Participation in contact or collision sports in athletes with epilepsy, genetic risk factors, structural brain lesions, or history of craniotomy

Sports participation after craniosynostosis repair: the critical role of post-operative guidance in parental decision-making

PURPOSE

Despite previous research supporting patient safety in sports after craniosynostosis surgery, parental anxiety remains high. This study sought to evaluate the role of healthcare providers in guiding patients and families through the decision-making process.

METHODS

Parents of children with repaired craniosynostosis were asked to assess sports involvement and parental decision-making in children ages 6 and older. Questions were framed primarily on 5-point Likert scales. Sport categorizations were made in accordance with the American Academy of Pediatrics. Chi-squared, linear regression, and Pearson correlation tests were used to analyze associations between the questions.

RESULTS

Forty-three complete parental responses were recorded. Mean ages at surgery and time of sports entry were 7.93 ± 4.73 months and 4.76 ± 2.14 years, respectively. Eighty-two percent of patients participated in a contact sport. Discussions with the primary surgeon were more impactful on parental decisions about sports participation than those with other healthcare providers (4.04 ± 1.20 vs. 2.69 ± 1.32). Furthermore, children whose parents consulted with the primary surgeon began participating in sports at a younger age (4.0 ± 1.0 vs. 5.8 ± 2.7 years, p = 0.034). The mean comfort level with contact sports (2.8 ± 1.4) was lower than that with limited-contact (3.8 ± 1.1, p = 0.0001) or non-contact (4.4 ± 1.3, p < 0.0001) sports.

CONCLUSION

This study underscores the critical role that healthcare professionals, primarily surgeons, have in guiding families through the decision-making process regarding their children's participation in contact sports.

Return to play in children with shunted hydrocephalus

OBJECTIVE

The objective of this study was to assess the relevance of shunted hydrocephalus in regard to participation by young patients in physical education (PE) classes. Students diagnosed with this condition are very often restricted in PE classes owing to the lack of official and well-defined guidelines. However, the medical literature suggests that there is no relationship between the disease and risk of sport-related injuries. In this study, the authors intended to evaluate not only the accuracy of this statement, but also to explore the factors that delay or foreclose return to exercise.

METHODS

The analysis was conducted on patients aged < 18 years with a diagnosis of shunt-treated hydrocephalus who received follow-up for a minimum of 1 year. Collected medical data were examined for factors limiting participation in PE at school. Indicators of both sport-related injuries and conditions acceptable for return to exercise were gathered during follow-up visits.

RESULTS

In this study, 72.72% of patients attended sport activities in schools. The group based on return to PE class differed significantly in the occurrence of neurological deficits, as well as presence of comorbidities. In univariate analysis, the authors identified these parameters as risk factors limiting participation in PE. On the contrary, etiology of hydrocephalus, type of shunting device, number of shunt malfunctions, and presence of epilepsy did not significantly influence sport engagement.

CONCLUSIONS

This study shows that many patients with shunt-treated hydrocephalus can safely participate in PE. Presence of neurological deficits before and after neurosurgical treatment, as well as presence of comorbidities, are factors that negatively impact the possibility of a patient returning to physical activity. Sport-related injuries do occur, but at a low incidence.

Chiari Malformation in Children

Chiari malformation type 1 (CM1) is often found incidentally. However, patients with symptoms or signs referable to CM1 or an associated syrinx will likely benefit from surgical intervention. Patients who are not symptomatic from CM1 at presentation are unlikely to become symptomatic at follow-up.

Sport-Related Structural Brain Injury and Return to Play: Systematic Review and Expert Insight

BACKGROUND

Sport-related structural brain injury (SRSBI) is intracranial pathology incurred during sport. Management mirrors that of non-sport-related brain injury. An empirical vacuum exists regarding return to play (RTP) following SRSBI.

OBJECTIVE

To provide key insight for operative management and RTP following SRSBI using a (1) focused systematic review and (2) survey of expert opinions.

METHODS

A systematic literature review of SRSBI from 2012 to present in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was conducted.

RESULTS

Of 27 included articles out of 241 systematically reviewed, 9 (33.0%) case reports provided RTP information for 12 athletes. To assess expert opinion, 31 of 32 neurosurgeons (96.9%) provided survey responses. For acute, asymptomatic SRSBI, 12 (38.7%) would not operate. Of the 19 (61.3%) who would operate, midline shift (63.2%) and hemorrhage size > 10 mm (52.6%) were the most common indications. Following SRSBI with resolved hemorrhage, with or without burr holes, the majority of experts (>75%) allowed RTP to high-contact/collision sports at 6 to 12 mo. Approximately 80% of experts did not endorse RTP to high-contact/collision sports for athletes with persistent hemorrhage. Following craniotomy for SRSBI, 40% to 50% of experts considered RTP at 6 to 12 mo. Linear regression revealed that experts allowed earlier RTP at higher levels of play (β = -0.58, 95% CI -0.111, -0.005, P = .033).

