85 a history of vomiting. The physical findings most easily evaluated were scalp hæmatoma, scalp laceration, and ear haemorrhage, and a neurological assessment including the level of consciousness, pupil reactions, and tendon reflexes. Patients with focal or general signs of central nervous system
ness, or
Questionable
Routines
POST-TRAUMATIC SKULL RADIOGRAPHS Time for a Reappraisal B. EYES
Sefton
General Hospital,
involvement were labelled "c.N.s. positive". Case management was assessed in terms of hospital admission, duration of admission, and further medical intervention.
Liverpool
A. F. EVANS
Department of Radiodiagnosis, University of Liverpool 504 patients who had skull radiographs for head injury are included in this study. Only 9 (1·9%) had demonstrable fractures. 129 (25%) of the patients reviewed were admitted to hospital. 93 of these were admitted for up to 24 hours, and 36 for a longer period, usually for conditions unrelated to the head trauma. All but 1 of the patients with a demonstrable skull fracture were admitted to hospital, and the radiographic findings initiated active medical intervention in 2 of these cases. There was no correlation between radiographic findings and the need for hospital admission, and little correlation between radiographic findings and the presenting signs and symptoms. It is, therefore, suggested that the indications for skull radiography in the management of head injuries require reappraisal.
Summary
INTRODUCTION
THIS study was undertaken to evaluate the influence of plain skull radiographic findings on the management of head injuries. Clinical experience had suggested that a large number of radiographic examinations are performed in trauma cases with little positive yield. In recent years there has been an increasing load on diagnostic radiology from casualty departments, radiography being performed in two-thirds of all new casualty attendances. The increasing use and indiscriminate reliance on radiology as a diagnostic sieve in excluding bone injury is a cause for concern. St John2 considered that a physical examination of a patient with head trauma was incomplete without a radiographic survey of the skull, although it is recognised that injury to the intracranial contents seldom bears any relationship to the presence of a skull fracture. Roberts and Shopfner3 have questioned the value of detecting skull fractures in children, pointing out that their detection increased the incidence of hospital admission but usually did not influence subsequent treatment. The cost-effectiveness of routine expensive procedures needs evaluation. Post-traumatic skull radiographs are often requested when only trivial injuries are present. This is the area we review here.
RESULTS
The number of hospital admissions and the incidence of skull fractures in this series is shown in table i. Skull fractures were detected in less than 2% of the patients examined and in 6.2% of those admitted to hospital. Almost three-quarters were discharged from casualty. The single case of skull fracture in a patient not admitted to hospital was detected in the radiology department after the patient had been discharged and was lost to fol-
low-up. Pineal calcification was detected in 280 (57.5%) of the examinations, and there were no cases of pineal shift. There was no correlation between hospital admission and either scalp haematoma and laceration or headache and/or mild concussion (table n). Patients with symptoms and signs referable to central-nervous-system disturbance had a high incidence of hospital admission. 93 of the 129 patients admitted were discharged within 24 hours, observation and treatment of superficial injuries being the only management. The remaining 36 patients remained in hospital for longer than 24 hours, but only 5 were detained for treatment related to head injury. The other 31 patients admitted required longer hospital stay for other medical problems, such as coronary thrombosis, cerebrovascular accidents, severe limb fractures, pneumothorax, and social problems. TABLE I-ADMISSIONS TO HOSPITAL AND INCIDENCE OF SKULL
FRACTURES IN
504
PATIENTS WITH HEAD
INJURY
METHODS AND INVESTIGATION
504 patients were referred to the radiology departments from casualty at two central Liverpool teaching hospitals. The medical records of each patient were reviewed to deterinine the influence, if any, of the radiological findings on subsequent management. An attempt was made to correlate presenting signs and symptoms with radiological findings. A minimum of four radiographic projections (Towne’s projection, posteroanterior, and both laterals) were used in the skull examinations. Patients were categorised as symptom-free or having symptoms including headache, mild concussion, loss of conscious-
*
9 of these patients refused hospital admission. The remaining 11 assessed in casualty and allowed home. All 3 of these patients were intoxicated and refused hospital admission and were lost to follow-up. were
86
f _ _.i3 unear Occurrence of presenting signs and symptoms in 9 patients with skull fractures.
