Tag Archives: Neurosurgery

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Do We Really Need To Consult Neurosurgery For Mild TBI?

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We consult our neurosurgeons too often. Think back on all the head injured patients you have admitted and placed a neurosurgical consult. How many times did they recommend something new or different, or take them to surgery? Not very often, I would guess.

This is becoming a hot topic. Check out the references below to read about a few other studies that have taken a similar approach.

The trauma group at Scripps Mercy in San Diego retrospectively reviewed their admissions to determine how often patients with mild TBI (GCS > 13) and some degree  intracranial hemorrhage required neurosurgical intervention, even if they were intoxicated or taking anti-platelet or anticoagulant drugs. A total of 500 patients were studied over a 28 month period.

Here are the factoids:

  • 49 (10%) of patients required some sort of neurosurgical intervention (41 craniotomy/craniectomy, 8 ICP monitors)
  • 93% of patients had neurosurgical consultation, and made additional recommendations in only 10 (2%),none of which changed management
  • There was no clinical difference in GCS between those who received an intervention and those who did not
  • Epidural and subdural hematomas were significant predictors of neurosurgical intervention
  • Intoxication or use of anti-platelet or anticoagulant drugs was not associated with intervention. These were present in 30% of all patients!
  • Unsurprisingly, ICU and hospital length of stay were longer in patient who underwent an intervention

Bottom line: As I said, this seems to be a hot research topic. And in this study, the numbers are getting larger and the criteria more inclusive (alcohol and anticoagulants allowed).

Neurosurgeons play a very important role in patients with more moderate to injury to their brain, and with spine injuries. But their input may not be needed in many patients with milder injuries. These data suggest that, in patients with GCS > 13, only subdural and epidural hematomas require consultation because they are much more likely to require intervention. 

This parallels a practice guideline we have in place where patients with subarachnoid or small intraparenchymal hemorrhage, or a linear skull fracture are managed by the trauma service without neurosurgical consultation. We do involve them if there is any intracranial hemorrhage with a history of anticoagulant use, however.

We all need to use our neurosurgeons wisely, and this paper helps to clarify situations where they may and may not be needed. 

Related posts:

Reference: Routine neurosurgical consultation is not necessary in mild blunt traumatic brain injury. J Trauma 82(4):776-780, 2017

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Can TBI Be Managed Without Neurosurgical Consultation?

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The standard of care in most high level trauma centers is to involve neurosurgeons in the care of patients with significant traumatic brain injury (TBI). However, not all hospitals that take care of trauma patients have immediate availability of this resource. An interesting paper looked at management of these patients by acute care surgeons.

The authors retrospectively reviewed all their patients who had a TBI and positive head CT managed with or without neurosurgery consultation over a two year period. They matched the patients with and without neurosurgical consultation for age, GCS, AIS-Head and presence of skull fracture and intracranial hemorrhage (parenchymal, epidural, subdural, subarachnoid). Neurosurgeons were available to the no-consult group if things went awry.

A total of 180 patients with and 90 patients without neurosurgical involvement were reviewed. Here are the interesting findings:

  • Hospital admission rate was identical for both groups (88%)
  • ICU admission was significantly higher if neurosurgeons were involved (20% vs 44%)
  • Repeat head CT was ordered more than 3 times as often by neurosurgeons (20% vs 86%)
  • Post-discharge head CT was ordered more often by neurosurgeons, but was not significantly higher (5% vs 12%)
  • There were no neurosurgical interventions, in-hospital mortalities, or readmissions within 30 days in either group

Based on this experience, the hospital adopted a set of guidelines for helping determine if neurosurgery should be consulted.

Bottom line: This work raises an interesting question: can general surgeons safely manage select patients with intracranial injury? The answer is probably yes. The majority of patients with mild to moderate TBI with small intracranial bleeds do well despite everything we throw at them. And it appears that surgeons use fewer resources managing them than neurosurgeons do. The keys to being able to use this type of system are to identify at-risk patients who really do need a neurosurgeon early, and having a quick way to get the neurosurgeon involved (by consultation or hospital transfer). Looking at the brain injury guidelines above, I am a little nervous about managing an epidural or contusion without one additional head CT. But this is certainly food for thought. As neurosurgery involvement in acute trauma declines, this concept will become more and more pertinent.

Related posts:

Reference: The acute care surgery model: managing traumatic brain injury without an inpatient neurosurgical consultation. J Trauma 75(1):102-105, 2013.

General

Update: Can TBI Be Managed Without Neurosurgical Consultation?

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This paper was presented at EAST in 2013, and this is an update of that work using the entire manuscript which has now been published.

The standard of care in most high level trauma centers is to involve neurosurgeons in the care of patients with significant traumatic brain injury (TBI). However, not all hospitals that take care of trauma patients have immediate availability of this resource. The University of Arizona at Tucson looked at management of these patients by their acute care surgeons.

