Category Archives: Head

Managing Mild TBI Without A Neurosurgeon

TBI is a very common injury, and neurosurgeons are relatively rare resources for trauma centers. That mismatch can create significant problems for trauma programs. Reflexively, we consult neurosurgeons for a wide variety of neurotrauma, ranging from the very severe to the extremely mild.

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Can we intelligently and selectively utilize the skills of our neurosurgeons, and not jeopardize patient safety? Surgeons at Baystate Medical Center in Springfield MA reviewed their own experience managing mild TBI.

They defined a mild TBI as one with patient GCS of 13-15. However, their study included only patients with “GCS>14”, which I presume means all patients with GCS=15 (unless this is a typo). They allowed patients with normal GCS and intoxication, epidural (EDH) or subdural hematoma (SDH)<4mm, small subarachnoid hemorrhage (SAH), and non-displaced skull fracture (Fx). Any patient taking any type of anticoagulant or anti-platelet drug was excluded. They looked at need for neurosurgical consultation or intervention, readmission, and 30 day mortality.

This prospective study spanned 13 months. This lower volume center admitted 1341 patients, of which 77 were included in the study. Average age was 55, and average ISS was 16. A total of 97% presented for a followup visit (!).

Here are the factoids:

  • 47% had SAH, 43% SDH, 16% intraparenchymal hemorrhage (not mentioned in inclusion criteria), 14% Fx, and no EDH
  • Only one patient required neurosurgery consult, and none required intervention
  • There were no mortalities
  • Most (62%) were admitted to a ward bed, and the average length of stay for all patients was 3 days
  • Cost savings was estimated at about $16,000

Bottom line: Yes there is no magic in getting a neurosurgical consult for most mild TBI. The study is small, but telling. A carefully crafted practice guideline can dramatically decrease the (over)use of our neurosurgeons, saving both time and money.

In reviewing their guideline, I would recommend shaving even one more point off the GCS (>14), but stipulating that any central subarachnoid hemorrhage require consultation because of the possibility of an aneurysm being the culprit.

Check out the guideline in use at my hospital below. Also, look at the first related post, which is similar in idea to this one, but you can see the difference in management by surgeons vs neurosurgeons.

Related posts:

Reference: Mild traumatic brain injuries can be safely managed without neurosurgical consultation: the end of a neurosurgical “nonsult”? AAST 2016, Poster 51.

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Cognitive Rest??

One of the more commonplace recommendations for recovery from mild traumatic brain injury (TBI) is “cognitive rest.” Sports medicine professionals recommend it, physiatrists recommend it, and trauma professionals talk about it.

First, what is it, exactly? I’ve seen a number of descriptions, and they vary quite a bit. The main concept is to avoid all activities that involve mental exertion. This includes using a computer, watching TV, talking on a cell phone, reading, playing video games, and listening to loud music. Huh?

What good does this allegedly do? Most articles that I’ve read theorize that cognitive activity somehow increases the metabolic activity of the brain and that this is bad. One of the more interesting papers I read (from 2010!) says it best: “It is now well-accepted that excessive neurometabolic activity can interfere with recovery from a concussion and that physical rest is needed.”

Read carefully. Well-accepted. The paper cites unpublished data on children by one of the authors, 2 meta-analyses and 2 consensus opinions. In other words, no data at all. Yet somehow the concept has caught on.

First of all, I don’t think it’s possible for most people to realistically practice cognitive rest. Who knows if there is really any difference in metabolism and energy use by the brain if you are engaging in any of the banned activities above? And let’s go to the other extreme: if one lies quietly in bed meditating, shouldn’t this be the ultimate cognitive rest? Yet fMRI and PET studies suggest (also limited data) that cerebral flow in specific areas of the brain increases during this state.

Maybe a modest increase in activity is good. Physical activity (within limits) has been shown to be very beneficial to physical and psychological well being time and time again. And the only paper I could find on the topic with respect to TBI showed that randomization to bedrest vs normal physical activity had no difference in post-concussive syndrome incidence or severity. However, the active group recovered with significantly less dizziness.

Bottom line: There is no data to support the concept of cognitive rest. Any type of activity, either mental or physical, can cause fatigue in a variable amount of time in people with mild TBI. It is probably best to interpret this as a signal to take it easy and recover for a while before exerting oneself again. But so far there is no objective data to show that cognitive activity either helps or hinders recovery.

References:

  • Cognitive rest: the often neglected aspect of concussion management. Athletic Therapy Today, March 2010, pg 1-3.
  • Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg Psychiatry 73:167-172, 2002.
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