Time for a review.

This is a simple fact that seems to elude many emergency departments (ED) today.  This fallacy needs to be buried six feet under and please, skip the eulogy, because it is better off dead. The fallacy that I am referring to is the notion that a CT scan or an MRI is sensitive to the presence of a mild traumatic brain injury (mTBI).  These two scans are simply taking pictures of the structures in body.  They save us from being forced to do exploratory surgery to see what is going on inside the body.  They are NOT sensitive to changes at the cellular level and detecting the ions that cross the cell membranes and create the symptoms that we refer to as mTBI or concussion.

This is VERY WELL documented and researched. (see Brady and Brady, The Concussion Blog, and Sports Concussion) However, it doesn't seem to matter to many EDs as they continue to tell patients "The CT came back negative and they do not have a concussion."

Currently, a new. much more expensive type of MRI is being researched as to its effectiveness in diagnosing mTBIs.  This is a functional MRI or fMRI.  This looks at the brain in a much different way than a more common MRI and shows some promise.  However, the expense in conducting this fMRI is incredibly high and cost prohibitive for most hospitals to perform.  At the moment, it is only used in research.

This is not to say that the CT Scans and/or MRIs are not useful.  By no means should they be skipped.  These diagnostic measures do detect hematomas and other issues, more serious and often life threatening issues in the brain that can result from the same hit that created the mTBI.  We must rule out any of the more severe conditions before we move on to treat the injury.

The only way to properly diagnose a mTBI is through a very long interview where a comprehensive set of questions about the patient's symptoms are asked, memory and cognitive functions are tested, and balance is issues are addressed.  This exam is often very tedious and takes a long time to conduct.  However, the information that is gained from the exam is invaluable in making the correct the diagnosis.

To compound the issue, EDs often instruct the athlete that they can return to play "in a of couple days."  This is impossible due to current standards of practice requirements.  There needs to be at least 5 days of slow progression before we can think about return to play.  There needs to be a lot of follow up work, and in this case, at least one neurocognitive test performed and another trip to the physician for clearance before this can happen.  Also, none of these steps can be implemented until the athlete is symptom free.

I am hoping beyond all reasonable sanity that we can get the proper people educated about this quickly and end this issue.

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