=Acta Nurochirurgica
Acta Neurochir (Wien) (1994) 129:11-14
9 Springer-Verlag 1994 Printed in Austria
Role of Skull Radiography in the Initial Evaluation of Minor Head Injury: A Retrospective Study W. R. Murshid Neurosurgery Division, Department of Surgery, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
Summary
Materials and Methods
The use of skull radiography in the initial evaluation of minor head injured patients is controversial. In an attempt to evaluate its benefits, a retrospective study of 566 cases subjected to skull radiography following close minor head trauma (Glasgow Coma Scale 13-15), is presented. A skull fracture (linear vault, depressed or base of skull) was present in 64 (11%) cases. Only three (5%) who were found to have a skull fracture on skull radiography developedan intracranial injury which required surgery. Intracranial injuries developed in 19 (3%) cases and were followed by surgery in six (32%). All, except for one case, had a decreased level of consciousness and a Glasgow Coma Scale less than 15, few had focal neurological deficits. Management had not been altered by the results of skull radiography in any of the cases. We concluded that skull radiographs are unnecessary for the decision process in closed minor head injury because management decisions are based primarily on a careful neurological examination. When intracranial injuries are a concern, a CT scan should be obtained.
This study was based on a retrospective review of records of 566 cases admitted with closed minor head injury (Glasgow Coma Scale 13-15) to King Khalid University Hospital from 1986 to 1992 inclusive. Out of the total number of cases, 396 (70%) were males and 170 (30%) were females showing male predominance. Ages ranged from one month to 80 years, with an average age of 17 years. The most common mechanism of injury were: falls in 312 (55%) and road traffic accidents in 217 (38%) cases. All of the patients had taken SRGs. Demography, mechanism of injury, radiological data, operative sequelae were reviewed. Demographic data collected included age, sex and time period between injury and presentation. To be included in the study, the patient must have presented to the accident and emergencycentre within 24 hours of the time of injury. Radiological studies reviewed included SRGs taken in l~ostero-anterior, lateral and Towne's views and CT scans of head. These studies were obtained as thought necessaryby the accident and emergencyphysicians and the neurosurgical team. No standard protocol was followed in the decision to obtain these studies. Treatment (type and response to) was analysed.
Keywords: Head injury; skull fracture; skull radiography. Introduction
Results
The role o f skull r a d i o g r a p h s ( S R G ) in the initial e v a l u a t i o n o f patients with m i n o r head i n j u r y is controversial ~-14. The discovery of a n isolated finding of a skull fracture rarely requires surgical intervention.
Sixty-four (11%) cases were f o u n d to have a skull fracture (linear vault, depressed or base of skull), this was followed by C T scans of the head in 127 (22%). Only three (5%) were associated with ICIs requiring surgical i n t e r v e n t i o n (Table 1). N i n e t e e n (3 %) patients developed I C I out of which eleven (58%) cases h a d n o
Rather, it is the i n t r a c r a n i a l injuries (ICI) e.g. intracerebral, s u b d u r a l a n d extradural h a e m a t o m a s that necessit~[te surgical intervention. Occasionally, skull radiographs m a y suggest the possible existence of a n I C I by featuring pineal shift or a depressed fracture. The objective of this study is to determine the usefulness or n o t of r o u t i n e S R G in patients presenting with closed m i n o r head injuries.
fracture o n S R G . T a b l e 2 shows a n a d d i t i o n a l case (Case 5) with a fracture n o t s h o w n o n S R G b u t diagnosed at c r a n i o t o m y . O n e p a t i e n t (Case 1) who deteriorated rapidly following a road traffic accident, a n d was t a k e n to the operating theatre w i t h o u t o b t a i n i n g a C T scan, was f o u n d to have bilateral extradural hae-
12
W . R . Murshid: Role of Skull Radiography
Table 1. Patients Requiring Surgery in Relation to SRG and ICI Findings SRG
ICI
Fracture Fracture No fracture No fracture Total
Y N N Y
Surgery no. (%) Y
N
3 (0.5%) i (0.2%) 0 3 (0.5%)
5 (0.9%) 55 (9.7%) 491 (86.8%) 8 (1.4%)
7 (1.2%)
559 (98.8%)
matomas, his SRG revealed a unilateral linear fracture. Case 8 who clinically had a ping pong fracture with no ICI was treated surgically for cosmotic reasons. Only one patient (0.2%) died, this was a 45-year-old male who sustained a base of skull fracture following a fall in the bathroom. No fracture was shown on SRG and CT scan showed multiple contusions and a burst temporal lobe with shift. His neurological condition was poor, and therefore was treated conservatively but continued to deteriorate and died. Discussion
SRG skull radiograph, ICI intracranial injury, Y yes, N no.
