Neurotrauma in Neurosurgery
This issue of AANS Neurosurgeon is devoted to the topic of neurotrauma. Having recently spent the better part of a weekend working online courses in order to fulfill my hospital’s mandatory 16 hours per year of dedicated “Trauma CMEs,” a requirement for maintaining hospital privileges and participation in the call schedule at the Level I trauma center, the topic is fresh on my mind.
Worldwide, accidents and injuries remain the ninth leading cause of death. Although injuries cross all socioeconomic spectra, they disproportionately affect a younger population. Among the various types of trauma, a head injury is the leading cause of death. Access to rapid transport systems, transport to a facility in which neurosurgical expertise is available and the ability to gain access to surgical and intensive care is lacking (1). In many developing countries, the management of head trauma continues to be provided by a general surgeon or non-physician, health-care provider.
In our country, it is estimated that 1.7 million people per year seek medical care for a traumatic brain injury (TBI). The spectrum of the disease is both largely and poorly-defined. The recent media attention given to sports concussions has created a paradigm shift in parental concerns regarding relatively mild brain injuries. Whereas 15 years ago, a father would argue with me in clinic over my decision to keep his child off of the football field until his post-concussive symptoms improved, now the parents voluntarily withdraw their child not just for a game or two but for a season or more. In a society in which over 13 percent of the children and over 35 percent of adults are overweight, some might question whether we have gone too far with our current concerns regarding concussion.
Alternatively, the spectrum of minor head injuries is poorly understood. In a recent study of 135 patients with mild head injuries and normal CT scans, 30 percent were found to demonstrate structural abnormalities on MRI. Furthermore, those with structural abnormalities on MRI were more likely to have ongoing symptoms beyond three months (2). Even the basic pathophysiology of the illness is debated. What are the genetic and epigenetic contributors that make one patient recover quickly and fully whereas another has persistent headache, memory problems and altered school performance?
In a recent Journal of the American Medical Association (JAMA) editorial, Geoffrey T. Manley, MD, PhD, FAANS, and Andrew I. R. Maas, MD, PhD, outline the need for funding of large, multi-country databases that can begin to more accurately tabulate the subtypes of disease, identify biomarkers that are more predictive of outcome and promote best practices worldwide. Given that the costs attributable to head injuries are estimated at over $76.5 billion annually for our country alone, how could we afford not to (3)?
1. Qureshi J.S., Ohm R., Rajala H., Mabedi C., Sadr-Azodi O., Andren-Sandberg A., & Charles A.G. (2013). Head injury triage in a sub Saharan African urban population. International Journal of Surgery, 11(3), 265-269.
2. Yuh E.L., Mukherjee P., Lingsma H.F., Yue, J.K., Ferguson, A.R. Gordon, W.A., Vladka, A.B., Schnyer, D.M., Okonkwo, D.O., Maas, A.I., & Manley, G.T. (2013). Magnetic resonance imaging improves 3-month outcome prediction in mild traumatic brain injury. Annals of neurology, 73(2), 224-235.
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