The Journal of Craniofacial Surgery
& Volume 24, Number 4, July 2013
of titanium cranioplasties as well as their indications for use as a primary repair material or a secondary option. Mohin Bhadkamkar, BS William McCaleb Weathers, MD Larry H. Hollier, MD Houston, TX
Review of ‘‘The Value of Scheduled Repeat Cranial Computed Tomography After Mild Head Injury: Single-Center Series and Meta-Analysis’’ by Almenawer SA, Yarascavitch B, Farrokhyer F, Reddy K, Bogza L, Sne N, Murty N in Neurosurgery 72:56Y62, 2013
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n the current medical environment and as we progress forward, the justification of medical practices needs to be continuously assessed for utility and cost effectiveness. As such, in a recent study, Almenawer et al assessed the value of routine repeat cranial computed tomography (CT) following confirmation of an intracranial hemorrhage. This scheduled follow-up cranial CT has become the standard of care in many trauma centers as a way to assess the need for intervention, regardless of the patient’s neurological status. At their institution, the authors of this study noticed that this practice did not yield a change in the management for their patients and that most intervention was driven by neurologic deterioration alone. Therefore, they put this observation to the test and investigated if neurological examination serves as a better indicator of intervention and repeat imaging in patients with mild traumatic brain injury (TBI).
Literature Scan
The authors provided a systematic review of the literature and retrospective case series to test their hypothesis. Over a 5-year period, 455 patients met their inclusion criteria within their institution. In their review of the literature, 15 studies with 2248 patients were included. The total number of patients was divided into 2 groups. The first group consisted of patients who had a change in their management based on neurologic deterioration and a second group whose management was changed based upon abnormalities seen on CT. Of the entire population studied, 2.7% had medical or surgical intervention based on neurologic findings while 0.6% underwent medical intervention due solely to follow-up head CT findings. The intervention rates were significantly different with P G0.001. From these results, the authors concluded that scheduled repeat CT scans, in patients who have a stable or improving neurological examination, may not be necessary. The authors’ research is timely and provides evidence that supports changes in medical practice. Evidence-based changes that benefit the patient while improving economic utilization of resources are vital. CT scans, although very useful, subject the patient to radiation exposure. Cumulative effects of radiation have been shown to increase the lifetime cancer risk. By relying on the neurologic examination, a risk-free indicator of intervention, repeat imaging would be suggested only in cases of deteriorating clinical findings. Although this places added importance on the clinical skills of the surgeon and the consequences of performing a vigilant examination, one can maintain a low threshold for obtaining repeat imaging. Hence, the need of obtaining a scheduled repeat CT scan in the setting of mild TBI may be diminishing. Although there are limitations with any systematic review, this article provides a sound argument for questioning the value of routine follow-up imaging given the associated accumulative increase in risk and medical costs. Studies similar to this will be important in determining the optimal practices for patient management. Erik M. Wolfswinkel, BS William M. Weathers, MD Larry H. Hollier Jr, MD, FACS Houston, TX
[email protected]
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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