The authors did a retrospective cohort study of patients at their center who had a mild TBI and positive head CT, managed with or without neurosurgery consultation, over a two year period. They matched the patients with and without neurosurgical consultation for age, GCS, AIS-Head and presence of skull fracture and intracranial hemorrhage.

A total of 90 patients with and 180 patients without neurosurgical involvement were reviewed. Here are the factoids:

  • Hospital admission rate was identical for both groups (87-89%)
  • ICU admission was significantly higher if neurosurgeons were involved (20% vs 44%)
  • Repeat head CT was ordered more than 3 times as often by neurosurgeons (20% vs 86%)
  • Post-discharge head CT was ordered more often by neurosurgeons, but was not significantly different (5% vs 12%)
  • There were no surgical interventions, in-hospital mortality, or readmissions within 30 days in either group.
  • Cost of the hospital stay was significantly increased if neurosurgery was consulted. 

Bottom line: Can surgeons safely manage select patients with intracranial injury? Granted, this is a small, retrospective study, but the answer is probably yes. The majority of patients with mild to moderate TBI with small intracranial bleeds or skull fractures do well despite everything we throw at them. And it appears that surgeons use fewer resources managing them than neurosurgeons do. The keys to being able to use this type of system are to identify at-risk patients who really do need a neurosurgeon early, and having a quick way to get the neurosurgeon involved (by consultation or hospital transfer). Having a specific practice guideline for management is essential as well. As neurosurgery involvement in acute trauma declines, this concept will become more and more pertinent.

Related posts:

Reference: The acute care surgery model: managing traumatic brain injury without an inpatient neurosurgical consultation. J Trauma 75(1):102-105, 2013.

General

Can TBI Be Managed Without Neurosurgical Consultation?

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The standard of care in most high level trauma centers is to involve neurosurgeons in the care of patients with significant traumatic brain injury (TBI). However, not all hospitals that take care of trauma patients have immediate availability of this resource. A paper to be presented at the upcoming EAST meeting looked at management of these patients by acute care surgeons.

The authors retrospectively reviewed all patients who had a TBI and positive head CT managed with or without neurosurgery consultation over a two year period. Although the authors were from the University of Arizona, a Level I ACS trauma center, the abstract does not explicitly state whether the patients were seen in their hospital or another lower level one.They matched the patients with and without neurosurgical consultation for age, GCS, AIS-Head and presence of skull fracture and intracranial hemorrhage.

A total of 90 patients with and 90 patients without neursurgical involvement were reviewed. Here are the interesting findings:

  • Hospital admission rate was identical for both groups (87-90%)
  • ICU admission was significantly higher if neurosurgeons were involved (20% vs 41%)
  • Repeat head CT was ordered more than 3 times as often by neurosurgeons (20% vs 72%)
  • Post-discharge head CT was ordered more often by neurosurgeons, but was not significantly higher (5% vs 12%)

Nothing is said about complications or mortality, or whether neurosurgeons were available in case things went awry.

Bottom line: This abstract raises an interesting question: can surgeons safely manage select patients with intracranial injury? The answer is probably yes, although this abstract is not complete enough to fully support the idea. The majority of patients with mild to moderate TBI with small intracranial bleeds do well despite everything we throw at them. And it appears that surgeons use fewer resources managing them than neurosurgeons do. The keys to being able to use this type of system are to identify at-risk patients who really do need a neurosurgeon early, and having a quick way to get the neurosurgeon involved (by consultation or hospital transfer). As neurosurgery involvement in acute trauma declines, this concept will become more and more pertinent.

Related posts:

Reference: The acute care surgery model: managing traumatic brain injury without an inpatient neurosurgical consultation. EAST Annual Scientific Assembly, Paper 10, January 2013.

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(In)appropriate Neurosurgical Consultation

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Emergency physicians and trauma surgeons routinely assess patients with potential neurotrauma and decide whether to obtain CT scans and/or neurosurgical consultations. The criteria they use to make these decisions are not always clear.

The neurosurgery department at the University of California – Davis performed a prospective study that looked at the appropriateness of consults they received and of CTs of the head ordered by other physicians in trauma and non-trauma patients. A total of 99 patients entered the study (32 head trauma, 29 spine trauma, 34 other disease, 4 not documented).

After reviewing the consultations, they found that 69 were appropriate, 32 were not appropriate, and 7 could not be classified. Additionally, they felt that 10 of the head CTs in injured patients (31%) were not indicated.

“Appropriateness” was difficult to define well in this study, and there is certainly a great deal of subjectivity involved. The authors recommend using the Canadian CT Head Rule to fine-tune use of head CT in trauma patients.

The bottom line: 1 in 4 consults were not appropriate, and 1 in 3 head CTs were not indicated. Despite its flaws, this study shows that we need to be better at evaluating our patients to reduce unnecessary consults and radiation!

Reference: (In)appropriate neurosurgical consultation. van Essen et al. Clinical Neurology and Neurosurgery. In press, for publication 10/2010.