IMPORTANCE: In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened ...concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control’s (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study. OBJECTIVE: To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI. EVIDENCE REVIEW: Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search. FINDINGS: Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking. CONCLUSIONS AND RELEVANCE: This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.
IMPORTANCE: Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency ...department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. OBJECTIVE: To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. EVIDENCE REVIEW: The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. FINDINGS: The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. CONCLUSIONS AND RELEVANCE: This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.
Abstract
BACKGROUND
Radiological evaluation of traumatic thoracolumbar fractures is used to classify the injury and determine the optimal treatment plan. Currently, there remains a lack of consensus ...regarding appropriate radiological protocol. Most clinicians use a combination of plain radiographs, 3-dimensional computed tomography with reconstructions, and magnetic resonance imaging (MRI).
OBJECTIVE
To determine, through evidence-based guidelines review: (1) whether the use of MRI to identify ligamentous integrity predicted the need for surgical intervention; and (2) if there are any radiological findings that can assist in predicting clinical outcomes.
METHODS
A systematic review of the literature was performed using the National Library of Medicine/PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically addressing the radiological evaluation of thoracolumbar spine trauma were selected for review.
RESULTS
Two of 2278 studies met inclusion criteria for review. One retrospective review (Level III) and 1 prospective cohort (Level III) provided evidence that the addition of an MRI scan in acute thoracic and thoracolumbar trauma can predict the need for surgical intervention. There was insufficient evidence that MRI can help predict clinical outcomes in patients with acute traumatic thoracic and thoracolumbar spine injuries.
CONCLUSION
This evidence-based guideline provides a Grade B recommendation that radiological findings in patients with acute thoracic or thoracolumbar spine trauma can predict the need for surgical intervention. This evidence-based guideline provides a grade insufficient recommendation that there is insufficient evidence to determine if radiographic findings can assist in predicting clinical outcomes in patients with acute thoracic and thoracolumbar spine injuries.
RECOMMENDATIONS
QUESTION 1
Are there radiographic findings in patients with traumatic thoracolumbar fractures that can predict the need for surgical intervention?
RECOMMENDATION 1
Because MRI has been shown to influence the management of up to 25% of patients with thoracolumbar fractures, providers may use MRI to assess posterior ligamentous complex integrity, when determining the need for surgery.
Strength of Recommendation: Grade B
QUESTION 2
Are there radiographic findings in patients with traumatic thoracolumbar fractures that can assist in predicting clinical outcomes?
RECOMMENDATION 2
Due to a paucity of published studies, there is insufficient evidence that radiographic findings can be used as predictors of clinical outcomes in thoracolumbar fractures.
Strength of Recommendation: Grade Insufficient
The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_3.
To develop a noninvasive method for intracranial elastance and intracranial pressure (ICP) measurement.
Intracranial volume and pressure changes were calculated from magnetic resonance (MR) imaging ...measurements of cerebrospinal fluid (CSF) and blood flow. The volume change was calculated from the net transcranial CSF and blood volumetric flow rates. The change in pressure was derived from the change in the CSF pressure gradient calculated from CSF velocity. An elastance index was derived from the ratio of pressure to volume change. The reproducibility of the elastance index measurement was established from four to five measurements in five healthy volunteers. The elastance index was measured and compared with invasive ICP measurements in five patients with an intraventricular catheter at MR imaging. False-positive and false-negative rates were established by using 25 measurements in eight healthy volunteers and six in four patients with chronically elevated ICP.
The mean of the fractional SD of the elastance index in humans was 19.6%. The elastance index in the five patients with intraventricular catheters correlated well with the invasively measured ICP (R:(2) = 0.965; P: <.005). MR imaging-derived ICPs in the eight healthy volunteers were 4.2-12.4 mm Hg, all within normal range. Measurements in three of the four patients with chronically elevated ICP were 20.5-34.0 mm Hg, substantially higher than the normal limit.
MR imaging-derived elastance index correlates with ICP over a wide range of ICP values. The sensitivity of the technique allows differentiation between normal and elevated ICP.
Abstract
QUESTION
Does early surgical intervention improve outcomes for patients with thoracic and lumbar fractures?
RECOMMENDATIONS
There is insufficient and conflicting evidence regarding the ...effect of timing of surgical intervention on neurological outcomes in patients with thoracic and lumbar fractures.
Strength of Recommendation: Grade Insufficient
It is suggested that “early” surgery be considered as an option in patients with thoracic and lumbar fractures to reduce length of stay and complications. The available literature has defined “early” surgery inconsistently, ranging from <8 h to <72 h after injury.
Strength of Recommendation: Grade B
The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_10.
Abstract
BACKGROUND
Treatment of thoracolumbar burst fractures has traditionally involved spinal instrumentation with fusion performed with standard open surgical techniques. Novel surgical ...strategies, including instrumentation without fusion and percutaneous instrumentation alone, have been considered less invasive and more efficient treatments.