The only patient in this series with a subdural hamahad normal skull radiographs, the diagnosis being made clinically and confirmed by an isotope brain scan. This patient was transferred to the nearby regional neurological centre for operative treatment. Another patient in the series with a normal skull radiograph deteriorated rapidly after admission, and an emergency carotid angiogram revealed an unsuspected left parietal toma
tumour.
The accompanying figure shows the incidence of presenting signs and symptoms in the patients with a skull fracture. The majority had demonstrable physical signs and symptoms which indicated a need for hospital admission independent of the radiographic findings. III shows the treatment of the fractures in admitted to hospital. The patient with the patients depressed fragment was successfully treated with surgery. Prophylactic antibiotic therapy was given when a fracture extended into the frontal sinus. The patient with the fractures base of the skull died from associated multiple injuries before treatment could be started.
Table
DISCUSSION
The low yield of positive findings in this series bears out the clinical impression of many radiologists that plain skull radiographs have a limited value in the management of head injuries. Bell and Loop4 evaluated the clinical criteria for requesting skull radiography, and
although they obtained a high yield of positive radiologifindings in patients with severe central-nervous-system signs and symptoms, they concluded that the radiological findings did little to influence medical treatment. The patients’ clinical condition, not the detection of a cal
TABLE
III-SITE, TYPE,
AND TREATMENT OF SKULL FRACTURE IN
PATIENTS ADMITTED TO HOSPITAL
skull fracture, determines the need for hospital admission and treatment. The radiological findings initiated active treatment in only 2 cases in the present series. In the context of head trauma, skull radiographs are seen as a routine investigation rather than the consequence of a clinical decision related to the individual patient. This attitude results in a low yield of positive ings. In view of its low value, skull radiography should not be regarded as routine. Jennett’s5 opinion of the importance of skull radiography in the initial investigation of all cases of head trauma, the evaluation of the intracranial contents by plain skull radiography is very limited and is indeed difficult to justify in the investigation of trivial trauma. A case has been made6 for the exclusion of skull fractures by adequate radiography in the casualty department, the implication being that this would result in fewer hospital admissions and a consequent saving to the N.H.S. Since the skull radiographic findings bear little relationship to brain damage, this concept is questionable. Pilling? has questioned the medicolegal justification for routine radiographic investigation in the accident department. He reported that he had never found a case in which failure to request a radiographic examination was found in law to be negligent. Therefore, provided the patient has an adequate clinical examination and a decision is made to radiograph or not on the findings in the individual case, it is a reasonable assumption that there is no place for a routine request for a skull series from the medicolegal viewpoint. Because of the limited value of plain skull radiographs in trauma, their cost is worth considering. The cost of a skull series is 3-10 per patient. On this basis it cost up to 300 to detect each fracture in this series. Almost half a million patients8 every year come to British hospitals after head injury, and nearly all of these have skull radiographs at an enormous total cost. The savings to the N.H.S. by more careful use of existing radiographic facilities could, for instance, be used to purchase computerised-tomography scanners-devices which can evaluate intracranial damage very accurately but which are available only in major neurological centres in the U.K. In this series almost 50% (table n) of the patients radiographed and subsequently discharged from casualty were free of symptoms at presentation. Almost a third of the patients who had skull radiographs and were subsequently discharged from casualty had only minor scalp lacerations, and a third had minor haematoma. Provided these are the only clinical features, no useful purpose is served by routine skull radiography. The number of requests for skull radiography could be cut by nearly half by excluding patients without symptoms, and this would still allow the casualty officer the reassurance of having radiographs in the rest of the head-injury cases if he deemed them necessary, even though this practice is of doubtful value, as shown in this series. REFERENCES 1. Galasko, C S. B., Monahan P. R. W. Br. med. J. 1971, i, 643. 2. St. John, E. Am. J. Roentg. 1956, 76, 315. 3. Roberts, F., Shopfner, C. E. ibid. 1972, 114, 230. 4. Bell, K. S., Loop, J. W. New Engl. J. Med. 1971, 284, 236. 5. Jennett, B. Br. med. J. 1975, iii, 267. 6. Lancet, 1978, i, 589. 7. Pilling, H. Proc. R. Soc. Med. 1976, 69, 755. 8. Field, J. H. Epidemiology of Head Injuries in England and Wales;
Stationery Office, 1976.
p. 4. H.M.
ness, or
Questionable
Routines
POST-TRAUMATIC SKULL RADIOGRAPHS Time for a Reappraisal B. EYES
Sefton
General Hospital,
involvement were labelled "c.N.s. positive". Case management was assessed in terms of hospital admission, duration of admission, and further medical intervention.
