Here is a selection of some of the
Publications by Gavin Davis.

Please click on any of the titles below to view the available abstract.

Peripheral nerve entrapment – How to diagnose and when to refer? Davis GA, Day TJ. Medical Journal of Australia. 2022, doi: 10.5694/mja2.51400


Peripheral nerve entrapment (entrapment
neuropathy) can affect any peripheral nerve in
the body. Entrapment may occur when nerves
pass through narrow, rigid tunnels, traverse highly
mobile joints, pass along hypertrophied muscles or
fibrous bands, or are subject to extrinsic pressure
from certain limb postures. Such compressions are
more likely with repetitive activity, presence of tissue
swelling, trauma, and generalised polyneuropathies
such as diabetic neuropathy, or in some inherited
neuropathies such as hereditary neuropathy with

liability to pressure palsies.1

Characteristics of Concussion Based on Patient Age and Sex: A Multicentre Prospective Observational Study. Babl, F. E., Rausa, V. C., Borland, M. L., Kochar, A., Lyttle, M. D., Phillips, N., Gilhotra, Y., Dalton, S., Cheek, J. A., Furyk, J., Neutze, J., Bressan, S., Davis, G. A., Anderson, V., Williams, A., Oakley, E., Dalziel, S. R., Crowe, L., Hearps, S. J. C. Journal of Neurosurgery: Pediatrics

Objective: Children with concussion frequently present to emergency departments (EDs). There is limited understanding of the differences in signs, symptoms, and epidemiology of concussion based on patient age. Here, the authors set out to assess the association between age and acute concussion presentations.
Methods: The authors conducted a multicenter prospective observational study of head injuries at 10 EDs in Australia and New Zealand. They identified children aged 5 to < 18 years, presenting with a Glasgow Coma Scale score of 13-15, presenting < 24 hours postinjury, with no abnormalities on CT if performed, and one or more signs or symptoms of concussion. They extracted demographic, injury-related, and signs and symptoms information and stratified it by age group (5-8, 9-12, 13 to < 18 years).
Results: Of 8857 children aged 5 to < 18 years, 4709 patients met the defined concussion criteria (5-8 years, n = 1546; 9-12 years, n = 1617; 13 to < 18 years, n = 1546). The mean age of the cohort was 10.9 years, and approximately 70% of the patients were male. Sport-related concussion accounted for 43.7% of concussions overall, increasing from 19.1% to 48.9% to 63.0% in the 5-8, 9-12, and 13 to < 18 years age groups. The most common acute symptoms postinjury were headache (64.6%), disorientation (36.2%), amnesia (30.0%), and vomiting (27.2%). Vomiting decreased with increasing age and was observed in 41.7% of the 5-8 years group, 24.7% of the 9-12 years group, and 15.4% of the 13 to < 18 years group, whereas reported loss of consciousness (LOC) increased with increasing age, occurring in 9.6% in the 5-8 years group, 21.0% in the 9-12 years group, 36.7% in the 13 to < 18 years group, and 22.4% in the entire study cohort. Headache, amnesia, and disorientation followed the latter trajectory. Symptom profiles were broadly similar between males and females.
Conclusions: Concussions presenting to EDs were more sports-related as age increased. Signs and symptoms differed markedly across age groups, with vomiting decreasing and headache, LOC, amnesia, and disorientation increasing with increasing age.

Accuracy of components of the SCAT5 and Child SCAT5 to identify children with concussion. Babl, F. E., Anderson, V., Rausa, V. C., Anderson, N., Pugh, R., Chau, T., Clarke, C., Fabiano, F., Fan, F., Hearps, S. J. C., Parkin, G., Takagi, M., Davis, G. A.

The Sport Concussion Assessment Tool 5th Edition (SCAT5) is a standardized measure of concussion. In this prospective observational study, the ability of the SCAT5 and ChildSCAT5 to differentiate between children with and without a concussion was examined. Concussed children (n=91) and controls (n=106) were recruited from an emergency department in three equal-sized age bands (5-8/9-12/13-16 years). Analysis of covariance models (adjusting for participant age) were used to analyze group differences on components of the SCAT5. On the SCAT5 and ChildSCAT5, respectively, youth with concussion reported a greater number (d=1.47; d=0.52) and severity (d=1.27; d=0.72) of symptoms than controls (all p<0.001). ChildSCAT5 parent-rated number (d=0.98) and severity (d=1.04) of symptoms were greater for the concussion group (all p<0.001). Acceptable levels of between-group discrimination were identified for SCAT5 symptom number (AUC=0.86) and severity (AUC=0.84) and ChildSCAT5 parent-rated symptom number (AUC=0.76) and severity (AUC=0.78). Our findings support the utility of the SCAT5 and ChildSCAT5 to accurately distinguish between children with and without a concussion.