Minor head injuries account for more than half of all hospitalized head injury patients. Different criteria
Table 2. Summary of Clinical Data of Patients Requiring Therapeutic Procedures Case Age (years)/Se?~ Clinical no. examination
Mechanism of injury
Fracture on SRG CT scan findings Therapeutic procedure
Outcome/ remarks
1
RTA
Y
not done
exploratory burr holes followed by ---, bilateral craniotomy for bilateral EDH
good
posterior fossa craniectomy
good/ operation done after 72 hours
20/M
GCS 15 ~ 13 focal signs
4/F
GCS 15 fall persistent vomiting
Y
posterior fossa EDH
3
45/M
GCS 13 clinically base of skull fracture fixed and dilated pupils
fall
N
burst temporal ventilation + lobe, multiple conservative treatment contusions, SDH
died
4
23/M
GCS 15 -~ 13 headache, blurry vision
fall
N
EDH
craniotomy
good
5
18/M
GCS 15 --* 13 sport deteriorated in A/E focal signs
N
EDH
craniotomy
good/skull fracture observed at operation
6
27/M
GCS 14 no focal deficits
RTA
N
EDH
craniotomy
good/ operation 48 hours after trauma
7
l/F
GCS 13 unilateral dilated pupil
fall
Y
EDH
craniotomy
good
8
0.9/F
GCS 15 clinically ping pong fracture
fall
Y
no ICI
elevation of fracture
good
GCS glasgow coma scale, -* deterioration, RTA road traffic accident, Yyes, Nno, SDHsubdural haematoma, EDHextradural haematoma, ICI intracranial injury, SRG skull radiography, A/E accident and emergency centre.
w. R. Murshid: Role of Skull Radiography have been used to minimize the number of admissions. S R G although controversial has been used for this purpose. It's rationale being that fractures, once present, predisposed to the development of an ICI and therefore the patient should be admitted and observed. The incidence of finding a skull fracture ranges from 4.6_14%4, 7, 8, 12, this can be increased by using high yield criteria up to 98.9% as reported by Bell and Loop 2. The occurrence of a skull fracture is associated with an increased probability of an ICI; however, ICIs can occur in the absence of a fracture. Masters e t al. 8 reported 4% (12 of 300) of their moderate-risk group patients to suffer from an ICI, only 5 of these cases had an associated skull fracture. Cooper and H o 3 retrospectively studied 16 minor head injured patients who developed an I C I and required surgery. A skull fracture was found in only 6 cases, of which 5 had multiple injuries and required admission anyway. Feuerman e t al. 5 retrospectively analysed 373 minor head injured patients and found no benefit from S R G in any of these patients, as it did not alter treatment in their cases. Masters e t al. 8 concluded in their multicentre prospective study, in which patients were divided into low, moderate and high-risk groups (the first 2 groups correspond to ours except for penetration injuries), that S R G were not recommended for the lowrisk group, and were thought to be rarely helpful for the moderate risk group when positive, and did not exclude an ICI when normal. A total of 3924 cases of the first two groups had SRGs, and the authors also concluded that their criteria were safe and would decrease the use of SRGs. Our study showed an 11.3% incidence of skull fractures, which is similar to Dacey e t al. 4 (11%). However, this incidence is affected by m a n y factors such as the age of the population studied, as reported by Rosenthal and Bergman 12who found a 14% incidence of fractures among 358 children with minor head injury. Intracranial injuries occurred in 19 cases and were not associated with fractures on S R G in 11 cases (58%), this result is similar to Masters e t a l . 8 (58%). The incidence of ICI was only 3%, a much lower figure as compared to Feuerman e t al. 5, who reported 20 (10%) ICI among 201 patients subjected to SRG. Mendelow e t a l . 7 who retrospectively studied 1442 patients admitted following minor head injury, found 11 cases out of 56 who developed intracranial haematoma, to have been alert and oriented on admission. Out of these 11 cases, 5 had a skull fracture, this represents only 0.3%