Liverpool
A. F. EVANS
Department of Radiodiagnosis, University of Liverpool 504 patients who had skull radiographs for head injury are included in this study. Only 9 (1·9%) had demonstrable fractures. 129 (25%) of the patients reviewed were admitted to hospital. 93 of these were admitted for up to 24 hours, and 36 for a longer period, usually for conditions unrelated to the head trauma. All but 1 of the patients with a demonstrable skull fracture were admitted to hospital, and the radiographic findings initiated active medical intervention in 2 of these cases. There was no correlation between radiographic findings and the need for hospital admission, and little correlation between radiographic findings and the presenting signs and symptoms. It is, therefore, suggested that the indications for skull radiography in the management of head injuries require reappraisal.
Summary
INTRODUCTION
THIS study was undertaken to evaluate the influence of plain skull radiographic findings on the management of head injuries. Clinical experience had suggested that a large number of radiographic examinations are performed in trauma cases with little positive yield. In recent years there has been an increasing load on diagnostic radiology from casualty departments, radiography being performed in two-thirds of all new casualty attendances. The increasing use and indiscriminate reliance on radiology as a diagnostic sieve in excluding bone injury is a cause for concern. St John2 considered that a physical examination of a patient with head trauma was incomplete without a radiographic survey of the skull, although it is recognised that injury to the intracranial contents seldom bears any relationship to the presence of a skull fracture. Roberts and Shopfner3 have questioned the value of detecting skull fractures in children, pointing out that their detection increased the incidence of hospital admission but usually did not influence subsequent treatment. The cost-effectiveness of routine expensive procedures needs evaluation. Post-traumatic skull radiographs are often requested when only trivial injuries are present. This is the area we review here.
RESULTS
The number of hospital admissions and the incidence of skull fractures in this series is shown in table i. Skull fractures were detected in less than 2% of the patients examined and in 6.2% of those admitted to hospital. Almost three-quarters were discharged from casualty. The single case of skull fracture in a patient not admitted to hospital was detected in the radiology department after the patient had been discharged and was lost to fol-
low-up. Pineal calcification was detected in 280 (57.5%) of the examinations, and there were no cases of pineal shift. There was no correlation between hospital admission and either scalp haematoma and laceration or headache and/or mild concussion (table n). Patients with symptoms and signs referable to central-nervous-system disturbance had a high incidence of hospital admission. 93 of the 129 patients admitted were discharged within 24 hours, observation and treatment of superficial injuries being the only management. The remaining 36 patients remained in hospital for longer than 24 hours, but only 5 were detained for treatment related to head injury. The other 31 patients admitted required longer hospital stay for other medical problems, such as coronary thrombosis, cerebrovascular accidents, severe limb fractures, pneumothorax, and social problems. TABLE I-ADMISSIONS TO HOSPITAL AND INCIDENCE OF SKULL
FRACTURES IN
504
PATIENTS WITH HEAD
INJURY
METHODS AND INVESTIGATION
504 patients were referred to the radiology departments from casualty at two central Liverpool teaching hospitals. The medical records of each patient were reviewed to deterinine the influence, if any, of the radiological findings on subsequent management. An attempt was made to correlate presenting signs and symptoms with radiological findings. A minimum of four radiographic projections (Towne’s projection, posteroanterior, and both laterals) were used in the skull examinations. Patients were categorised as symptom-free or having symptoms including headache, mild concussion, loss of conscious-
*
9 of these patients refused hospital admission. The remaining 11 assessed in casualty and allowed home. All 3 of these patients were intoxicated and refused hospital admission and were lost to follow-up. were
86
f _ _.i3 unear Occurrence of presenting signs and symptoms in 9 patients with skull fractures.
