Neurosurgical forum indications for surgery in cervical spine fractures and that was the reason why this group of patients was included in the overall calculation. The percentage of patients who were managed in the halo vest alone was 59.1% of the t 73 patients: 41.9% had good anatomical outcome and 17.2% had poor anatomical results. The rest of the patients (40.8 % of the total series) underwent surgery for four main reasons: neurological deterioration (5.7%); inability for closed reduction (11.5%); slippage at the fracture site while in the halo vest (20.7%); and instability after halo vest removal (2.9%). "Poor anatomical results" is a radiological definition and its clinical importance is not yet clear. I would not consider this group as representing a failure of halo vest management unless we can prove that some angulation or subtuxation and even unilateral facet jump carries long-term consequences in these patients. The halo vest remains a good apparatus in the management of cervical spine fractures, especially in the subgroup without facet joint dislocation, and authors advocate the use of this apparatus as the primary approach for treatment of cervical spine fractures.
TABLE 1 Outcome 1 year after injury* Status
Vegetative at 1 Month
Vegetative at 3 Months
no. of cases dead vegetative severely disabled independent
140 51% 11% 26% 10%
49 49% 31% 20% 0%
* Data obtained from Braakman.et at. ~ TABLE 2 Follow-up results in 140 patients vegetative at 1 month after injury* Age at Injury
Total Cases
% Independent at 1 Year 19
< 20 yrs
53
20-40 yrs
46
9
> 40 yrs
41
0
* Data obtained from Braakman, el al. ~
MAttMOOD FAZL M . D . , F.R.C.S.(C)
Sunnybrook Medical Centre, University of Toronto Toronto, Ontario, Canada
Severe Traumatic Brain Injury To THE EDITOR: The outcome of "prolonged posttraumatic unawareness" in the large series reported from Israel (Sazbon L, Groswasser Z: Outcome in 134 patients with prolonged posttraumatic unawareness. Parts 1 and 2. J N e u r o s u r g 72:75-84, January, 1990) is difficult to compare with the experience of others. It is unclear whether the patients described were truly in coma 1 month after injury, because there is no mention of eye opening or of other aspects of the Glasgow Coma Scale. It may be that these patients had simply not yet made "a meaningful communicative contact with the environment by either motor, visual, or verbal act" (the authors' definition of the recovery of consciousness). The Glasgow Outcome Scale (GOS) is not used, nor are the outcome categories employed by these authors related to it. Independence for activities of daily life need not imply the degree of social independence that defines being better than severely disabled on the GOS. The variable follow-up periods (5 to 14 years) also make comparisons difficult. It seems that at least 10 of the patients listed as "recovered" were dead at 1 year, and there is no mention of how many remained vegetative at various periods after injury. The authors "found only four series that presented the outcome of patients in prolonged unawareness." They did not refer to the 1988 publication from the Glasgow-based International Data Bank t which analyzed 140 patients considered to be vegetative for 1 month after head injury. At 1 year, 36% were alive and J. Neurosurg. / Volume 73/September, 1990
conscious (Table 1), compared with perhaps 46% in the Israel series (by deduction). We found a striking correlation between age and recovery to independence for patients who were vegetative at 1 month (Table 2). No patient who was still vegetative at 3 months became independent, whatever his age. It would have been interesting to know whether combinations of the factors that were correlated with recovery in the Israel series could lead to more reliable predictions, in particular of recovery to social independence. BRYAN JENNETT, M . D . REINDER BRAAKMAN, M . D .
University of Glasgow Glasgow, Scotland
Reference Braakman R, Jennett WB, Minderhoud JM: Prognosis of the posttraumatic vegetative state. Aeta Neuroehir 95: 49-52, 1988 RESPONSE: We thank Drs. Jennett and Braakman for their comments. Unfortunately, their article came to our notice after we had submitted our paper. All of our patients suffered from severe traumatic brain injury with an initial Glasgow Coma Scale (GCS) score of 7 or less, with closed eyes. The present series included patients whose eyes were open at the start of the 2nd month postinjury, but who otherwise remained devoid of any detectable cognitive activity (that is, they were awake but unaware). These patients were consistent with the definition of "vegetative state; "~ however, we prefer to describe this state as "prolonged posttraumatic unawareness" because our term highlights its basic feature, etiology, and time 479
Neurosurgical forum TABLE 1
TABLE 2
Two combinations of GCS scores in relation to outcome of patients'*
Recovery and mortality data in 134 cases
Outcome
GCS Scores
GCS Scores
3+4+5 6+7 3 4+5 6+7 recovery 46 15 8 38 15 nonrecovery 49 7 13 36 7 * Difference with both combinations was not significant by chisquare testing. GCS = Glasgow Coma Scale.
