Neurosurgical forum L e t t e r s to the e d i t o r
Antibiotics for Basilar Skull Fracture To THE EDITOR: The recent article on the merits of prophylactic antibiotics in the treatment of patients with basilar skull fractures (Ignelzi R J, VanderArk GD: Analysis of the treatment of basilar skull fractures with and without antibiotics. J Neurosurg 43:721-726, December, 1975) is in accord with a similar study just concluded at San Francisco General Hospital. In our study 160 patients with a diagnosis of basilar skull fracture based on clinical or radiographic evidence were assigned randomly and blindly to one of three treatment groups for 3 days in the hospital. In the first group no antibiotics were given; in the second, 1.2 million units of penicillin were given intravenously every 24 hours for 3 days, and in the third, 20 million units of penicillin intravenously every 24 hours for 3 days. Patients were excluded from the study if an allergy to penicillin had occurred previously or if a cerebrospinal fluid (CSF) leak was obvious immediately after injury. None of our 160 patients developed signs or symptoms of central nervous system (CNS) infection. As a result of our study we have abandoned the use of prophylactic antiobiotics in patients with simple basilar skull fracture and no CSF leak. We believe, however, that evidence for or against the usefulness of prophylactic antibiotics in patients with obvious CSF leak is not sufficiently abundant to warrant withholding antibiotics. Leech and Paterson, ~ Brawley and Kelly, 1 and Raaf a have shown in earlier studies that CNS infections occur less often in patients with CSF leaks when prophylactic antibiotics have been used. Concurrent with our randomized study, two patients who were not included died of posttraumatic pneumococcal meningitis. Both had frontal basilar skull fractures identified at autopsy. One patient had been excluded because of prior penicillin allergy, the other because the ethmoid sinus fracture was not evident clinically or radiographically. J. Neurosurg. / Volume 44 / May, 1976
These two deaths might have been avoided had antibiotics been given early after injury. We agree with Drs. Ignelzi and VanderArk that patients with basilar skull fractures should not be given antibiotics routinely. At the same time, we think more information about patients with obvious CSF leak is needed before we abandon prophylaxis altogether. Finally, we urge those who treat patients with basilar skull fractures, whether simple or not, to maintain constant vigil for the occult posttraumatic CNS infection which may be fulminant and ultimately fatal. JULIAN T. HOFF, M.D. AUSTIN BgEWlrq, M.D. Hol SANG U, M.D. San Francisco, California
References I. Brawley BW, Kelly WA: Treatment of basal skull fractures with and without cerebrospinal fluid fistulae. J Neurosurg 26:57-61, 1967 2. Leech P J, Paterson A: Conservative and operative management for cerebrospinal fluid leakage after closed head injury. Lancet 1:1013-1016, 1973 3. Raaf J: Post-traumatic cerebrospinal fluid leaks. Arch Surg 95:648-651, 1967
Suprascapular Entrapment Neuropathy To T~t~ EDITOR: The Journal o f Neurosurgery has published an article on suprascapular entrapment neuropathy (Clein L J: Suprascapular entrapment neuropathy. J Neurosurg 43.'337-342, September, 1975) which purports to be the first case report of this syndrome and the first description of the operative procedure. Apparently the author in his search of the English literature failed to take note of the fact that this was published previously. 1 The diagnostic studies involved were published later. I hope you will set the record straight and open up to the neurosurgical community the information in this article. Relative to the two operative approaches Dr. Clein and I have suggested for this 649
Antibiotics for Basilar Skull Fracture To THE EDITOR: The recent article on the merits of prophylactic antibiotics in the treatment of patients with basilar skull fractures (Ignelzi R J, VanderArk GD: Analysis of the treatment of basilar skull fractures with and without antibiotics. J Neurosurg 43:721-726, December, 1975) is in accord with a similar study just concluded at San Francisco General Hospital. In our study 160 patients with a diagnosis of basilar skull fracture based on clinical or radiographic evidence were assigned randomly and blindly to one of three treatment groups for 3 days in the hospital. In the first group no antibiotics were given; in the second, 1.2 million units of penicillin were given intravenously every 24 hours for 3 days, and in the third, 20 million units of penicillin intravenously every 24 hours for 3 days. Patients were excluded from the study if an allergy to penicillin had occurred previously or if a cerebrospinal fluid (CSF) leak was obvious immediately after injury. None of our 160 patients developed signs or symptoms of central nervous system (CNS) infection. As a result of our study we have abandoned the use of prophylactic antiobiotics in patients with simple basilar skull fracture and no CSF leak. We believe, however, that evidence for or against the usefulness of prophylactic antibiotics in patients with obvious CSF leak is not sufficiently abundant to warrant withholding antibiotics. Leech and Paterson, ~ Brawley and Kelly, 1 and Raaf a have shown in earlier studies that CNS infections occur less often in patients with CSF leaks when prophylactic antibiotics have been used. Concurrent with our randomized study, two patients who were not included died of posttraumatic pneumococcal meningitis. Both had frontal basilar skull fractures identified at autopsy. One patient had been excluded because of prior penicillin allergy, the other because the ethmoid sinus fracture was not evident clinically or radiographically. J. Neurosurg. / Volume 44 / May, 1976
These two deaths might have been avoided had antibiotics been given early after injury. We agree with Drs. Ignelzi and VanderArk that patients with basilar skull fractures should not be given antibiotics routinely. At the same time, we think more information about patients with obvious CSF leak is needed before we abandon prophylaxis altogether. Finally, we urge those who treat patients with basilar skull fractures, whether simple or not, to maintain constant vigil for the occult posttraumatic CNS infection which may be fulminant and ultimately fatal. JULIAN T. HOFF, M.D. AUSTIN BgEWlrq, M.D. Hol SANG U, M.D. San Francisco, California
References I. Brawley BW, Kelly WA: Treatment of basal skull fractures with and without cerebrospinal fluid fistulae. J Neurosurg 26:57-61, 1967 2. Leech P J, Paterson A: Conservative and operative management for cerebrospinal fluid leakage after closed head injury. Lancet 1:1013-1016, 1973 3. Raaf J: Post-traumatic cerebrospinal fluid leaks. Arch Surg 95:648-651, 1967
Suprascapular Entrapment Neuropathy To T~t~ EDITOR: The Journal o f Neurosurgery has published an article on suprascapular entrapment neuropathy (Clein L J: Suprascapular entrapment neuropathy. J Neurosurg 43.'337-342, September, 1975) which purports to be the first case report of this syndrome and the first description of the operative procedure. Apparently the author in his search of the English literature failed to take note of the fact that this was published previously. 1 The diagnostic studies involved were published later. I hope you will set the record straight and open up to the neurosurgical community the information in this article. Relative to the two operative approaches Dr. Clein and I have suggested for this 649