The only patient in this series with a subdural hamahad normal skull radiographs, the diagnosis being made clinically and confirmed by an isotope brain scan. This patient was transferred to the nearby regional neurological centre for operative treatment. Another patient in the series with a normal skull radiograph deteriorated rapidly after admission, and an emergency carotid angiogram revealed an unsuspected left parietal toma
tumour.
The accompanying figure shows the incidence of presenting signs and symptoms in the patients with a skull fracture. The majority had demonstrable physical signs and symptoms which indicated a need for hospital admission independent of the radiographic findings. III shows the treatment of the fractures in admitted to hospital. The patient with the patients depressed fragment was successfully treated with surgery. Prophylactic antibiotic therapy was given when a fracture extended into the frontal sinus. The patient with the fractures base of the skull died from associated multiple injuries before treatment could be started.
Table
DISCUSSION
The low yield of positive findings in this series bears out the clinical impression of many radiologists that plain skull radiographs have a limited value in the management of head injuries. Bell and Loop4 evaluated the clinical criteria for requesting skull radiography, and
although they obtained a high yield of positive radiologifindings in patients with severe central-nervous-system signs and symptoms, they concluded that the radiological findings did little to influence medical treatment. The patients’ clinical condition, not the detection of a cal
TABLE
III-SITE, TYPE,
AND TREATMENT OF SKULL FRACTURE IN
PATIENTS ADMITTED TO HOSPITAL
skull fracture, determines the need for hospital admission and treatment. The radiological findings initiated active treatment in only 2 cases in the present series. In the context of head trauma, skull radiographs are seen as a routine investigation rather than the consequence of a clinical decision related to the individual patient. This attitude results in a low yield of positive ings. In view of its low value, skull radiography should not be regarded as routine. Jennett’s5 opinion of the importance of skull radiography in the initial investigation of all cases of head trauma, the evaluation of the intracranial contents by plain skull radiography is very limited and is indeed difficult to justify in the investigation of trivial trauma. A case has been made6 for the exclusion of skull fractures by adequate radiography in the casualty department, the implication being that this would result in fewer hospital admissions and a consequent saving to the N.H.S. Since the skull radiographic findings bear little relationship to brain damage, this concept is questionable. Pilling? has questioned the medicolegal justification for routine radiographic investigation in the accident department. He reported that he had never found a case in which failure to request a radiographic examination was found in law to be negligent. Therefore, provided the patient has an adequate clinical examination and a decision is made to radiograph or not on the findings in the individual case, it is a reasonable assumption that there is no place for a routine request for a skull series from the medicolegal viewpoint. Because of the limited value of plain skull radiographs in trauma, their cost is worth considering. The cost of a skull series is 3-10 per patient. On this basis it cost up to 300 to detect each fracture in this series. Almost half a million patients8 every year come to British hospitals after head injury, and nearly all of these have skull radiographs at an enormous total cost. The savings to the N.H.S. by more careful use of existing radiographic facilities could, for instance, be used to purchase computerised-tomography scanners-devices which can evaluate intracranial damage very accurately but which are available only in major neurological centres in the U.K. In this series almost 50% (table n) of the patients radiographed and subsequently discharged from casualty were free of symptoms at presentation. Almost a third of the patients who had skull radiographs and were subsequently discharged from casualty had only minor scalp lacerations, and a third had minor haematoma. Provided these are the only clinical features, no useful purpose is served by routine skull radiography. The number of requests for skull radiography could be cut by nearly half by excluding patients without symptoms, and this would still allow the casualty officer the reassurance of having radiographs in the rest of the head-injury cases if he deemed them necessary, even though this practice is of doubtful value, as shown in this series. REFERENCES 1. Galasko, C S. B., Monahan P. R. W. Br. med. J. 1971, i, 643. 2. St. John, E. Am. J. Roentg. 1956, 76, 315. 3. Roberts, F., Shopfner, C. E. ibid. 1972, 114, 230. 4. Bell, K. S., Loop, J. W. New Engl. J. Med. 1971, 284, 236. 5. Jennett, B. Br. med. J. 1975, iii, 267. 6. Lancet, 1978, i, 589. 7. Pilling, H. Proc. R. Soc. Med. 1976, 69, 755. 8. Field, J. H. Epidemiology of Head Injuries in England and Wales;
Stationery Office, 1976.
p. 4. H.M.