CONCLUSION

RTP decisions following structural brain injury in athletes are markedly heterogeneous. While individualized RTP decisions are critical, aggregated expert opinions from 31 international sports neurosurgeons provide key insight. Level of play was found to be an important consideration in RTP determinations.

Return to play after brain tumor surgery in children

PURPOSE

Children with a history of brain tumors do not appear to be at a significantly higher risk of sports-related injuries. Nevertheless, according to the systematic review and survey conducted by Perreault et al., 75% of healthcare professionals restrict their patients' participation in physical activities after brain tumor surgery. The aim of our study was to verify whether children after brain tumor surgery return to physical education (PE) classes. It was also an attempt to explore factors limiting return to physical activity.

METHODS

Patients after brain tumor surgery, ≤ 18 years old on admission with ≥ 1 year follow-up were included in the analysis. Data concerning the disease were collected and summarized in search of factors limiting return to physical activity. Meticulous information about return to sports and physical education at school was gathered during follow-up visits.

RESULTS

71.43% of patients returned to school sports activities. Children who did not return to PE had markedly higher neoplasm WHO grade. Significant differences were also found between the groups in terms of hydrocephalus occurrence and need for additional oncological treatment. In univariate analysis, we identified neoplasm WHO grade, tumor location, presence of neurological deficit after the procedure, additional oncological treatment, and occurrence of hydrocephalus needing shunting as the risk factors for not returning to school physical education.

CONCLUSIONS

The majority of pediatric brain tumor survivors return safely to physical education. Higher neoplasm WHO grade, presence of neurological deficit after the procedure, additional oncological treatment, and occurrence of hydrocephalus are risk factors for not returning to physical education.

Complicated Mild Traumatic Brain Injury at a Level I Pediatric Trauma Center: Burden of Care and Imaging Findings

OBJECTIVE

The aims of this study were: (1) to characterize mild traumatic brain injury (mTBI), mTBI with skull fracture, and complicated mTBI in school-aged children seen at a Level I pediatric trauma center and (2) to examine the nature of imaging findings seen in children with mTBI with skull fracture and those with complicated mTBI.

METHODS

A total of 1777 pediatric patients (male: 1193 or 67.1%; age = 11.1 ± 3.5 years) sustaining mTBI who presented to the Emergency Department or directly to the trauma service in the years 2010 to 2013 were identified and classified into mTBI (n = 1,319 or 74.2%), mTBI with skull fracture (n = 127 or 7.2%), and complicated mTBI (n = 331 or 18.6%). Patient characteristics and imaging findings were analyzed using descriptive statistics, Pearson's χ² test, Fisher's exact test, and logistic regression analysis.

RESULTS

In children with complicated mTBI, subdural hematoma (36.9%) was the most common finding. Of the 331 children with complicated mTBI, 241 (72.8%) had multiple findings compared with one (0.8%) of 127 children having mTBI with skull fracture (Fisher's exact P < 0.001), with logistic regression analysis revealing younger age as a potential risk factor (P < 0.01). Children sustaining a depressed or complex skull fracture were nearly twice as likely as those with simple, linear skull fracture to have intracranial abnormality.

CONCLUSIONS

Multiple radiographic findings in children sustaining mTBI with skull fracture or complicated mTBI are prevalent (72.8%), with younger age as a potential risk factor.

Children With Arachnoid Cysts Who Sustain Blunt Head Trauma: Injury Mechanisms and Outcomes

OBJECTIVES

Arachnoid cysts are abnormal intracranial fluid collections, and there is concern that these cysts may bleed or rupture following blunt head trauma. Our objective was to determine the risk of cyst-related complications in a cohort of children with arachnoid cysts who were evaluated for head trauma.

METHODS

We analyzed the Pediatric Emergency Care Applied Research Network (PECARN) head trauma public use data set, which was the product of a study that enrolled children with blunt head trauma from June 2004 to September 2006. We identified children with arachnoid cysts on cranial computed tomography (CT) and described the patient demographics, mechanisms of injury, clinical presentations, CT evidence of traumatic brain injury (TBI), and clinical outcomes. Clinically important TBI was defined as TBI leading to: 1) death from TBI, 2) neurosurgical intervention, 3) intubation for > 24 hours for the TBI, or 4) hospitalization for 2 or more nights for the head injury in association with TBI on CT.

RESULTS

Data were available for 43,399 children who sustained blunt head trauma, of whom 15,899 had cranial CT scans obtained and 68 (0.4%) had arachnoid cysts. Falls were the most common mechanisms of injury (47%) and 87% of children had either moderate or severe injury mechanisms. Glasgow Coma Scale (GCS) scores ranged from 6 to 15, with 61 (90%) having GCS scores of 15. Two of the children with arachnoid cysts had TBIs on CT, one of which was clinically important. There were no identified cases of arachnoid cyst-related bleeding or complications.

CONCLUSIONS

In this cohort of 68 children with arachnoid cysts who sustained head trauma, none demonstrated cyst-related bleeding or complications. This suggests the risk of arachnoid cyst-related complications in children following blunt head trauma is low and evaluation should align with existing clinical decision rules.

Sports and childhood brain tumors: Can I play?

