gms | German Medical Science

Background: Although the energy absorbing effect of the craniofacial soft tissue and bone gives some protection to the brain, orbitofrontal injuries may cause severe complications and neurological deficits requiring staged muiltidisciplinary treatment.

Materials and methods: From 1985 to 2015 197 patients suffering from complex orbitofrontal injuries were treated. Their therapies, clinical courses, complications and results were evaluated retrospectively.

Results: Two thirds of the patients had traffic accidents, working accidents as well as criminal attacs with firearms, hitting or stabbing were less frequent. On admission, 68% of the patients were comatous with a GCS<8. Rupture, contusion or laceration of the eyeball occured in 46% of the patients. Cranial nerve deficits were frequent: 31% Anosmia, 58% impaired vision, 28% oculomotor disturbances and 3% facial or cochlear nerve lesions. 89% of the patients required neurosurgical operations: elevation or debridement of impressed fractures or bone splinters (55%), evacuation of hematomas (13%), frontobasal dura plasty (14%), secondary cranioplasty (4%) as well as trapping or embolization of carotid-cavernous sinus fistulas (3%). 67% of the patients could be treated in one interdisciplinary session, 28% had to undergo up to 4 secondary operations. There were 18% fatalities, 2% vegetative states and 18% severely disabled patients, mostly bercause of visual deficits or psychosyndromas. Improvement of vision occured only in one case of localized compression of the globe, but not after optic nerve decompression when the optic canal was fractured.

Conclusion: The prognosis of patients with orbitofrontal injuries is determined by the severity of the brain injury and the intracranial complications. Most patients can be treated in one interdisciplinary session starting with decompression of the brain, reconstruction of eyelids and globe followed by reconstruction of the dura and skull. Large, extended fractures with brain prolaps should be covered transcranially, well evaluated small frontobasal fractures can be treated transnasal without time interval. Surgical techniques develope from wide open to navigation or endoscopy assisted localized procedures due to the improvement of protection in modern cars and advanced surgical tools. However, the experiences from the extremely severe early cases are still valuable in modern tretment. Vascular injuries can occur even secondary after an interval of days or weeks and should be treated endovscular. We had no improvement after optic nerve decompression in cases of primary complete visual loss, so this therapy is only effective when there is deterioration of initiallly preserved vision.