Validation of the SCAT5 and Child SCAT5 word-list memory task. Jesse S Shapiro, Stephen Hearps, Vanessa C. Rausa, Vicki Anderson, Nicholas Anderson, Remy Pugh, Tracey Chau, Cathriona Clarke, Gavin A. Davis, Fabian Fabiano, Feiven Fan, Georgia M Parkin, Michael Takagi, Franz E. Babl. Journal of Neurotrauma

The Sports Concussion Assessment Tool–5th Edition (SCAT5) and the child version (Child SCAT5) are the current editions of the SCAT and have updated the memory testing component from previous editions. This study aimed to validate this new memory component against the Rey Auditory Verbal Learning Test (RAVLT) as the validated standard. This prospective, observational study, carried out within The Royal Children's Hospital Emergency Department, Melbourne, Australia, recruited 198 participants: 91 with concussion and 107 upper limb injury or healthy sibling controls. Partial Pearson correlations showed that memory acquisition and recall on delay aspects of the SCAT5 were significantly correlated with the RAVLT equivalents when controlling for age (p < 0.001, r = 0.565 and p < 0.001, r = 0.341, respectively). Factor analysis showed that all RAVLT and SCAT5 memory components load on to the same factor, accounting for 59.13% of variance. Logistic regression models for both the RAVLT and SCAT5, however, did not predict group membership (p > 0.05). Receiver operating curve analysis found that the area under the curve for all variables and models was below the recommended 0.7 threshold. This study demonstrated that the SCAT5 and Child SCAT5 memory paradigm is a valid measure of memory in concussed children.

No evidence of a difference in SWI lesion burden or functional network connectivity between children with typical and delayed recovery two weeks post-concussion. Jesse S Shapiro, Michael Takagi, Tim Silk, Nicholas Anderson, Cathriona Clarke, Gavin A Davis, Stephen JC Hearps, Vera Ignjatovic, Vanessa Rausa, Marc L Seal, Franz E Babl, and Vicki Anderson. Journal of Neurotrauma

Susceptibility weighted imaging and resting state functional magnetic resonance imaging
have been highlighted as two novel neuroimaging modalities that have been underutilised
when attempting to predict whether a child with concussion will recover normally or have

a delayed recovery course. This study aimed to investigate whether there was a difference

between children who recover normally from a concussion and children with delayed

-recovery in terms of SWI lesion burden and resting state network makeup. Forty-one
children who presented to the emergency department of a tertiary level paediatric
hospital with concussion, participated in this study as a part of a larger prospective,
longitudinal observational cohort study into concussion assessment and recovery. Children
underwent neuroimaging two weeks post injury and were classified as either normally
recovering (n=27), or delayed recovering (n=14) based on their post-concussion symptoms

at 2 weeks post injury. No participants showed lesions detected using SWI; therefore, no
group differences could be assessed. No between group resting state network differences
were uncovered using dual regression analysis. These findings alongside previously
published work suggest that potential causes of delayed recovery from concussion may
not be found using current neuroimaging paradigms.

Risk Factors and Outcomes in 385 cases of Ulnar Nerve Submuscular Transposition. Gavin A. Davis, Trisha Lal, Stephen J.C. Hearps. Journal of Clinical Neuroscience.

Submuscular transposition (SMT) for treatment of ulnar nerve entrapment is commonly performed, how-
ever published comparisons of surgical techniques exclude a high proportion of the at-risk population
encountered in real world practice. To examine the influence of risk factors on the clinical outcome fol-
lowing SMT we performed a retrospective review of all patients who underwent SMT, including patient
self-reported outcome and Louisiana State University Medical Centre ulnar nerve grading scale. A total of
403 ulnar nerves were operated, with follow-up data available for 385 cases (359 patients). Risk factors
(including smoking, diabetes, previous elbow trauma/pathology, subluxation, workers’ compensation)
were reported in 266 of 385 surgeries (69.09%). SMT was the primary procedure in 339 nerves
(88.05%), revision procedure in 46 nerves (11.95%). At last follow up 91.05% reported symptomatic
improvement. Nerve grade improvement in 71.09% of primary and 67.39% revision surgery (p = 0.605).
No significant difference in improvement was identified between demographic and risk categories,
except for patient reported improvement in those without peripheral neuropathy (90.59% vs 73.33%,
p = 0.027), and those not improved were on average older than those improved (62.94 vs. 55.68 years,
p = 0.012). Superficial infection occurred in 2.6% and there were no deep infections. Application of pub-
lished exclusion criteria would have resulted in exclusion of ½–of our cohort. SMT in patients with a
history of elbow trauma, diabetes, workers compensation, smoking history, nerve subluxation or revision
surgery have similar outcomes compared to those without these factors, whilst improved results were
observed in younger patients and those without peripheral neuropathy.

Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children. Franz E Babl, Emma Tavender, Dustin W Ballard, Meredith L Borland, Ed Oakley, Elizabeth Cotterell, Lambros Halkidis, Stacy Goergen, Gavin A Davis, David Perry, Vicki Anderson, Karen M Barlow, Peter Barnett, Scott Bennetts, Roisin Bhamjee, Joanne Cole, John Craven, Libby Haskell, Ben Lawton, Anna Lithgow, Glenda Mullen, Sharon O’Brien, Michelle Paproth, Catherine L Wilson, Jenny Ring, Agnes Wilson, Grace SY Leo, Stuart R Dalziel on behalf of Paediatric Research in Emergency Departments International Collaborative (PREDICT).

