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Comment & Response |

Neurosurgeons’ Critical Role in Managing Traumatic Brain Injury—Reply

Bellal Joseph, MD1; Viraj Pandit, MD1; Hassan Aziz, MD1
[+] Author Affiliations
1Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson
JAMA Surg. 2016;151(2):200. doi:10.1001/jamasurg.2015.3645.
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In Reply We would like to thank Ullman et al for their insightful comments and discussion. First, we would like to reiterate the fact the Brain Injury Guidelines (BIG) were developed and implemented at our center in coordination with our neurosurgical colleagues. There have been multiple collaborative studies from our institution on BIG with neurosurgeons on the author panel.1

We would also like to emphasize that the management of patients with traumatic brain injury (TBI) requires a multidisciplinary approach that we only aim to improve and streamline with our present guidelines. It is well established that the vast majority of cases of TBI are nonoperative and that the majority of care is provided by the critical care team, especially for patients with mild TBI.2 We know that the neurosurgical workforce is on the decline.3 As a result, multiple studies by neurosurgeons have highlighted and supported the increasing role of trauma surgeons for managing cases of nonoperative TBI.46 Furthermore, with the improvement in the quality of computed tomographic scans, the number of miniscule findings without clinical relevance has increased. The goal of the BIG is to triage initial resources, and our neurosurgical colleagues are included at any time that there is clinical relevance. We believe that these findings are synchronous with the Trauma Quality Improvement Program guidelines for TBI triage. We follow the Trauma Quality Improvement Program guidelines recommended by the expert panel and authored cooperatively by neurosurgeons and trauma surgeons, and we understand how these guidelines refer to the management of severe TBI in which neurosurgeons form a critical component. In addition, these guidelines also recommend no mandatory requirement that patients with a Glasgow Coma Scale score of higher than 13 be transferred to a level I trauma center because the majority of these patients have mild TBI. Our BIG 1 category exclusively defines this subset of patients as patients who can be managed independently without neurosurgeons.


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February 1, 2016
Jamie S. Ullman, MD; Shelly D. Timmons, MD, PhD; Alex B. Valadka, MD
1Hofstra North Shore-LIJ School of Medicine, Hempstead, New York2Department of Neurosurgery, North Shore University Hospital, Manhasset, New York
3Geisinger Health System, Danville, Pennsylvania
4Department of Neurosurgery, Virginia Commonwealth University, Richmond
JAMA Surg. 2016;151(2):199-200. doi:10.1001/jamasurg.2015.3642.
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