BACKGROUND

It is unknown whether children with brain tumors have a higher risk of complications while participating in sports. We sought to estimate the prevalence of such events by conducting a systematic review of the literature, and we surveyed providers involved with pediatric central nervous system (CNS) tumor patients.

METHODS

A systematic review of the literature in the PubMed, Scopus, and Cochrane databases was conducted for original articles addressing sport-related complications in the brain-tumor population. An online questionnaire was created to survey providers involved with pediatric CNS tumor patients about their current recommendations and experience regarding sports and brain tumors.

RESULTS

We retrieved 32 subjects, including 19 pediatric cases from the literature. Most lesions associated with sport complications were arachnoid cysts (n = 21), followed by glioma (n = 5). The sports in which symptom onset most commonly occurred were soccer (n = 7), football (n = 5), and running (n = 5). We surveyed 111 pediatric neuro-oncology providers. Sport restriction varied greatly from none to 14 sports. Time to return to play in sports with contact also varied considerably between providers. Rationales for limiting sports activities were partly related to subspecialty. Responders reported 9 sport-related adverse events in patients with brain tumor.

CONCLUSIONS

Sport-related complications are uncommon in children with brain tumors. Patients might not be at a significantly higher risk and should not need to be excluded from most sports activities.

Risk of athletes with Chiari malformations suffering catastrophic injuries during sports participation is low

OBJECTIVE

To estimate the risk of athletes with Chiari malformations sustaining a catastrophic injury.

DESIGN

Retrospective, descriptive cohort study.

PARTICIPANTS

All patients diagnosed with Chiari malformation at our institution between June 2008 and November 2011.

ASSESSMENT OF RISK FACTORS

Participants were mailed a questionnaire regarding the number of seasons they participated in organized athletics. Magnetic resonance images were reviewed to describe the characteristics of respondent's Chiari malformations.

MAIN OUTCOME MEASURES

Whether or not the patient had sustained an injury resulting in death, coma, or paralysis.

RESULTS

We had a 53% (N = 147) response rate. Respondents were of a mean age of 15 years (SD, 2 years) at the time of diagnosis. The mean length of protrusion of the cerebellar tonsils below the foramen magnum was 11.2 mm (SD, 5.7 mm). Most of the respondents had pointed cerebellar tonsils and some degree of crowding within the foramen magnum. During a total of 1627 athletic seasons played by patients with Chiari malformation, 0 respondents [95% confidence interval (CI), 0.0000-0.0023] sustained an injury resulting in death, coma, or paralysis. Likewise, during 191 collision sport athletic seasons, 0 (95% CI, 0.0000-0.0191) respondents sustained an injury resulting in death, coma, or paralysis.

CONCLUSIONS

The risk of athletes with Chiari malformations suffering catastrophic injuries during sports participation is low. This estimate of risk should be considered when making return-to-play decisions. Given the variability of anatomical consideration for patients with Chiari malformations, however, each return-to-play decision must continue to be made on a case-by-case basis, considering all of the available information.

CLINICAL RELEVANCE

The low risk of athletes with Chiari malformations suffering catastrophic injuries in sports should be considered when making return-to-play decisions.

Spinal cord injury without radiographic abnormality and the Chiari malformation: controlled observations

BACKGROUND

Case reports have suggested an association between the Chiari malformation type 1 (CM1) and spinal cord injury without radiographic abnormality (SCIWORA). No controlled observations have appeared. We report a case-control study.

METHODS

The Kids' Inpatient Database (KID) is a product of the Healthcare Utilization Project of the Agency for Healthcare Research and Quality. For the years 1997, 2000, 2003, 2006, and 2009, the KID includes discharge data abstracted from almost 14 million pediatric admissions. We hypothesized that CM1 predisposes children to SCIWORA in the cervicomedullary region, and we reasoned that, if this hypothesis were true, then KID admissions coded for upper cervical SCIWORA would be associated with CM1 more frequently than admissions coded for lower cervical SCIWORA.

RESULTS

After exclusion of admissions with a variety of confounding diagnostic codes, we identified 754 admissions coded for upper cervical SCIWORA and 424 coded for lower cervical SCIWORA. Concurrent coding for CM1 was more prevalent among admissions coded for upper cervical SCIWORA than for lower cervical SCIWORA, but the difference did not attain statistical significance (p = 0.093; Fisher's exact test).

CONCLUSIONS

These controlled observations fail to support the hypothesis that CM1 is associated with SCIWORA in childhood. If there is a real association, in the context of recent estimates of the prevalence of CM1 in the pediatric population, the magnitude of the incremental risk must be very small.

Return-to-play decisions

Concussions occur as a result of forces directed to the head or neck, or from impulsive forces transmitted from the body to the head. They result in the rapid onset and spontaneous recovery of short-lived impairment of neurologic function. Concussions represent a functional, rather than structural, disturbance, and do not result in abnormalities on standard structural imaging. This article discusses a comprehensive approach to return to play in sports concussion, including managing athletes returning after prolonged postconcussion syndrome, multiple concussions, and intracranial hematomas and craniotomy.