Objective: Children frequently present
with head injuries to acute care settings. Although international paediatric
clinical practice guidelines for head injuries exist, they do not address all
considerations related to triage, imaging, observationversusadmission,
transfer, discharge and follow-up of
mild to moderate head injuries relevant to the Australian and New Zealand
context. The Paediatric Research in Emergency Departments International
Collaborative (PREDICT) set out to develop an evidence-based, locally applicable, practical clinical guide-
line for the care of children with
mild to moderate head injuries presenting to acute care settings.
Methods: A multidisciplinary Guideline Working Group (GWG) developed 33 questions in three key areas triage, imaging and discharge of
children with mild to moderate head injuries presenting to acute care
settings. We identied existing high-quality guidelines and from these
guidelines recommendations were
mapped to clinical questions. Updated literature searches were undertaken, and key new evidence
identied. Recommendations were created through either adoption,
adaptation or development ofdenovorecommendations. The guideline was revised after a period of
public consultation.
Results: The GWG developed 71 recommendations (evidence-informed =35, consensus-based = 17, practice
points = 19), relevant to the Australian and New Zealand setting. The
guideline is presented as three documents: (i) a detailed Full Guideline
summarising the evidence underlying
each recommendation; (ii) a Guideline Summary; and (iii) a clinical
Algorithm: Imaging and Observation
Decision-making for Children with Head Injuries.
Conclusions: The PREDICT Australian and New Zealand Guideline for
Mild to Moderate Head Injuries in
Children provides high-level evidence and practical guidance for
front line clinicians.

Sport-related structural brain injury and return to play: systematic review and expert insights. Scott L. Zuckerman, Aaron M. Yengo-Kahn, Alan R. Tang, Julian E. Bailes, Kathryn Beauchamp, Mitchel S. Berger, Christopher M. Bonfield, Paul J. Camarata, Robert C. Cantu, Gavin A. Davis, Richard G. Ellenbogen, Michael J. Ellis, Hank Feuer, Eric Guazzo, Odette A. Harris, Peter Heppner, Stephen Honeybul, Geoff Manley, Joseph C. Maroon, Vincent J. Miele, Brian V. Nahed, David O. Okonkwo, Mark E. Oppenlander, Jerry Petty, Howard Ian Sabin, Uzma Samadani, Eric W. Sherburn, Mark Sheridan, Charles H. Tator, Nicholas Theodore, Shelly D. Timmons, Graeme F. Woodworth, Gary S. Solomon, Allen K. Sills. Neurosurgery.

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) guide-
lines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was
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 neurosur-
geons (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,
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.

Neuroimaging in paediatric mild traumatic brain injury: a systematic review. Rausa, VC., Shapiro, J., Seal, ML., Davis, GA., Anderson, V., Babl, FE., Veal, R., Parkin, G., Ryan, NP., Takagi, M. Neuroscience and Biobehavioral Reviews.

Neuroimaging is being increasingly applied to the study of paediatric mild traumatic brain injury (mTBI) to
uncover the neurobiological correlates of delayed recovery post-injury. The aims of this systematic review were
to: (i) evaluate the neuroimaging research investigating neuropathology post-mTBI in children and adolescents
from 0-18 years, (ii) assess the relationship between advanced neuroimaging abnormalities and PCS in children,
(iii) assess the quality of the evidence by evaluating study methodology and reporting against best practice
guidelines, and (iv) provide directions for future research. A literature search of MEDLINE, PsycINFO, EMBASE,
and PubMed was conducted. Abstracts and titles were screened, followed by full review of remaining articles
where specific eligibility criteria were applied. This systematic review identified 58 imaging studies which met
criteria. Based on several factors including methodological heterogeneity and relatively small sample sizes, the
literature currently provides insufficient evidence to draw meaningful conclusions about the relationship be-
tween MRI findings and clinical outcomes. Future research is needed which incorporates prospective, longitu-
dinal designs, minimises potential confounds and utilises multimodal imaging techniques.

Worsening respiratory failure in an adult hydrocephalic patient with a ventriculo-pleural shunt. Edmond Wong, Vishnu Jeganathan, Samuel Wreghitt, Gavin Davis, Hari Wimaleswaran, Mark Howard. Respirology Case Reports, 8(8), 2020

Ventriculo-pleural (VPL) shunt insertion is performed in hydrocephalic
patients when alternative sites of cerebrospinaluid (CSF) diversion are
contraindicated. These include patients with peritoneal complications from
ventriculo-peritoneal shunts. Despite its utility, VPL shunts are uncommon.
Hydrothoraces should be considered as a potential cause of dyspnoea in the
setting of a VPL shunt. We present a case of worsening respiratory failure
in the setting of a massive CSF hydrothorax in a hydrocephalic patient with
a VPL shunt to highlight this potential complication of pleural CSF diver-
sion, and present a potential management strategy in patients with
premorbid underlying lung pathology. In this case, the hydrothorax was
drained and the shunt was converted to ventriculo-atrial (VA) shunt.

