Sport-Related Structural Brain Injury and Return to Play: Systematic Review and Expert Insight

Scott L. Zuckerman, Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Aaron M. Yengo-Kahn, Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Alan R. Tang, Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Julian E. Bailes, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA.
Kathryn Beauchamp, Division of Neurological Surgery, Denver Health Medical Center, Department of Neurological Surgery University of Colorado, Denver, Colorado, USA.
Mitchel S. Berger, Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.
Christopher M. Bonfield, Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Paul J. Camarata, Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA.
Robert C. Cantu, Boston University, Boston, Massachusetts, USA.
Gavin A. Davis, Department of Neurosurgery, Austin and Cabrini Health, Melbourne, Australia.
Richard G. Ellenbogen, Department of Neurological Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, Washington, USA.
Michael J. Ellis, Department of Surgery and Pediatrics, Section of Neurosurgery, University of Manitoba, Pan Am Concussion Program, Winnipeg, Canada.
Hank Feuer, Player Health and Safety Department, National Football League, New York, New York, USA.
Eric Guazzo, Department of Neurosurgery, Townsville University Hospital, Townsville, Australia.
Odette A. Harris, Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA.
Peter Heppner, Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand.
Stephen Honeybul, Department of Neurosurgery, Sir Charles Gairdner Hospital, Perth Western Australia.
Geoff Manley, Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.
Joseph C. Maroon, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
Vincent J. Miele, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
Brian V. Nahed, Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
David O. Okonkwo, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
Mark E. Oppenlander, Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.
Jerry Petty, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA.
H Ian Sabin, The Wellington Hospital, London, UK.
Uzma Samadani, Division of Neurosurgery, Minneapolis VAMC; Department of Bioinformatics and Computational Biology, University of Minnesota, Minneapolis, Minnesota, USA.
Eric W. Sherburn, The Center for Concussion, University of Oklahoma College of Medicine, Tulsa, Oklahoma, USA.
Mark Sheridan, Department of Neurosurgery, Liverpool Hospital, Liverpool, Australia.
Charles H. Tator, Canadian Concussion Centre and Division of Neurosurgery, Toronto Western Hospital and University of Toronto, Toronto, Canada.
Nicholas Theodore, Department of Neurosurgery, Johns Hopkins University Medical Center, Baltimore, Maryland, USA.
Shelly D. Timmons, Department of Neurological Surgery, Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA.
Graeme F. Woodworth, Department of Neurosurgery & R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA.

Document Type

Article

Abstract

BACKGROUND: Sport-related structural brain injury (SRSBI) is intracranial pathology incurred during sport. Management mirrors that of non-sport-related brain injury. An empirical vacuum exists regarding return to play (RTP) following SRSBI. OBJECTIVE: To provide key insight for operative management and RTP following SRSBI using a (1) focused systematic review and (2) survey of expert opinions. METHODS: A systematic literature review of SRSBI from 2012 to present in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was conducted. RESULTS: Of 27 included articles out of 241 systematically reviewed, 9 (33.0%) case reports provided RTP information for 12 athletes. To assess expert opinion, 31 of 32 neurosurgeons (96.9%) provided survey responses. For acute, asymptomatic SRSBI, 12 (38.7%) would not operate. Of the 19 (61.3%) who would operate, midline shift (63.2%) and hemorrhage size > 10 mm (52.6%) were the most common indications. Following SRSBI with resolved hemorrhage, with or without burr holes, the majority of experts (>75%) allowed RTP to high-contact/collision sports at 6 to 12 mo. Approximately 80% of experts did not endorse RTP to high-contact/collision sports for athletes with persistent hemorrhage. Following craniotomy for SRSBI, 40% to 50% of experts considered RTP at 6 to 12 mo. Linear regression revealed that experts allowed earlier RTP at higher levels of play (β = -0.58, 95% CI -0.111, -0.005, P = .033). CONCLUSION: RTP decisions following structural brain injury in athletes are markedly heterogeneous. While individualized RTP decisions are critical, aggregated expert opinions from 31 international sports neurosurgeons provide key insight. Level of play was found to be an important consideration in RTP determinations.

Medical Subject Headings

Athletes; Athletic Injuries (psychology, rehabilitation); Brain Concussion (psychology, rehabilitation); Brain Injuries, Traumatic (psychology, rehabilitation); Decision Making; Humans; Return to Sport (psychology, statistics & numerical data); Sports

Publication Date

5-13-2021

Publication Title

Neurosurgery

E-ISSN

1524-4040

Volume

88

Issue

6

First Page

E495

Last Page

E504

PubMed ID

33693899

Digital Object Identifier (DOI)

10.1093/neuros/nyab041

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