A study was undertaken to determine the degree to which paediatric neurosurgeons agreed on the optimum management of sport related concussion in children. At the present time, a paradigm for management of concussion in children has not been defined, and the management of such patients largely relies on expert advice from neurosurgeons. This pilot study aimed to establish current consensus neurosurgical practice for management of children with sport related concussion.

Methods

For the purposes of this study, we defined sport related concussion as a head injury occurring during sport or play in children aged 5–15 years of age with a Glasgow coma score of 15 at admission and a normal neurological examination. A standardised questionnaire was sent to 20 neurosurgeons throughout Australia who were identified as having specific expertise in paediatric neurosurgery. There were three parts to the questionnaire. The first related to the routine management of uncomplicated sport related concussion in children. The second involved the role of follow up neuroimaging, neuropsychology, protective equipment recommendations, and return to school advice. The third examined the degree of importance placed on a number of clinical prognostic indicators by the neurosurgeons.

Results

Thirteen paediatric neurosurgeons responded to the study (65% response rate). With respect to general management of paediatric concussion, only three respondents said that they would routinely use skull radiographs, and two would routinely use computed tomography in uncomplicated sport related concussion. The disposition of concussed patients varied among respondents with some recommending hospital admission, some discharging the patient home with the parents, and others recommending a period of observation in the emergency department.

There was a complete lack of consensus among the respondents as to whether a specialist neurosurgeon needs to follow up the patient up. Among those who thought that follow up was necessary, the time to follow up varied from one to six weeks. None of the respondents stated that they would routinely perform neuroimaging or neuropsychological testing at follow up. Similar variable results were found for return to school and return to sport time frames, with ranges of 1–6 weeks.

Six of the 13 respondents would routinely advise the use of a helmet, and three of the 13 would recommend the use of a mouthguard after such injuries.

With respect to clinical prognostic indicators, the following symptoms and signs were examined: headache, vomiting, scalp haematoma, scalp laceration, loss of consciousness, pallor, dry tongue, tiredness or sleepiness, irritability or restlessness, refusal to eat, abusiveness or aggressiveness, withdrawn, amnesic, and parental concern. There was no consensus on which of these symptoms or signs are of prognostic importance.

Discussion

In children aged 15 years and under, traumatic brain injury is a common cause of presentation to emergency departments and general practitioners. In the United States, it has been estimated that more than 1 million children sustain a traumatic brain injury annually (of which 85% are mild injuries) and that traumatic brain injury accounts for more than 250 000 paediatric hospital admissions as well as more than 10% of all visits to emergency service settings.¹ In this setting neurosurgeons are often asked to provide expert opinion on the management of such patients.

After the First International Conference on Concussion in Sport in Vienna 2001, guidelines were drafted on management of concussion in sport.² The scientific data on which these recommendations were based relates specifically to adults and not to children. The American Academy of Paediatrics published guidelines on the management of mild closed head injury in children in 1999; however, these guidelines were more concerned with predicting which children would subsequently develop intracranial complications than the issues of return to sport and neuropsychological recovery.³ The American Academy of Paediatrics guidelines state that there is no indication for routine use of skull radiographic examination in paediatric concussion and “no data are available that demonstrate that children who undergo CT scanning early after minor closed head injury with loss of consciousness have different outcomes compared with children who receive observation alone after injury”.³

It is not surprising given the paucity of literature on this subject that considerable differences exist, even among experts, as to the management of sport related concussion in children. This has a number of important implications over and above the acute management of the injury given the potential for concussive injuries to have detrimental effects on the child’s development and scholastic performance. After this pilot study, we plan to undertake a larger study examining the neurological and neuropsychological management of children with sport related concussion.