Expert panel survey to update the American Congress of Rehabilitation Medicine definition of mild traumatic brain injury. Silverberg, N.D., Iverson, G.L, Arciniegas, D.B., Bayley, M.T., Bazarian, J.J., Bell, K.R., Broglio, S.P., Cifu, D., Davis, G.A., Dvorak, J., et al. (2020). Archives of Physical Medicine and Rehabilitation.

Objective:As part of an initiative led by the Brain Injury Special Interest Group Mild Traumatic Brain Injury (TBI) Task Force of the American
Congress of Rehabilitation Medicine (ACRM) to update the 1993 ACRM definition of mild TBI, the present study aimed to characterize current
expert opinion on diagnostic considerations.
Design:Cross-sectional web-based survey.
Setting:Not applicable.
Participants:An international, interdisciplinary group of clinician-scientists (NZ31) with expertise in mild TBI completed the survey by
invitation between May and July 2019 (100% completion rate).
Interventions:Not applicable.
Main Outcome Measures:Ratings of agreement with statements related to the diagnosis of mild TBI and ratings of the importance of various
clinical signs, symptoms, test findings, and contextual factors for increasing the likelihood that the individual sustained a mild TBI, on a scale
ranging from 1 (“not at all important”) to 10 (“extremely important”).
Results:Men (nZ25; 81%) and Americans (nZ21; 68%) were over-represented in the sample. The survey revealed areas of expert agreement
(eg, acute symptoms are diagnostically useful) and disagreement (eg, whether mild TBI with abnormal structural neuroimaging should be
considered the same diagnostic entity as “concussion”). Observable signs were generally rated as more diagnostically important than subjective
symptoms (Wilcoxon signed ranks test,ZZ3.77;P<.001;rZ0.68). Diagnostic importance ratings for individual symptoms varied widely, with
some common postconcussion symptoms (eg, fatigue) rated as unhelpful (<75% of respondents indicated at least 5 out of 10 importance). Certain
acute test findings (eg, cognitive and balance impairments) and contextual factors (eg, absence of confounds) were consistently rated as highly
important for increasing the likelihood of a mild TBI diagnosis (75% of respondents indicated at least 7 out of 10).
Conclusions:The expert survey findings identified several potential revisions to consider when updating the ACRM mild TBI definition,
including preferentially weighing observable signs in a probabilistic framework, incorporating symptoms and test findings, and adding differential
diagnosis considerations.

Protocol for a randomised clinical trial of multimodal post-concussion symptom treatment and recovery: The Concussion Essentials Study. Vicki Anderson, Vanessa Rausa, Nicholas Anderson, Georgia M. Parkin, Cathriona Clarke, Katie Davies, Audrey McKinlay, Ali Crichton, Gavin A. Davis, Kim Dalziel, Kevin Dunne, Peter Barnett, Stephen J. C. Hearps, Michael Takagi, Franz E. Babl. BMJ Open.

Introduction While most children recover from a
concussion shortly after injury, approximately 30%
experience persistent postconcussive symptoms (pPCS)
beyond 1- month postinjury. Existing research into the
treatment of pPCS have evaluated unimodal approaches,
despite evidence suggesting that pPCS likely represent an
interaction across various symptom clusters. The primary
aim of this study is to evaluate the effectiveness of a
multimodal, symptom-
tailored intervention to accelerate
symptom recovery and increase the proportion of children
with resolved symptoms at 3 months postconcussion.
Methods and analysis In this open- label, assessor-
blinded, randomised clinical trial, children with concussion
aged 8–18 years will be recruited from The Royal
Children’s Hospital (The RCH) emergency department,
or referred by a clinician, within 17 days of initial injury.
Based on parent ratings of their child’s PCS at ~10
days postinjury, symptomatic children (≥2 symptoms
at least 1- point above those endorsed preinjury) will
undergo a baseline assessment at 3 weeks postinjury and
randomised into either Concussion Essentials (CE, n=108),
a multimodal, interdisciplinary delivered, symptom-
tailored treatment involving physiotherapy, psychology
and education, or usual care (UC, n=108) study arms. CE participants will receive 1 hour of intervention each week,
for up to 8 weeks or until pPCS resolve. A postprogramme
assessment will be conducted at 3 months postinjury for
all participants. Effectiveness of the CE intervention will
be determined by the proportion of participants for whom
pPCS have resolved at the postprogramme assessment
(primary outcome) relative to the UC group. Secondary
outcome analyses will examine whether children receiving
CE are more likely to demonstrate resolution of pPCS,
earlier return to normal activity, higher quality of life and a
lower rate of utilisation of health services, compared with
the UC group.
Ethics and dissemination Ethics were approved by The
RCH Human Research Ethics Committee (HREC: 37100).
Parent, and for mature minors, participant consent, will be
obtained prior to commencement of the trial. Study results
will be disseminated at international conferences and
international peer- reviewed journals.