OBJECTIVE
To review the current literature and determine the role of fusion in instrumented fixation, as well as the role of percutaneous instrumentation, in the treatment of patients with thoracolumbar burst fractures.
METHODS
The task force members identified search terms/parameters and a medical librarian implemented the literature search, consistent with the literature search protocol (see Appendix I), using the National Library of Medicine PubMed database and the Cochrane Library for the period from January 1, 1946 to March 31, 2015.
RESULTS
A total of 906 articles were identified and 38 were selected for full-text review. Of these articles, 12 articles met criteria for inclusion in this systematic review.
CONCLUSION
There is grade A evidence for the omission of fusion in instrumented fixation for thoracolumbar burst fractures. There is grade B evidence that percutaneous instrumentation is as effective as open instrumentation for thoracolumbar burst fractures.
RECOMMENDATIONS
QUESTION
Does the addition of arthrodesis to instrumented fixation improve outcomes in patients with thoracic and lumbar burst fractures?
RECOMMENDATION
It is recommended that in the surgical treatment of patients with thoracolumbar burst fractures, surgeons should understand that the addition of arthrodesis to instrumented stabilization has not been shown to impact clinical or radiological outcomes, and adds to increased blood loss and operative time.
Strength of Recommendation: Grade A
QUESTION
How does the use of minimally invasive techniques (including percutaneous instrumentation) affect outcomes in patients undergoing surgery for thoracic and lumbar fractures compared to conventional open techniques?
RECOMMENDATION
Stabilization using both open and percutaneous pedicle screws may be considered in the treatment of thoracolumbar burst fractures as the evidence suggests equivalent clinical outcomes.
Strength of Recommendation: Grade B
The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_12.
Abstract
BACKGROUND
The thoracic and lumbar (“thoracolumbar”) spine are the most commonly injured region of the spine in blunt trauma. Trauma of the thoracolumbar spine is frequently associated with ...spinal cord injury and other visceral and bony injuries. Prolonged pain and disability after thoracolumbar trauma present a significant burden on patients and society.
OBJECTIVE
To formulate evidence-based clinical practice recommendations for the care of patients with injuries to the thoracolumbar spine.
METHODS
A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to thoracolumbar spinal injuries based on specific clinically oriented questions. Relevant publications were selected for review.
RESULTS
For all of the questions posed, the literature search yielded a total of 6561 abstracts. The task force selected 804 articles for full text review, and 78 were selected for inclusion in this overall systematic review.
CONCLUSION
The available evidence for the evaluation and treatment of patients with thoracolumbar spine injuries demonstrates considerable heterogeneity and highly variable degrees of quality. However, the workgroup was able to formulate a number of key recommendations to guide clinical practice. Further research is needed to counter the relative paucity of evidence that specifically pertains to patients with only thoracolumbar spine injuries.
The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.
Abstract
QUESTION 1
Does routine screening for deep venous thrombosis prevent pulmonary embolism (or venous thromboembolism (VTE)-associated morbidity and mortality) in patients with thoracic and ...lumbar fractures?
RECOMMENDATION 1
There is insufficient evidence to recommend for or against routine screening for deep venous thrombosis in preventing pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures.
Strength of Recommendation: Grade Insufficient
QUESTION 2
For patients with thoracic and lumbar fractures, is one regimen of VTE prophylaxis superior to others with respect to prevention of pulmonary embolism (or VTE-associated morbidity and mortality)?
RECOMMENDATION 2
There is insufficient evidence to recommend a specific regimen of VTE prophylaxis to prevent pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures.
Strength of Recommendation: Grade Insufficient
QUESTION 3
Is there a specific treatment regimen for documented VTE that provides fewer complications than other treatments in patients with thoracic and lumbar fractures?
RECOMMENDATION 3
There is insufficient evidence to recommend for or against a specific treatment regimen for documented VTE that would provide fewer complications than other treatments in patients with thoracic and lumbar fractures.
Strength of Recommendation: Grade Insufficient
RECOMMENDATION 4
Based on published data from pooled (cervical and thoracolumbar) spinal cord injury populations, the use of thromboprophylaxis is recommended to reduce the risk of VTE events in patients with thoracic and lumbar fractures.
Consensus Statement by the Workgroup
The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_7.
Abstract
QUESTION 1
Does the surgical treatment of burst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment?
RECOMMENDATION 1
There is conflicting ...evidence to recommend for or against the use of surgical intervention to improve clinical outcomes in patients with thoracolumbar burst fracture who are neurologically intact. Therefore, it is recommended that the discretion of the treating provider be used to determine if the presenting thoracic or lumbar burst fracture in the neurologically intact patient warrants surgical intervention.
Strength of Recommendation: Grade Insufficient
QUESTION 2
Does the surgical treatment of nonburst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment?
RECOMMENDATION 2
There is insufficient evidence to recommend for or against the use of surgical intervention for nonburst thoracic or lumbar fractures. It is recommended that the decision to pursue surgery for such fractures be at the discretion of the treating physician.
Strength of Recommendation: Grade Insufficient
The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.
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