轻度钝性颅脑损伤无需常规神经外科会诊。
Routine neurosurgical consultation is not necessary in mild blunt traumatic brain injury.
作者信息
Lewis Paul R, Dunne Casey E, Wallace James D, Brill Jason B, Calvo Richard Y, Badiee Jayraan, Sise Michael J, Bansal Vishal, Sise C Beth, Shackford Steven R
机构信息
From the Trauma Service, Scripps Mercy Hospital, San Diego, California.
出版信息
J Trauma Acute Care Surg. 2017 Apr;82(4):776-780. doi: 10.1097/TA.0000000000001388.
BACKGROUND
The Brain Trauma Foundation guidelines provide indications for neurosurgical intervention in traumatic brain injury (TBI) with moderate or severe intracranial hemorrhage (ICH). In TBI patients with less severe ICH, the utility of neurosurgical consultation remains unclear. We sought to determine if routine neurosurgical consultation is necessary for mild blunt TBI patients with ICH.
METHODS
A retrospective cohort study was conducted on 500 consecutive blunt TBI patients aged 15 years or older with Glasgow Coma Scale score of ≥13 and ICH on initial head computed tomography admitted to a Level I trauma center over 28 months. Outcomes were neurosurgical intervention (craniotomy, craniectomy, ventriculostomy, or intracranial pressure monitor placement) and in-hospital mortality. Statistical significance was assessed at a p < 0.05.
RESULTS
Of 500 patients, 49 (9.8%) underwent neurosurgical intervention. Neurosurgical intervention was more frequent in male patients (75.5% vs. 61.2%, p = 0.049), patients with higher head Abbreviated Injury Scale score (4.7 vs. 3.8, p < 0.0001), patients with an abnormal initial neurological examination (30.6% vs. 12.6%, p = 0.001), or patients with skull fracture (28.6% vs. 16.0%, p = 0.026) and was associated with higher mortality (8.2% vs. 2.0%, p = 0.010). Neurosurgical intervention was not associated with intoxication, preinjury antiplatelet/anticoagulation agents, or progression of ICH on second head computed tomography. Neurosurgical consultation was documented in 466 patients (93.2%). For patients without neurosurgical intervention, consultation did not change management.
CONCLUSION
Routine neurosurgical consultation for blunt TBI with ICH seems unnecessary, regardless of intoxication or preinjury antiplatelet or anticoagulation therapy. A more selective approach is warranted to decrease hospital charges and optimize use of neurosurgical consultation.
LEVEL OF EVIDENCE
Care management study, level IV.
背景
脑外伤基金会指南为中度或重度颅内出血（ICH）的创伤性脑损伤（TBI）患者的神经外科干预提供了指征。对于ICH不太严重的TBI患者，神经外科会诊的作用仍不明确。我们试图确定轻度钝性TBI合并ICH患者是否需要常规神经外科会诊。
方法
对一家一级创伤中心在28个月内收治的500例年龄≥15岁、格拉斯哥昏迷量表评分≥13且初次头颅计算机断层扫描显示有ICH的连续钝性TBI患者进行回顾性队列研究。结局指标为神经外科干预（开颅手术、颅骨切除术、脑室造瘘术或颅内压监测器置入）和住院死亡率。统计学显著性以p<0.05进行评估。
结果
500例患者中，49例（9.8%）接受了神经外科干预。男性患者（75.5%对61.2%，p=0.049）、头部简明损伤量表评分较高的患者（4.7对3.8，p<0.0001）、初次神经系统检查异常的患者（30.6%对12.6%，p=0.001）或有颅骨骨折的患者（28.6%对16.0%，p=0.026）接受神经外科干预的频率更高，且与较高的死亡率相关（8.2%对2.0%，p=0.010）。神经外科干预与中毒、伤前抗血小板/抗凝药物或第二次头颅计算机断层扫描时ICH的进展无关。466例患者（93.2%）记录了神经外科会诊。对于未接受神经外科干预的患者，会诊并未改变治疗方案。
结论
无论是否中毒或伤前使用抗血小板或抗凝治疗，钝性TBI合并ICH患者进行常规神经外科会诊似乎并无必要。有必要采取更具选择性的方法来降低医院费用并优化神经外科会诊的使用。
证据级别
护理管理研究，四级。
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