Posterior fossa epidural hematoma (PFEDH) is rare, occurring in less than 3% of head injuries. It can be managed either operatively or non-operatively. Management guidelines date from 2006, without recent updates providing class III evidence.

We searched PubMed and other databases for English language observational studies up to 2021 that compared the two treatment approaches for PFEDH and.

Twenty-four of the 350 references, for involving 874 patients, met the study criteria. Conservative management showed higher GOS 5 scores and lower mortality. GCS 13–15 patients were more prevalent in the conservative group. Surgical cases often involved ventriculomegaly/compression, hydrocephalus or contusion.

The study shed light on surgical versus conservative PFEDH management, although evidence is sparse. Generally, conservative methods showed better initial outcomes, and should be preferred. However, respect of individual patient traits and Brain Trauma Foundation guidelines is crucial: conservative management may not suit all cases. To enhance the evidence base, RCTs are important for optimal PFEDH management. Bridging this gap can substantially improve patient outcomes and clinical decision-making, emphasizing the need to consider both the available evidence and patient-specific factors for effective guidance.