Mild Traumatic Brain Injury in Children with Ventricular Shunts. A PREDICT study. Franz E Babl, Mark D Lyttle, Natalie Phillips, Amit Kochar, Sarah Dalton, John A Cheek, Jeremy Furyk, Jocelyn Neutze, Silvia Bressan, Amanda Williams, Stephen Hearps, Ed Oakley, Gavin A Davis, Stuart R Dalziel, Meredith L Borland, on behalf of Paediatric Research in Emergency Departments International Collaborative (PREDICT). Journal of Neurosurgery: Pediatrics.

OBJECTIVE Current clinical decision rules (CDRs) guiding the use of CT scanning in pediatric traumatic brain injury
(TBI) assessment generally exclude children with ventricular shunts (VSs). There is limited evidence as to the risk of
abnormalities found on CT scans or clinically important TBI (ciTBI) in this population. The authors sought to determine
the frequency of these outcomes and the presence of CDR predictor variables in children with VSs.
METHODS The authors undertook a planned secondary analysis on children with VSs included in a prospective exter-
nal validation of 3 CDRs for TBI in children presenting to 10 emergency departments in Australia and New Zealand. They
analyzed differences in presenting features, management and acute outcomes (TBI on CT and ciTBI) between groups
with and without VSs, and assessed the presence of CDR predictors in children with a VS.
R ES U LT S A total of 35 of 20,137 children (0.2%) with TBI had a VS; only 2 had a Glasgow Coma Scale score < 15.
Overall, 49% of patients with a VS underwent CT scanning compared with 10% of those without a VS. One patient had
a finding of TBI on CT scanning, with positive predictor variables on CDRs. This patient had a ciTBI. No patient required
neurosurgery. For children with and without a VS, the frequency of ciTBI was 2.9% (95% CI 0.1%–14.9%) compared with
1.4% (95% CI 1.2%–1.6%) (difference 1.5% [95% CI −4.0% to 7.0%]), and TBI on CT 2.9% (95% CI 0.1%–14.9%) com-
pared with 2.0% (95% CI 1.8%–2.2%) (difference 0.9%, 95% CI −4.6% to 6.4%).
CONCLUSIONS The authors’ data provide further support that the risk of TBI is similar for children with and without a VS.

Use of the sport concussion assessment tools in the emergency department to predict persistent post-concussive symptoms in children. Silvia Bressan, Cathriona J Clarke, Vicki Anderson, Michael Takagi,Stephen JC Hearps,Vanessa Rausa, Nicholas Anderson, Melissa Doyle, Kevin Dunne, Ed Oakley, Gavin A Davis and Franz E Babl. Journal of Paediatrics and Child Health

Aim:The Sport Concussion Assessment Tool v3 (SCAT3) and its child version (ChildSCAT3) are composite tools including a symptom scale, a
rapid cognitive assessment (standardised assessment of concussion (SAC)) and the modified Balance Error Scoring System (mBESS). It is unclear
whether their use for the acute assessment of paediatric concussion in the emergency department (ED) may help predict persistent post-
concussive symptoms (PPCS). We aim to assess the predictive value of the main SCAT3/ChildSCAT3 components for PPCS when applied in the ED.
Methods:A single-site, prospective longitudinal cohort study of children aged 518 years assessed within 48 h of their concussion at the ED
of a state-wide tertiary paediatric hospital and followed up at the afliated concussion clinic, between November 2013 and August 2017. PPCS
was dened as≥2 new or worsening symptoms at 1 month post-injury using the Post-Concussive Symptom Inventory.
Results:Of the 370 children enrolled, 213 (57.7% <13 years old) provided complete data. Of these, 34.7% had PPCS at 1 month post-injury
(38.2% of children <13 years and 30.0%13 years of age,P= 0.272). The adjusted ORs from multiple logistic regression models, for number and
severity of symptoms, and for the SAC and mBESS performance in both the ChildSCAT3/SCAT3, were all not signicant. The area under the curve
of receiver operator characteristic curves for all analysed ChildSCAT3/SCAT3 components was below 0.6.
Conclusions:Although SCAT3 and ChildSCAT3 are recommended tools to assist with concussion diagnosis and monitoring of patient recovery,
their use in the ED does not seem to help predict PPCS.

Circumferential Adipose Lesion of the Sciatic Nerve. Gavin A. Davis, Tomas Marek, Kimberly K. Amrami, Mark A. Mahan, Robert J. Spinner. World Neurosurgery.

BACKGROUND:Adipose lesions of nerve are generally distinguished as
either extraneural or intraneural lipomas or, alternatively, lipomatosis of nerve.
We present a patient with an unusual circumferential lipoma that completely
encircles the right sciatic nerve and discuss a possible pathogenesis.
CASE DESCRIPTION:A 44-year-old woman presented with progressive
symptoms and signs of sciatic neuropathy for 1 year. Magnetic resonance im-
aging revealed a large lipomatous mass extending from the level of the lesser
trochanter to the distal third of the femur. The sciatic nerve was completely
enveloped by the lipoma in the proximal segment, partially enveloped in the mid-
segment and was separate from the nerve in the distal segment. The lipoma was
not covered by the epineurium. The tumor was completely resected and the
patients neurologic symptoms improved.
CONCLUSIONS:The pathogenetic mechanism of the reported circumferential
lipoma of the sciatic nerve is not known. Two possible mechanisms considered
included 1) envelopment by an extraneural lipoma over time and 2) occurrence
of a lipoma in the paraneurial compartment (and in this case, extension into an
extraneural one). Based on the available literature, lipomas that circum-
ferentially envelop the entire nerve seem to be underrecognized and poorly
understood. Analogous cases of lipomas enveloping nerves or other structures
than nerves have been reported in the literature. Our reported case highlights the
complexity of adipose lesions affecting nerves.

