Introduction: “Mild” traumatic brain injuries (TBI) are frequently encountered in pediatrics with increased numbers of patients seen after implementation of return to play rules in sports. Studies reveal long-term neuropsychological, behavioral, and cognitive issues may occur following injury. To our knowledge, no study has specifically and systematically evaluated symptoms/follow-up in mild TBI patients requiring neurosurgical consultation. We present one neurosurgeon's experience in evaluating and managing these patients.
Methods: With IRB approval, retrospective review of consecutive patients presenting to the ED with mild TBI diagnosis codes requiring neurosurgical consultation in 2012 was performed. Outpatient follow-up included serial assessment with the Acute Concussion Evaluation (ACE) form developed by the CDC. Data were collected on injury mechanism, reported symptoms, duration of follow-up, and premorbid conditions felt to contribute to protracted recovery.
Results: Thirty-three patients were identified; with thirty having reliable follow-up data for study. Three were lost to follow-up. Mechanisms of injury included motor vehicle crash (8), sports (13), isolated falls (7), and other (2). Twenty-eight were male. Ages ranged 5 to 17 years (mean 11.9). Five carried pre-injury psychiatric diagnoses (e.g. ADHD). Thirteen had negative head CT’s. All were admitted for observation.
First mean follow-up occurred 37 days post-injury. Mean reported symptoms on ACE inventory were 3.5; nine patients were symptom-free. One patient with ADHD was symptom-free with others averaging 6 reported symptoms. Patients with negative CT’s averaged 3.2 ACE symptoms; those with skull fracture or intracranial blood averaged 3.8 symptoms at initial follow-up. Average length of follow-up was 1.3 visits.
Conclusions: Our data suggest that patients with mild TBI often report symptoms for several weeks after injury, particularly if they have psychiatric co-morbidities. Evaluation with the ACE tool helps systemically identify patients experiencing continued symptomatology; prompting appropriate patient management and referral.
Patient Care: As pediatric concussions and the long-term repercussions of mild TBI continue to receive public and research interest, neurosurgeons are increasingly asked to evaluate this unique patient population in the acute setting. It is important for the pediatric neurosurgeon to have a strong understanding of the typical post-injury course for these patients and be able to identify those patients who are at risk for more protracted recovery. Such knowledge will lead to better care for these patients in terms of education and appropriate patient management and referral.
Learning Objectives: By the conclusion of this session, participants should:
1) Have a better understanding of outcomes for the subset of pediatric mild TBI patients referred for neurosurgical evaluation.
2) Identify patients at higher risk for protracted recovery from mild TBI.
3) Be aware of the resources and services available to assist in the optimal assessment and management of these patients.
References: 1. Johnston KM, Lassonde M, Ptito A: A contemporary neurosurgical approach to sport-related head injury: the McGill concussion protocol. J Am Coll Surg 192:515-524, 2001
2. Lee LK: Controversies in the sequelae of pediatric mild traumatic brain injury. Pediatr Emerg Care 23:580-583; quiz 584-586, 2007
3. Yeates KO, Taylor HG: Neurobehavioural outcomes of mild head injury in children and adolescents. Pediatr Rehabil 8:5-16, 2005
4. Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB: Pediatric providers' self-reported knowledge, practices, and attitudes about concussion. Pediatrics 130:1120-1125, 2012