Guest post written on behalf of the neurosurgery members of the CDC Pediatric Mild Traumatic Brain Injury Guideline Workgroup
Michael S. Turner, MD, FAANS; Shelly D. Timmons, MD, PhD, FACS, FAANS; Edward C. Benzel, MD, FAANS; Ann-Christine Duhaime, MD, FAANS; Richard G. Ellenbogen, MD, FAANS, FACS; John Ragheb, MD, FAANS, FACS; Patricia B. Raksin, MD, FAANS; and Theodore James Spinks, MD, FAANS.
Neurosurgery has always been at the forefront of management of adult and pediatric Traumatic Brain Injury (TBI). Mild TBI (mTBI), including concussions, is a large segment of TBI, especially in the pediatric population. In 2012, the Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control’s (NCIPC) Board of Scientific Counselors established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. Establishing guidelines has demonstrated improved quality in patient care in a number of conditions, and it was the goal for this workgroup. After many years of hard work, on Aug. 10, 2016, the draft report was published online. On Sept. 7, 2016, the Board of Scientific Counselors met and approved the draft developed by the workgroup. Currently, the final review process is ongoing, and although we can’t discuss the final recommendations until they are published in a peer-reviewed journal, we thought it would be helpful to share the process that was followed to develop them.
Development of Guideline Workgroup
On Oct. 17, 2000, the Children’s Health Act of 2000 (Pub.L. 106–310) was in law. The law was intended to do the following:
- Deliver a national education and awareness campaign about TBI;
- Direct CDC to compile the latest science on pediatric mTBI;
- Create a definition for mTBI; and
- Determine the best methods to quantify its incidence and prevalence.
After the passage of the Children’s Health Act, the CDC developed mTBI Workgroup which produced a report that was released in 2003. The report proposed conceptual and operational definitions of mTBI and made recommendations for mTBI surveillance. However, it was not pediatric specific. To this end, the CDC NCIPC Board of Scientific Counselors established the Pediatric Mild TBI Guideline Workgroup in 2012. The group was comprised of the following:
- 21 Workgroup Members (Neurology, Neurosurgery, Neuropsychology, Emergency Medicine and Physiatry); and
- 21 Ad Hoc Experts (Neurology, Neurosurgery, Neuropsychology, Emergency Medicine and Physiatry).
Several mTBI Guidelines Published in Recent Years:
- In 2008, CDC and American College Emergency Physicians produce neuroimaging and decision-making guidelines for adults (>16 y/o) with mTBI in acute setting;
- In 2012, Canadian consensus guideline on managing patients mTBI with persisting symptoms;
- In 2013, American Academy of Neurology published an evidence-based guideline for the management of sports-related concussion in both children and adults;
- In 2014, Ontario Neurotrauma Foundation published evidence-based guidelines for diagnosing and managing pediatric concussion.
The objective of the Pediatric mTBI Guideline Workgroup was, “to establish evidence-based recommendations for healthcare providers, developed using a rigorous scientific process that systematically reviewed the existing literature to address the lack of clinical consensus on the acute diagnosis and management of mTBI in children ages 18 and younger.”
The Patient-Intervention-Comparator or Co-Intervention-Outcome (PICO) format was used to develop questions for the investigation. Members nominated questions and using the modified Delphi process six questions were selected:
- For children (18 years of age and younger) with suspected mild TBI, do specific tools, as compared with a reference standard, accurately diagnose mild TBI? Acceptable diagnostic reference standards for question 1 were not pre-specified. Reference standards used in the identified studies were tracked during the data extraction process.
- For children (18 years of age and younger) presenting to the emergency department (or other acute care setting) with mild TBI, how often does routine head imaging identify important intracranial injury?
- For children (18 years of age and younger) presenting to the emergency department (or other acute care setting) with mild TBI, which features identify patients at risk for important intracranial injury?
- For children (18 years of age and younger) with mild TBI, what factors identify patients at increased risk for ongoing impairment, more severe symptoms, or delayed recovery (< 1-year post-injury)?
- For children (18 years of age and younger) with mild TBI, which factors identify patients at increased risk of long-term (≥ 1-year post-injury) sequelae?
- For children (18 years of age and younger) with mild TBI (with ongoing symptoms), which treatments improve mild TBI-related outcomes?
A literature search was then performed by trained librarians including MEDLINE, EMBASE, ERIC, SPORTDISCUS and CINAHL. Two consecutive searches were limited by publication type and date from Jan. 1, 1990 to Nov. 30, 2012, and an updated search from Dec. 1, 2012, to July 31, 2015. Across all six questions, 37,000 abstracts were reviewed, almost 2,900 full-text articles were reviewed, more than 340 articles underwent data extraction, and close to 100 articles were included in the qualitative analysis.
Recommendations on the clinical care of pediatric mTBI were developed and categorized into three topics:
- Prognosis and management; and
These recommendations were drafted based on evidence for the systematic review and well as related evidence, scientific principles and expert inference. Recommendations were collated and distributed to the Workgroup in sequential rounds of voting to determine consensus. After four rounds, consensus was achieved on 46 clinical recommendations.
Our hope is that these guidelines will assist health care providers in all aspects of care of mTBI to begin consistent management strategies. We also hope they serve to stimulate research that will develop even better evidence to improve these guidelines over the next decade. Neurosurgeons remain an integral part of establishing optimal care for the youngest and smallest patients sustaining concussions, and we will continue to lead the charge to ensure they get the best treatment possible.
Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #ConcussionFacts.