Trajectories and Risk Factors for Pediatric Post-Concussive Symptom Recovery. Katherine Truss, Stephen JC Hearps, Michael Takagia, Franz E Babl, Silvia Bressan, Cathriona Clarke, Nicholas Anderson, Vanessa Rausa, Gavin A Davis, Kevin Dunne, Vicki Anderson. Neurosurgery.

BACKGROUND:Persistent postconcussive symptoms (PCS) are poorly understood in
children. Research has been limited by an assumption that children with concussion are
a homogenous group.
OBJECTIVE:To identify (i) distinctive postconcussive recovery trajectories in children and
(ii) injury-related and psychosocial factors associated with these trajectories.
METHODS:This study is part of a larger prospective, longitudinal study. Parents of 169
children (5-18 yr) reported their child’s PCS over 3 mo following concussion. PCS above
baseline levels formed the primary outcome. Injury-related, demographic, and preinjury
information, and child and parent mental health were assessed for association with
trajectory groups. Data were analyzed using group-based trajectory modeling, multi-
nomial logistic regression, and chi-squared tests.
RESULTS:We identified 5 postconcussive recovery trajectories from acute to 3 mo
postinjury. (1) Low Acute Recovered (26.6%): consistently low PCS; (2) Slow to Recover
(13.6%): elevated symptoms gradually reducing; (3) High Acute Recovered (29.6%):
initially elevated symptoms reducing quickly to baseline; (4) Moderate Persistent (18.3%):
consistent, moderate levels of PCS; (5) Severe Persistent (11.8%): persisting high PCS. Higher
levels of child internalizing behaviors and greater parental distress were associated with
membership to the Severe Persistent group, relative to the Low Acute Recovered group.
CONCLUSION:This study indicates variability in postconcussive recovery according to 5
differential trajectories, with groups distinguished by the number of reported symptoms,
levels of child internalizing behavior problems, and parental psychological distress. Identi-
fication of differential recovery trajectories may allow for targeted early intervention for
children at risk of poorer outcomes.

Trajectories and Predictors of Clinician-Determined Recovery after Child Concussion. Vicki Anderson, Gavin A Davis, Michael Takagi, Kevin Dunne, Cathriona Clarke, Nicholas Anderson, Vanessa C Rausa, Melissa Doyle, Georgia Parkin, Katie Truss, Emma Thompson, Silvia Bressan, Stephen Hearps, Franz E Babl. Journal of Neurotrauma 2020

By age 16, 20% of children will suffer a concussion. Many experience persisting post-concussive symptoms (PCS), the
cause(s) of which remain unclear. We mapped concussion recovery to 3 months post-injury and explored non-modifiable
(e.g., age, sex, pre-injury factors, injury mechanism, acute PCS) and modifiable (post-acute child symptoms) predictors of
persisting symptoms in order to identify opportunities for early intervention. We conducted a prospective, longitudinal
study in the emergency department of a tertiary, pediatric hospital recruiting children within 48 h of concussion (T0), with
follow-up at 2 days (T1), 2 weeks (T2), 1 month (T3), and 3 months (T4). Primary outcome was T2 clinician diagnosis.
Clinical history, injury mechanism, acute symptoms, and physical and cognitive function were assessed. Parents rated
child behavior and fatigue, and their mental health. We enrolled 256 participants, 72% males: 62 (24.3%) were symp-
tomatic at T2. Recovered and symptomatic groups endorsed similar pre-injury PCS, but group differences were found at
T1 across all PCS subscales, except Emotional, where symptoms were not evident until T2. By T2, there was significant
PCS reduction, steepest in the ‘‘Recovered’’ group, which also had a lower rate of pre-injury psychiatric diagnoses, acute
CT scans and less severe parent-rated PCS at T1 than the symptomatic group. They all demonstrated lower parent-rated
PCS and less internalizing behaviors (all,p<0.01). No differences were detected for child age, sex, injury factors, pre-
injury parent-rated PCS, or acute physical and cognitive status. Our findings also highlight the importance of considering
both pre- and post-injury mental health status in managing post-concussion.

