Classification of orbitocranial wooden foreign body penetration injuries: what to do when they violate the intracranial space? A systematic review.

Introduction: Orbitocranial wooden foreign body (OWF) penetrations are rare but challenging occurrences that may violate the intracranial space resulting in brain damage and hemorrhagic, as well as infectious, complications. Moreover, there is a specific subset of cases of OWF penetrations that are particularly challenging to treat. Although there are well-defined management guidelines for pure intraorbital localization, there is not yet a defined treatment protocol for foreign bodies reaching the intracranial space. However, their removal performed either directly or through craniotomy, is often easily attainable given the condition that all necessary precautions are accounted for.

Evidence Acquisition: After having treated a 48-year-old man with a transorbital OWF penetration injury at our neurosurgical department, we systematically reviewed the last 15 years of literature to define and summarize the best management strategy. Multiple databases were searched for case reports and case series involving patients with intraorbital and transorbital OWF penetration injuries. For each study, we extracted data on age, sex, imaging modality, type of wood (processed vs. unprocessed), location of periorbital and intracranial entry site, treatment type ("pull and see" or "open and see"), antibiotic therapy, and complications.

Evidence Synthesis: We classified transorbital OWFs into two categories: transorbital with only cavernous sinus involvement and transorbital with more extensive intracranial involvement. We described what we believed was the most appropriate management conduct in each case.

Conclusions: Grounded on our experience and on the review of the literature, we suggest, based on the anatomical localization of the OWF, a classification system for OWFs which is coupled with a tailored treatment strategy for each case. These suggestions are made to provide surgeons with direction on the correct management of such rare but challenging occurrences.