course. The less negative connotation is appropriate, as recovery o f consciousness is still possible in at least half o f these patients. The initial G C S scores in relation to recovery o f consciousness and the mortality and recovery rates in our series are shown in Tables 1 and 2. The deduction put forward by Drs. Jennett and Braakman about the mortality o f our patients recovering consciousness is not correct, as all o f these patients but one (included in the group who recovered but had to be further institutionalized) were alive 1 year following trauma. As to the statement about our not using the Glasgow O u t c o m e Scale as an o u t c o m e criterion, we refer the reader to Part 2 o f our paper (page 83). We prefer to use "return to work" as an o u t c o m e criterion expressing social reintegration. The concept o f return to work as an integrative o u t c o m e criterion for patients with traumatic brain injury has gained wider use in recent years. 2-4 Almost three-quarters o f the patients who recovered consciousness are living at h o m e and have achieved various degrees o f independence in activities of daily
480
Time Postinjury 3 mos 6 mos 9 mos 12 mos
Recovered
Still Unaware
Dead
No.
%
No.
%
No.
%
57 66 70 72
42.5 49.2 52.2 53.7
68 43 27 19
50.7 32.1 20.1 14.2
9 25 37 43
6.7 18.6 27,6 32.1
life, which are basic goals in the rehabilitation program. Because o f cognitive and behavioral disturbances, only a fraction o f these patients returned to gainful employment; therefore, we had to rely on assessment of the patients' ability to live in their natural environment as a rehabilitation o u t c o m e measure. LEON SAZBON, M.D. ZEEV GROSWASSER, M.D.
Loewenstein Hospital Rehabilitation Center Ra'anana, Israel References 1. Jennett B, Plum F: The persistent vegetative state: a syndrome in search of name. Lancet 1:734-737, 1972 2. McMordie R, Barker SL, Paolo TM: Return to work (RTW) after head injury. Brain Injury 4:57-69, 1990 3. Rao N, Rosenthal M, Cronin-Stubbs D, et al: Return to work after rehabilitation following traumatic brain injury. Brain Injury 4:49-56, 1990 4. Vogenthaler DR, Smith KR, Goldfader P: Head injury, a multivariate study: predicting long-term productivity and independent living outcome. Brain Injury 3:369-385, 1989
J. Neurosurg. / Volume 73 /September, 1990
TABLE 1 Outcome 1 year after injury* Status
Vegetative at 1 Month
Vegetative at 3 Months
no. of cases dead vegetative severely disabled independent
140 51% 11% 26% 10%
49 49% 31% 20% 0%
* Data obtained from Braakman.et at. ~ TABLE 2 Follow-up results in 140 patients vegetative at 1 month after injury* Age at Injury
Total Cases
% Independent at 1 Year 19
< 20 yrs
53
20-40 yrs
46
9
> 40 yrs
41
0
* Data obtained from Braakman, el al. ~
MAttMOOD FAZL M . D . , F.R.C.S.(C)
Sunnybrook Medical Centre, University of Toronto Toronto, Ontario, Canada
Severe Traumatic Brain Injury To THE EDITOR: The outcome of "prolonged posttraumatic unawareness" in the large series reported from Israel (Sazbon L, Groswasser Z: Outcome in 134 patients with prolonged posttraumatic unawareness. Parts 1 and 2. J N e u r o s u r g 72:75-84, January, 1990) is difficult to compare with the experience of others. It is unclear whether the patients described were truly in coma 1 month after injury, because there is no mention of eye opening or of other aspects of the Glasgow Coma Scale. It may be that these patients had simply not yet made "a meaningful communicative contact with the environment by either motor, visual, or verbal act" (the authors' definition of the recovery of consciousness). The Glasgow Outcome Scale (GOS) is not used, nor are the outcome categories employed by these authors related to it. Independence for activities of daily life need not imply the degree of social independence that defines being better than severely disabled on the GOS. The variable follow-up periods (5 to 14 years) also make comparisons difficult. It seems that at least 10 of the patients listed as "recovered" were dead at 1 year, and there is no mention of how many remained vegetative at various periods after injury. The authors "found only four series that presented the outcome of patients in prolonged unawareness." They did not refer to the 1988 publication from the Glasgow-based International Data Bank t which analyzed 140 patients considered to be vegetative for 1 month after head injury. At 1 year, 36% were alive and J. Neurosurg. / Volume 73/September, 1990
conscious (Table 1), compared with perhaps 46% in the Israel series (by deduction). We found a striking correlation between age and recovery to independence for patients who were vegetative at 1 month (Table 2). No patient who was still vegetative at 3 months became independent, whatever his age. It would have been interesting to know whether combinations of the factors that were correlated with recovery in the Israel series could lead to more reliable predictions, in particular of recovery to social independence. BRYAN JENNETT, M . D . REINDER BRAAKMAN, M . D .