The Berlin statement on sport-related concussion was published in 2017 using evidence- based recommendations. We aimed to examine (1) the implementation of, distribution and education based on the Berlin recommendations, and the development of sport-specific protocols/guidelines among professional and elite sports, (2) the implementation of guide- lines at the community level, (3) translation of guidelines into different languages, and (4) research activities. Senior medical advisers and chief medical officers from Australian Football League, All Japan Judo Federation, British Horseracing Authority, Cricket Australia, Fédération Equestre Internationale, Football Association, Gaelic Athletic Association, Inter- national Boxing Association, Irish Horseracing Regulatory Board, Major League Baseball, National Football League, National Hockey League, National Rugby League, and World Rugby completed a questionnaire. The results demonstrated that all 14 sporting organi- zations have published concussion protocols/guidelines based on the Berlin recommen- dations, includingRecognize,Removal from play, Re-evaluation, Rest, Recovery,andReturn to play.There is variable inclusion ofProlonged symptoms.PreventionandRisk reduction andLong-term effectsare addressed in the guidelines, rules and regulations, and/or sport-specific research. There is variability in education programs, monitoring compliance with guidelines, and publication in other languages. All sporting bodies are actively involved in concussion research. We conclude that the Berlin recommendations have been included in concussion protocols/guidelines by all the sporting bodies, with consistency in the essential components of the recommendations, whilst also allowing for sport- and regional-specific variations. Education at the elite, community, and junior levels remains an ongoing challenge, and future iterations of guidelines may consider multiple language versions, and community- and junior-level guidelines.

Abstract: Pediatric concussion is a growing health concern. Concussion is generally poorly understood
within the community. Many parents are unaware of the signs and varying symptoms of concussion. Despite
the existence of concussion management and return to play guidelines, few parents are aware of how to
manage their child’s recovery and return to activities. Digital health technology can improve the way this
information is communicated to the community. A multidisciplinary team of pediatric concussion researchers
and clinicians translated evidence-based, gold-standard guidelines and tools into a smartphone application
with recognition and recovery components. HeadCheck* is a community facing digital health application
developed in Australia for management of concussion in children aged 5–18 years. The application consists
of (I) a sideline concussion check and (II) symptom monitoring and symptom-targeted psychoeducation to
assist the parent manage their child’s safe return to school, exercise and sport. The application was tested
with target end users as part of the development process. HeadCheck provides an accessible platform for
disseminating best practice evidence. It provides feedback to help recognize a concussion and symptoms of
more serious injuries and assists parents guide their child’s recovery.

Concussion Guidelines in National and International Professional and Elite Sports. Gavin A Davis, Michael Makdissi, Paul Bloomfield, Patrick Clifton, Charlotte Cowie, Ruben Echemendia, Eanna C Falvey, Gordon Ward Fuller, Gary Alan Green, Peter Harcourt, Jerry Hill, Kevin Leahy, Mike P. Loosemore, Paul McCrory, Adrian McGoldrick, Willem Meeuwisse, Kevin Moran, Shinji Nagahiro, John W Orchard, Jennifer Pugh, Martin Raftery, Allen K. Sills, Gary S. Solomon, Alex B. Valadka. Neurosurgery

The Berlin statement on sport-related concussion was published in 2017 using evidence-
based recommendations. We aimed to examine (1) the implementation of, distribution and
education based on the Berlin recommendations, and the development of sport-specific
protocols/guidelines among professional and elite sports, (2) the implementation of guide-
lines at the community level, (3) translation of guidelines into different languages, and
(4) research activities. Senior medical advisers and chief medical officers from Australian
Football League, All Japan Judo Federation, British Horseracing Authority, Cricket Australia,
Fédération Equestre Internationale, Football Association, Gaelic Athletic Association, Inter-
national Boxing Association, Irish Horseracing Regulatory Board, Major League Baseball,
National Football League, National Hockey League, National Rugby League, and World
Rugby completed a questionnaire. The results demonstrated that all 14 sporting organi-
zations have published concussion protocols/guidelines based on the Berlin recommen-
dations, includingRecognize,Removal from play, Re-evaluation, Rest, Recovery,andReturn
to play.There is variable inclusion ofProlonged symptoms.PreventionandRisk reduction
andLong-term effectsare addressed in the guidelines, rules and regulations, and/or
sport-specific research. There is variability in education programs, monitoring compliance
with guidelines, and publication in other languages. All sporting bodies are actively
involved in concussion research. We conclude that the Berlin recommendations have been
included in concussion protocols/guidelines by all the sporting bodies, with consistency
in the essential components of the recommendations, whilst also allowing for sport- and
regional-specific variations. Education at the elite, community, and junior levels remains
an ongoing challenge, and future iterations of guidelines may consider multiple language
versions, and community- and junior-level guidelines.

Reflections on the history of nerve repair - Sir Sydney Sunderland’s final presentation to the Neurosurgical Society of Australasia. Gavin A. Davis. Neurosurgery.

Sir Sydney Sunderland (1910-1993) was an eminent physician and anatomist who identified
the fascicular structure of nerves, and developed the eponymous 5-tiered classification of
nerve injuries. Not long before his death, he presented a keynote address to the Annual
Scientific Meeting of the Neurosurgical Society of Australasia. Recently, the videotape
of his presentation was discovered. In the presentation, Sir Sydney included discussion
on the history of nerve repair, commencing with Herophilus and Galen, and progressing
through the Middle Ages, including Leonardo of Bertapaglia, and he further noted the
discoveries during the 1800s of the microscope, the axon, and nerve histology (including
Remak, Schwann, Nissl, and Golgi), Waller’s findings on nerve degeneration, and nerve
injury (His, Cajal, Forsmann, and Harrison). Sir Sydney discussed nerve injuries sustained
during World War I, with the deleterious effects of infection, and following the many nerve
injuries sustained during World War II, he discussed his own discoveries of internal topog-
raphy of nerve fascicles, and the anatomical substrate of nerve fascicles that limit surgery
for nerve repair, nerve grafts, and the basic science of spinal cord repair. This paper presents
a transcript of Sunderland’s presentation and includes many of his original images used to
illustrate this tour de force of nerve repair.

