{"id":"d3c7ca19-40cb-476c-bfb7-b45b6df6109e","slug":"a-clinical-scale-to-communicate-surgical-urgency-for-traumatic-brain-injury-a-preliminary-study","title":"A clinical scale to communicate surgical urgency for traumatic brain injury: A preliminary study","authors":["Eric A. Sribnick","John J. Hanfelt","Sanjay S. Dhall"],"abstract":"Background: While the Glasgow Coma Scale (GCS) provides a tool for evaluating traumatic brain injury (TBI) patients, there is no widely used scale that provides guidance for surgical management. This study introduces a scoring system that physicians potentially could use to determine and communicate the need for surgical decompression in TBI patients. The proposed system is designed to be both comprehensive and easy to use. Methods: The Surgical Intervention for Traumatic Injury (SITI) scale uses radiographic and clinical findings. Patients were graded based on their GCS: GCS >12 received 0 points, GCS 9-12 received 1 point, and GCS 10 mm received 4 points. The presence of temporal pathology added 1 point, and epidural hematoma (EDH) ≥10 mm added 2 points. Retrospective analysis of 48 patients was then performed using the SITI scale. Results: Of the 48 patients reviewed, 24 patients underwent craniotomy and the other 24 were treated non-operatively. The mean SITI score was 5.7 (range 3-10) for operative patients and 2.5 (range 1-4) for non-operative patients. Conclusions: The proposed SITI scale is designed to be a simple, objective system for assisting in communication between clinical services and for suggesting the need for surgical decompression for TBI. Based upon our initial review, a SITI score of 3 or less correlated with non-operative management and a score of 5 or greater correlated with operative management. Given the results of this study, we believe that further development and research of the SITI scale are warranted. This year, 2014, marks the 40th anniversary of the Glasgow coma scale (GCS),[ 7 ] which aided in the assessment of comatose patients with traumatic brain injuries (TBI). The GCS has found widespread adoption and been used in thousands of studies to stratify head patients[ 3 ] and has furthermore been incorporated into various other scoring systems (e.g. APACHE, TRISS, CRAMS)[ 2 ] and has been found useful for prognostication of clinical outcome in various studies.[ 4 ] However, it is rather astonishing that thus far no other reliable scale has been developed aiming to go one step further: At providing a suitable management guideline when encountering such injuries. There is hence a persistent lack of any established standardized assessment tool that allows care providers to communicate the likelihood of the need of any surgical intervention. This could be of considerable importance, for instance, when transferring a TBI patient from a smaller receiving institution to a specialized tertiary care facility or trauma level 1 center and it is especially valuable to have such a scale available for the nonneurosurgical provider. The current paper by Sribnick and colleagues is therefore a long overdue attempt to introduce a clinically meaningful scoring system (SITI), an acronym for surgical intervention for traumatic head injury. The author's goal is that “physicians could use such a scale to determine and communicate the need for surgical decompression in TBI patients”. The proposed SITI system is designed to be both comprehensive and easy to use, especially for nonneurosurgeons. To this end, the current SITI scale uses basic radiographic aspects obtained by standard computed tomography (CT)-scanning (the existence and degree of midline shift; the presence of temporal pathology or an epidural hematoma) and principal clinical findings (the admission GCS and the possible presence of a dilated pupil), all of which in isolation have proven to be of clinical relevance. By retrospectively assigning patients of a sizeable cohort with a numeric scoring value, the authors were able to show that low scoring patients did not undergo surgical intervention, whereas high scoring patients had a surgical intervention performed. This retrospective observation is compelling and warrants further prospective study since it could help in appropriate triage decisions, preparation of timely intervention, and allocation of resources to head trauma victims. Needless to say, any new scoring system needs to stand the proof of time and further prospective proper evaluation and will change and develop over time. The incorporation of further physiological data and interventions will be needed[ 1 6 ] and other clinical parameters will modify its applicability (e.g. the presence of anticoagulation, presence of base deficit).[ 5 8 9 ] Obviously, any scale that incorporates the GCS or a modified ranking system based on it will carry its intrinsic flaws (such as the question as to use the admission GCS or the postresuscitation GCS but also the known numerical bias toward motor scores) with it. As with the intention of the original GCS, it should be stressed that for clinical use, the patient's clinical status score should better be reported by the three separate components to allow for better validity.[ 2 ] But time will tell how one should go about these specific aspects. We hope that the proposed SITI scale will initially instigate widespread use of it and thus raise attention to the need for further research in this area. May it prove its usefulness and allow the development of it or subsequent tools into a meaningful instrument to effectively communicate the needs of respective patients for better surgical planning and thereby ultimately improve outcome. Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA E-mail: [email protected]","thumbnailUrl":"https://sni-digital-videos.s3.amazonaws.com/articles/d3c7ca19-40cb-476c-bfb7-b45b6df6109e/featured/hero-1782420847901.png","publishDate":"2015-01-05T00:00:00.000Z","doi":"10.4103/2152-7806.148541","categories":["Original Article"],"fullTextUrl":"https://surgicalneurologyint.com/wp-content/uploads/2015/05/3095/SNI-6-1.pdf"}