University of Glasgow Glasgow, Scotland
Reference Braakman R, Jennett WB, Minderhoud JM: Prognosis of the posttraumatic vegetative state. Aeta Neuroehir 95: 49-52, 1988 RESPONSE: We thank Drs. Jennett and Braakman for their comments. Unfortunately, their article came to our notice after we had submitted our paper. All of our patients suffered from severe traumatic brain injury with an initial Glasgow Coma Scale (GCS) score of 7 or less, with closed eyes. The present series included patients whose eyes were open at the start of the 2nd month postinjury, but who otherwise remained devoid of any detectable cognitive activity (that is, they were awake but unaware). These patients were consistent with the definition of "vegetative state; "~ however, we prefer to describe this state as "prolonged posttraumatic unawareness" because our term highlights its basic feature, etiology, and time 479
Neurosurgical forum TABLE 1
TABLE 2
Two combinations of GCS scores in relation to outcome of patients'*
Recovery and mortality data in 134 cases
Outcome
GCS Scores
GCS Scores
3+4+5 6+7 3 4+5 6+7 recovery 46 15 8 38 15 nonrecovery 49 7 13 36 7 * Difference with both combinations was not significant by chisquare testing. GCS = Glasgow Coma Scale.
course. The less negative connotation is appropriate, as recovery o f consciousness is still possible in at least half o f these patients. The initial G C S scores in relation to recovery o f consciousness and the mortality and recovery rates in our series are shown in Tables 1 and 2. The deduction put forward by Drs. Jennett and Braakman about the mortality o f our patients recovering consciousness is not correct, as all o f these patients but one (included in the group who recovered but had to be further institutionalized) were alive 1 year following trauma. As to the statement about our not using the Glasgow O u t c o m e Scale as an o u t c o m e criterion, we refer the reader to Part 2 o f our paper (page 83). We prefer to use "return to work" as an o u t c o m e criterion expressing social reintegration. The concept o f return to work as an integrative o u t c o m e criterion for patients with traumatic brain injury has gained wider use in recent years. 2-4 Almost three-quarters o f the patients who recovered consciousness are living at h o m e and have achieved various degrees o f independence in activities of daily
480
Time Postinjury 3 mos 6 mos 9 mos 12 mos
Recovered
Still Unaware
Dead
No.
%
No.
%
No.
%
57 66 70 72
42.5 49.2 52.2 53.7
68 43 27 19
50.7 32.1 20.1 14.2
9 25 37 43
6.7 18.6 27,6 32.1
life, which are basic goals in the rehabilitation program. Because o f cognitive and behavioral disturbances, only a fraction o f these patients returned to gainful employment; therefore, we had to rely on assessment of the patients' ability to live in their natural environment as a rehabilitation o u t c o m e measure. LEON SAZBON, M.D. ZEEV GROSWASSER, M.D.
Loewenstein Hospital Rehabilitation Center Ra'anana, Israel References 1. Jennett B, Plum F: The persistent vegetative state: a syndrome in search of name. Lancet 1:734-737, 1972 2. McMordie R, Barker SL, Paolo TM: Return to work (RTW) after head injury. Brain Injury 4:57-69, 1990 3. Rao N, Rosenthal M, Cronin-Stubbs D, et al: Return to work after rehabilitation following traumatic brain injury. Brain Injury 4:49-56, 1990 4. Vogenthaler DR, Smith KR, Goldfader P: Head injury, a multivariate study: predicting long-term productivity and independent living outcome. Brain Injury 3:369-385, 1989
J. Neurosurg. / Volume 73 /September, 1990
