics or surgery with antibiotic cover. 
 
Results: Of 246 patients treated, 234 (95%) were male and 12 (5%) were female. The mean age of subjects was 32 +/12 years. In terms of compound skull fracture management 23 (9%) were treated with simple suturing and antibiotics and 223 (91%) were treated surgically with antibiotics. Considering pre-operative suspicion of a dural breach in all 246 patients in 95 (39%) of cases a dural breach was suspected and in 151 (61%) a dural breach was not suspected. In the operative group of 223 patients a dural breach was confirmed in 109 (49%) of cases and excluded in 113 (51%) of cases. 
Conclusion: Although a dural breach was suspected in 95 (39%) of all 246 subjects using all available clinical and radiological evidence, in the operative group of 223 subjects a dural breach was confirmed in 113 (49%) of subjects. Hence the attending surgeon should have a low threshold for surgical exploration of skull fractures secondary to assault for fear of missing approximately 10% of dural breaches.