Timing of Surgical Intervention in Anterior Frontobasal Fractures with Pneumocephalus and Cerebrospinal Fluid Leaks: A Retrospective Analysis on a Series of 314 Patients and Proposal of a Novel Classification and Management Algorithm

Background: Anterior frontobasal fractures are complex injuries, with treatment strategies varying based on fracture type and associated complications, particularly pneumocephalus and cerebrospinal fluid (CSF) leaks. The optimal timing for surgical intervention remains a topic of debate. Methods: We retrospectively reviewed data from 314 patients with anterior frontobasal fractures treated at our Department (Neurosurgery, "Sapienza" University of Rome), between 2012 and 2023. Fractures were classified into Types A, B, and C, with subtypes, based on clinical and radiological features. The duration of pneumocephalus and CSF leaks was analyzed with one-way ANOVA and Tukey-Kramer post-hoc tests. Posterior frontal sinus (FS) wall diastasis and its impact on surgical decisions were assessed using Chi-square and Fisher's exact tests. Results: The mean duration of pneumocephalus was significantly longer in the surgical group (5.13 days, SD 0.79) compared to the conservative group (2.3 days, SD 0.69) (p < 0.0001). Similarly, the mean duration of CSF leaks was 5 days (SD 0.84) in the surgical group and 1.74 days (SD 0.76) in the conservative group (p < 0.0001). Critical thresholds for surgery were 3 days for pneumocephalus and 3.5 days for CSF leaks. Posterior FS wall diastasis > 2 mm was significantly associated with the need for surgery (p < 0.0001). Clinical outcomes were comparable between groups. Conclusions: Conservative management is effective for pneumocephalus and CSF leaks up to 3 and 3.5 days, respectively. Surgery is recommended when these complications persist or recur, especially in cases with significant posterior FS wall diastasis.