Neurosurgical Emergencies in Sport

Evaluation of Neurosurgical Emergencies in the Pediatric Emergency Department: Clinical Warning Signs

BACKGROUND

We aimed to evaluate the patients who underwent neuroimaging with suspicion of neurosurgery pathology and identify the clinical warning signs for the early recognition of neurosurgical emergencies.

METHODS

Patients aged one month to 18 years who underwent neuroimaging with a preliminary diagnosis of intracranial pathology requiring emergency surgery and symptom duration less than one month were included in the study. Patients were divided into three groups according to their definitive diagnosis as neurosurgical emergencies, neurological emergencies, and nonurgents.

RESULTS

A total of 140 patients were included in the study (the median age was 8 [interquartile range IQR 3 to 13] years and 52.8% were male). Neurosurgery emergency group and neurological emergency group were significantly younger than the nonurgent group (P < 0.001). Vomiting, meningeal irritation findings, and papilledema (grade 2 and above) were more common in the neurosurgical emergency group (P 0.029, 0.023, and < 0.001, respectively). For neurosurgical emergencies, in the presence of papilledema (grade 2 and above) and focal neurological deficit, the specificity was 99.2%, positive predictive value (PPV) 83.3%, negative predictive value (NPV) 88.1%, and odds ratio (OR) 36.8 (P < 0.001, confidence interval [CI] 4.04 to 336.0); in the presence of altered consciousness and focal neurological deficit, the specificity was 97.5%, PPV 50%, NPV 86.6%, and OR 6.4 (P = 0.014, CI 1.20 to 34.4).

CONCLUSIONS

Younger age, presence of vomiting, signs of meningeal irritation, papilledema grade 2 and above, and altered consciousness are the crucial "warning signs" of a potential neurosurgical emergency.

Early Predictors and Outcomes of American Spinal Injury Association Conversion at Discharge in Surgical and Nonsurgical Management of Sports-Related Spinal Cord Injury

OBJECTIVE

This study aims to evaluate the rate of improvement in neurologic recovery of patients with sports-related spinal cord injury (SRSCI) who had surgical intervention (SS) and those who did not (NSS). We aimed to 1) evaluate the rate of American Spinal Injury Association (ASIA) conversion in patients with and without surgery, and 2) assess predictors of conversion in ASIA grade.

METHODS

The National Spinal Cord Injury Model Systems Database (SCIMS) was used from 1973 to 2016. Patients with SRSCI were included. The primary outcome was rate of conversion in ASIA grade. Multivariate logistic regression was performed with separate subgroup analysis on patients with cervical injury (represented by odds ratio [OR]; 95% confidence interval [CI]).

RESULTS

A total of 1647 patients had SRSCI with 1502 (91%) SSs. Most patients (88%) were male, white (87%), and between the ages of 15 and 29 years (63%). Patients undergoing SS had significantly longer inpatient rehabilitation length of stay (LOS) (P < 0.001) and a more patients undergoing SS had complete motor or sensory loss compared with the NSS group. Multivariate logistic regression showed that injury at the thoracic level (OR, 0.41; 95% CI, 0.21-0.78), age 15-29 years (OR, 0.44; 95% CI, 0.20-0.97]), water-based injury (OR, 0.45; 95% CI, 0.21-0.95), and ASIA impairment grades of B, C, and D at admission were significantly associated with ASIA SCORE conversion.

CONCLUSIONS

We found that patients undergoing SS had longer LOS and a higher prevalence of complete injuries. Surgical intervention was not associated with conversion in ASIA grade to an improved status at time of discharge in a large cohort of patients with SRSCI and in a subcohort of patients with cervical SRSCI.

Overview of Traumatic Brain Injury in American Football Athletes

OBJECTIVE

The aim of this review is to provide a summary of the epidemiology, clinical presentation, pathophysiology, and treatment of traumatic brain injury in collision athletes, particularly those participating in American football.

DATA SOURCES

A literature search was conducted using the PubMed/MEDLINE and Google Scholar databases for publications between 1990 and 2019. The following search phrases were used: "concussion," "professional athletes," "collision athletes," "mild traumatic brain injury," "severe traumatic brain injury," "management of concussion," "management of severe traumatic brain injury," and "chronic traumatic encephalopathy." Publications that did not present epidemiology, clinical presentation, pathophysiology, radiological evaluation, or management were omitted. Classic articles as per senior author recommendations were retrieved through reference review.

RESULTS

The results of the literature review yielded 147 references: 21 articles discussing epidemiology, 16 discussing clinical presentation, 34 discussing etiology and pathophysiology, 10 discussing radiological evaluation, 34 articles for on-field management, and 32 articles for medical and surgical management.

CONCLUSION

Traumatic brain injuries are frequent in professional collision athletes, and more severe injuries can have devastating and lasting consequences. Although sport-related concussions are well studied in professional American football, there is limited literature on the epidemiology and management of severe traumatic brain injuries. This article reviews the epidemiology, as well as the current practices in sideline evaluation, acute management, and surgical treatment of concussions and severe traumatic brain injury in professional collision athletes. Return-to-play decisions should be based on individual patient symptoms and recovery.

On-field Emergencies and Emergency Action Plans

Sideline coverage can be an enjoyable experience and provide the opportunity to witness and evaluate an athlete's pathology at the time of injury. While the majority of on-field injury will likely be of low acuity, it is essential to develop an Emergency Action Plan (EAP) to deliver excellent medical care efficiently. The EAP should provide a written, standardized multidisciplinary approach involving key personnel. The EAP should be rehearsed on at least an annual basis and should highlight the initial assessment of the patient while also accounting for the various types of trauma that may occur on the field and appropriate field extrication procedures. As most players who have a true on-field emergency will not return to same-day play, a thorough understanding of how to deliver emergency care and transfer the player to a higher level of care is essential.

Recommended Musculoskeletal and Sports Medicine Curriculum for Internal Medicine Residency Training

ABSTRACT

Patients present to primary care physicians with musculoskeletal complaints more often than they do for upper respiratory infections, hypertension, or diabetes. Despite this, instruction in musculoskeletal medicine for internal medicine residents represents less than 1% of their total didactic and clinical education time. We recognize the immense breadth of knowledge and skill required to train residents in the practice of internal medicine. This curriculum guideline defines a recommended training strategy, and supplies relevant resources, to improve musculoskeletal education among internal medicine residents to optimize patient care. This curriculum guideline was created by internists who are sports medicine specialists. Sports medicine physicians promote overall health and well-being while providing expertise in acute and chronic musculoskeletal conditions, as well as how disease affects exercise and using exercise as medicine for people with chronic disease.