The American Association of Neurological Surgeons and the Congress of Neurological Surgeons recently joined the American Board of Internal Medicine’s Choosing Wisely campaign with their own list of five practices to avoid in neurosurgery. “The purpose,” says Daniel K. Resnick, MD, “is to alert patients and physicians to common practices that may not be necessary or efficacious.”

The Recommendations

1) Do not administer steroids after severe traumatic brain injuries. According to Dr. Resnick, high-quality studies from the last 20 years demonstrate that although steroids decrease intracranial pressure, they are also associated with several side effects. “The net effect of steroids in patients with severe head injuries is a negative one,” he says.

2) Do not obtain imaging (plain radiographs, MRI, CT, or other advanced imaging) of the spine in patients with non-specific acute low back pain and without red flags. “Decades of experience and hundreds of papers indicate that the chance of finding an issue on imaging that would need to be addressed in patients with acute low back pain but without certain red flags is miniscule,” says Dr. Resnick. “Such imaging leads to unnecessary spending and is a hassle for patients. It often discloses information that is irrelevant and causes angst for patients. It could also lead to needless referrals to surgeons and may promote fear/avoidance behaviors in patients.”

3) Do not routinely obtain CT scans in children with mild head injuries. CT scans expose children to radiation, which has been shown in these patients to increase risks for the later development of cancer, explains Dr. Resnick. “CT should be reserved for children with severe injuries or neurological deficits,” he says.

4) Do not routinely screen for brain aneurysms in asymptomatic patients without a family or personal history of brain aneurysms, subarachnoid hemorrhage, or genetic disorders that may predispose them to aneurysms. Dr. Resnick explains that studies demonstrate that these scans are unnecessary and that they often disclose findings that are irrelevant. Such practices can also lead to more unnecessary testing resulting from defensive medicine.

5) Do not routinely use seizure prophylaxis in patients following ischemic stroke. “Patients with ische­mic stroke don’t need seizure prophylaxis,” Dr. Resnick says. “It doesn’t make sense to give them a medication that is associated with complications.”

Refining-Neurosurgery-Callout

More Is Not Always Better

Clinical inertia and defensive medicine are the drivers behind the need for the recommendations, according to Dr. Resnick. “We’re hoping to spread the message to providers and their patients that more imaging is not necessarily better care,” he says. “This Choosing Wisely list is something that physicians should point to when patients want inappropriate imaging.”

References

American Association of Neurological Surgeons and Congress of Neurological Surgeons. Five things physicians and patients should question. Available at www.choosingwisely.org/doctor-patient-lists/american-association-of-neurological-surgeons.

Bratton S, Chestnut R, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. XV. Steroids. J Neurotrauma. 2007;24(Suppl):S91-S95.

Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.

Kuppermann N, Holmes J, Dayan P, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374:1160-1170.