13 of all the cases studied. N o clinical or radiological details were given for the remaining 45 cases who developed haematomas except that they were not alert nor orientated. Only 3 cases who required surgery had both a fracture on S R G and an ICI, these represent only 0.5% of all patients studied here. In our cases S R G did not alter the management, a similar finding to others 4' 5. Z i m m e r m a n e t al. 14 have declared that S R G is unnecessary if CT scanning is available. On reviewing Table 2, all of the cases with ICI who required surgery or intensive care had a depressed level of consciousness and some with focal signs, none had a full GCS except for one case (Case 2), who sustained an occipital fracture following a fall and was vomiting for more than 48 hours, CT scan at that stage revealed a posterior fossa extradural haematoma, which was evacuated electively after 72 hours. I n c o n c l u s i o n , it is the clinical evaluation which should be the main indication for admission. Once there is any doubt of an ICI, CT scan of the head is the next step in the evaluation of cases. In circumstances where a CT scan is not available, a different system should be evolved.
References 1. Briggs M, Clarke P, Crockard A, etal (1984) Guidelines for initial managementafter head injury in adults. Suggestionsfrom a group of neurosurgeons. BMJ 288:983-985 2. Bell RS, Loop JW (1971) The utility and futility of radiographic skull examination for trauma. N Engl J Med 284:236-239 3, Cooper PR, Ho V (1983) Role of emergency skull X-ray films in the evaluation of the head-injured patient: a retrospective study. Neurosurgery 13:136-140 4. Dacey RG, Alives WM, Rimel RW, Winn R, Jane JA (1986) Neurosurgical complicationsafter apparently minor head injury. J Neurosurgery 65:203-210 5. Feuerman T, Wackym PA, Gade GF, Becker DP (1988) Value of skull radiography,head computed tomographic scanning, and admission for observation in cases of minor head injury. Neurosurgery 22:449.453 6. Jennett B (1980) Skull X-rays after recent head injury. Clin Radiol 31:463-469 7. Mendelow AD, Campbell DA, Jeffrey RR, Miller JD, Hessett C, Bryden J, Jennett B (1982) Admission after mild head injury: Benefits and costs. BMJ 285:1530-1532 8. Masters SJ, McClean PM, Arcarese JS, etal (1987) Skull X-ray examinations after head trauma. N Engl J Med 316:84-91 9. Royal College of Radiologists (eds) (1981) Costs and benefits of skull radiography for head injury. A national study. Lancet ii: 791-795 10. Royal College of Radiologists (eds) (1983) Patient selection for skull radiography in uncomplicated head injury. A national study. Lancet i: 115-118
14 11. Phillips LA (1979) Emergency services utilization of skull radiography. Neurosurgery 4:580-582 12. Rosenthal BW, Bergman I (1989) Intracranial injury after moderate head trauma in children. J Pediatr 115:346-350 13. Vollmer DG, Dacey RG (1991) The management of mild and moderate head injuries. Neurosurg Clin North Am 2:437455 14. Zimmerman RA, Bilaniuk LT, Gennarelli T (1978) Computed
W.R. Murshid: Role of Skull Radiography tomography of shearing injuries of the cerebral white matter. Radiology 127:393-396 Correspondence: Waleed R. Murshid, M.D., FRCSEd, FRCS(SN), Neurosurgery Division, Department of Surgery (37), King Khalid University Hospital, P.O. Box 7805, Riyadh 11472, Saudi Arabia.