Dacey R G, Alves W M, Rimel R W, Winn H R, Jane J A
J Neurosurg. 1986 Aug;65(2):203-10. doi: 10.3171/jns.1986.65.2.0203.
A small number of patients with an apparently minor head injury will develop a life-threatening intracranial hematoma that must be rapidly detected and removed. To assess the risk of a significant intracranial neurosurgical complication after apparently minor head injury, the authors collected data prospectively on 610 patients who had sustained a transient posttraumatic loss of consciousness or other neurological function and who had a Glasgow Coma Scale (GCS) score of 13, 14, or 15 in the emergency room. Skull x-ray films were obtained in 583 patients, 66 of whom (10.8% of the study population) had cranial fractures. Eighteen of the 610 patients (3.0%) required a neurosurgical procedure. Three acute subdural hematomas, one epidural hematoma, and one traumatic intracerebral hematoma required craniotomy. Of the 66 patients who had skull fracture, 7.6% required a craniotomy for intracranial hematoma. Thirteen (19.7%) of the 66 patients with skull fracture required an operative procedure as compared to five (1.0%) of the 517 patients without skull fracture. Two patients with a normal GCS score of 15 and normal skull x-ray films subsequently underwent operative treatment. The cost of three alternative management schemes for these patients was estimated. A 50% reduction in cost of management could be effected by the use of computerized tomography (CT) scans (or possibly skull x-ray films) in determining which of the patients who are alert at the time of presentation should be admitted for observation. Several other conclusions can be drawn from this study. First, an initial GCS score between 13 and 15 does not necessarily indicate that a patient has sustained a trivial head injury, since 3% of such patients will require an operative procedure despite an initially normal level of alertness. Second, an abnormal skull x-ray film increases by a factor of 20 the probability that a patient will need neurosurgical treatment. Third, it is very unusual for patients who have a GCS score of 15 and a normal skull x-ray film to have a significant neurosurgical complication. Fourth, the alternative management schemes that depend on selective use of skull films and CT scans may significantly reduce the cost of caring for patients with minor head injury.
少数看似头部轻伤的患者会出现危及生命的颅内血肿，必须迅速检测并清除。为评估看似头部轻伤后发生严重颅内神经外科并发症的风险，作者前瞻性收集了610例患者的数据，这些患者有创伤后短暂意识丧失或其他神经功能障碍，且在急诊室格拉斯哥昏迷量表（GCS）评分为13、14或15分。583例患者进行了颅骨X光片检查，其中66例（占研究人群的10.8%）有颅骨骨折。610例患者中有18例（3.0%）需要进行神经外科手术。3例急性硬膜下血肿、1例硬膜外血肿和1例创伤性脑内血肿需要开颅手术。在66例有颅骨骨折的患者中，7.6%因颅内血肿需要开颅手术。66例有颅骨骨折的患者中有13例（19.7%）需要手术治疗，而517例无颅骨骨折的患者中有5例（1.0%）需要手术治疗。2例GCS评分为15分且颅骨X光片正常的患者随后接受了手术治疗。估计了针对这些患者的三种替代管理方案的成本。通过使用计算机断层扫描（CT）扫描（或可能是颅骨X光片）来确定哪些就诊时清醒的患者应住院观察，可使管理成本降低50%。从这项研究中还可以得出其他几个结论。首先，初始GCS评分在13至15分之间并不一定表明患者头部受轻伤，因为3%的此类患者尽管最初意识水平正常，但仍需要进行手术。其次，颅骨X光片异常会使患者需要神经外科治疗的概率增加20倍。第三，GCS评分为15分且颅骨X光片正常的患者发生严重神经外科并发症的情况非常罕见。第四，依赖选择性使用颅骨X光片和CT扫描的替代管理方案可能会显著降低轻度头部损伤患者的护理成本。
