NO: Neurosurgeons are not needed to care for mild TBI with a positive head CT

Dr. Bellal Joseph
Bellal Joseph

Over the past decade, technological improvements in imaging have resulted in the detection of minuscule and clinically insignificant findings on computed tomographic (CT) scans which has led to over-diagnosis of mild TBI.1 As a consequence, there has been a tremendous increase in the use of healthcare resources due to TBI, the greatest increase is seen in the subgroup of patients with mild TBI. Annually, 282,000 patients are hospitalized due to a TBI resulting in a financial burden of $76.5 billion. Mild TBI accounts for 75% of these admissions.

Despite the advancement in diagnostic modalities, the management protocols for TBI have not evolved. The neurosurgeons comprise the main core for management of TBI. However, over the past decade, the country is facing a severe shortage of neurosurgeons. According to the American Association of Neurological Surgeons (AANS), there is a big discrepancy between the supply and demand of neurosurgery workforce as a result almost 25% of the US population is living in a county without a neurosurgeon. In addition, the neurosurgical workforce is aging with almost 46% neurosurgeons are over the age of 55 which will further aggravate the decline of the workforce in future.2 Classically, patients presenting with a suspected TBI are initially managed by a trauma surgeon. If an intracranial injury is identified on the CT scan, the common practice in most of the trauma centers is to get a neurosurgical consultation and perform a repeat head CT scan, regardless of the type or size of head bleed, clinical presentation or associated risk factors. This practice has put a burden on neurosurgeons who are already suffering from significant workforce shortage.3

Brain injury guidelines

Recent literature has opposed this approach because of three principal reasons. First, over 90% of these patients have mild TBI not requiring neurosurgical intervention and these patients usually are managed nonoperatively by the critical care physician in the ICU.4 Second, most patients with mild TBI have benign physical findings that resolve in 7-10 days. As a result, long-term follow-up in this patient population is very low. Around 10% patients may develop a constellation of cognitive, physical and behavioral symptoms after mild TBI referred to as chronic postconcussion syndrome and they are mainly managed by neurologists and primary care physicians.5 Third, TBI is a clinical diagnosis, and serial clinical examinations can reliably predict the requirement for neurosurgical intervention or a repeat head CT scan in this subgroup of trauma patients.4

To improve and streamline the multidisciplinary management of patients with TBI, our institution has developed and implemented the brain injury guidelines (BIG) in collaboration with our neurosurgical colleagues (Fig 1). Patient safety is the basic and fundamental objective of these guidelines. BIG was developed by the analysis of 3,803 patients and prospectively validated and now proven to be safe in over 4,000 cases.6,7 Since its implementation at our Level-I trauma center, acute care service has been able to manage TBI patients with ICH and bleeds less than 8mm, normal neurological exam, not on any anticoagulant/antiplatelet, and nondisplaced skull fractures by adhering to the protocol. This practice has resulted in a significant decrease in the rate of neurosurgical consultation, repeat head CT scans, hospital costs, and hospital length of stay without any change in mortality (Fig 2a & 2b).8 Five other level I trauma centers have implemented BIG for the management of patients with TBI. In addition, the safety and efficacy of BIG have also been established in the management of mild-TBI among the pediatric population.9 The application of BIG is especially important for institutions with limited resources. Martin et al. from the University of Cincinnati have validated BIG and concluded that implementation of BIG is both safe and feasible at a Level-III trauma center without an increase in adverse outcomes.10 Currently, an American Association for the Surgery of Trauma (AAST) sponsored multiinstitutional trial is underway to implement BIG on a national level.

Brain injury guidelines figure 2a

Brain injury guidelines figure 2b

Over the last decade, there has been a paradigm shift in the management of patients with TBI. Acute care surgeons have assumed a critical role alongside the neurosurgeons for the management of these patients resulting in an efficient resource utilization and reduction in the unnecessary burden on our neurosurgery colleagues.

References

1) Miglioretti DL, Smith-Bindman R. Overuse of computed tomography and associated risks. Am Fam Physician. 2011;83(11):1252-4.

2) Kenning TJ. Neurosurgical Workforce Shortage: The Effect of Subspecialization and a Case for Shortening Residency Training 2016 [1/22/2018]. Available from: http://aansneurosurgeon.org/ departments/neurosurgical-workforce-shortageeffect- subspecialization-cast-shortening-residencytraining/.

3) Gottfried ON, Rovit RL, Popp AJ, Kraus KL, Simon AS, Couldwell WT. Neurosurgical workforce trends in the United States. Journal of neurosurgery. 2005;102(2):202-8.

4) Patel NY, Hoyt DB, Nakaji P, Marshall L, Holbrook T, Coimbra R, Winchell RJ, Mikulaschek AW. Traumatic brain injury: patterns of failure of nonoperative management. Journal of Trauma and Acute Care Surgery. 2000;48(3):367-75.

5) Ryan LM, Warden DL. Post concussion syndrome. International review of psychiatry. 2003;15(4):310-6.

6) Joseph B, Aziz H, Pandit V, Kulvatunyou N, Sadoun M, Tang A, O’Keeffe T, Gries L, Green DJ, Friese RS. Prospective validation of the brain injury guidelines: Managing traumatic brain injury without neurosurgical consultation. Journal of Trauma and Acute Care Surgery. 2014;77(6):984-8.

7) Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, Wynne J, Tang A, O’Keeffe T, Rhee P. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. Journal of Trauma and Acute Care Surgery. 2014;76(4):965-9.

8) Joseph B, Haider AA, Pandit V, Tang A, Kulvatunyou N, O’Keeffe T, Rhee P. Changing paradigms in the management of 2184 patients with traumatic brain injury. Annals of surgery. 2015;262(3):440-8.

9) Azim A, Jehan FS, Rhee P, O’keeffe T, Tang A, Vercruysse G, Kulvatunyou N, Latifi R, Joseph B. Big for small: Validating brain injury guidelines in pediatric traumatic brain injury. Journal of trauma and acute care surgery. 2017;83(6):1200-4.

10) Martin GE, Carroll CP, Plummer ZJ, Millar DA, Pritts TA, Makley AT, Joseph BA, Ngwenya LB, Goodman MD. Safety and efficacy of brain injury guidelines at a Level III trauma center. Journal of trauma and acute care surgery. 2017.