Acute Cognitive Postconcussive Symptoms Follow Longer Recovery Trajectories than Somatic Postconcussive Symptoms in Young Children. Zoe Teh, Michael Takagi, Stephen. J. C. Hearps, Franz E. Babl, Nicholas Anderson, Cathriona Clarke, Gavin A. Davis, Kevin Dunne, Vanessa Rausa, and Vicki Anderson. Brain Injury.

Objective: To investigate somatic and cognitive postconcussive symptoms (PCS) using the symptom
evaluation subtest (cSCAT3-SE) of the Child Sports Concussion Assessment Tool 3 (Child SCAT) in
tracking PCS up to 2 weeks postinjury.
Methods: A total of 96 participants aged 5 to 12 years (Mage= 9.55,SD= 2.20) completed three
assessment time points: 48 h postinjury (T0), 2 to 4 days postinjury (T1), and 2 weeks postinjury (T2). The
Wilcoxon signed-rank test was used to analyze differences between cognitive and somatic symptoms
over time, while the Friedman test was used to analyze differences within symptom type over time.
Results: Cognitive PCS were found to be significantly higher than somatic PCS at all assessment time
points and were also found to significantly decline from 4 days onwards postinjury; in contrast, somatic
PCS significantly declined as early as 48 hpostinjury.
Discussion: Differences between cognitive and somatic PCS emerge as early as a few days postinjury,
with cognitive PCS being more persistent than somatic PCS across 2 weeks. Research in symptom-
specific interventions may be of benefit in helping young children manage severe PCS as early as 2
weeks postinjury.

Sports participation by children and adolescents is generally high in Australia and New Zealand,1,2 and many children sustain head injuries of varying severity during such ac- tivities. Concussion has received increasing attention, but less is known about the risk of severe acute intracranial injuries in children with sports- related head injurie

Delayed recovery from concussion can dramatically affect a child’s social, emotional, and educational development, yet
little is known about what causes some children to recover faster than others. The contribution of white matter disruption
in children with delayed recovery has been hypothesized, but findings are limited by methodological issues such as: small
heterogeneous samples, bias toward children with delayed recovery, and inconsistencies in timing of brain imaging, both
within and between studies. The aim of the present study was to assess diffusion neuroimaging correlates of delayed
recovery post-concussion in children. A prospective, longitudinal, observational cohort study was conducted at a statewide
tertiary pediatric hospital. Forty-three children who presented to the emergency department (ED) with concussion (defined
according to the Zurich/Berlin Consensus Statement on Concussion in Sport) underwent magnetic resonance imaging
( MRI) at a 2 weeks post-injury and were classified as either normally recovering (n=26) or delayed recovering (n=17).
Diffusion imaging comparison using voxelwise tract-based spatial statistics (TBSS) analysis found no difference between
the groups in fractional anisotropy, axial diffusion, radial diffusion, or mean diffusivity metrics (p>0.05 threshold-free
cluster enhancement [TFCE] corrected). Post-hoc tract-based Bayesian analysis found evidence for the null in 11 unique
white matter tracts (Bayes factor>3). These findings indicate that delayed recovery from post-concussive symptoms in
children is unlikely to be caused by white matter microstructural damage.

Clinically important sport- related traumatic brain injuries in children. Nitaa Eapen, Gavin A Davis, Meredith L Borland, Natalie Phillips, Ed Oakley, Stephen Hearps, Amit Kochar, Sarah Dalton, John Cheek, Jeremy Furyk, Mark D Lyttle, Silvia Bressan, Louise Crowe, Stuart Dalziel, Emma Tavender, Franz E Babl. Medical Journal of Australia. 2019

Sports participation by children and adolescents is generally
high in Australia and New Zealand,1,2 and many children
sustain head injuries of varying severity during such ac
tivities. Concussion has received increasing attention, but less
is known about the risk of severe acute intracranial injuries in
children with sports- related head injuries

Barriers to participation in a placebo-surgical trial for lumbar spinal stenosis. David B. Anderson, Ralph J. Mobbs, Jillian Eyles, S. Eileen Meyer, Gustavo C. Machado, Gavin A. Davis, Ian A. Harris, Rachelle Buchbinder, Manuela L. Ferreira. Heliyon

Background:Placebo-controlled trials are an important tool when assessing the efcacy of spinal surgical pro-
cedures. The most common spinal surgical procedure in older adults is decompression for lumbar spinal stenosis.
Before conducting a placebo-surgical trial on decompression surgery, an investigation of patientswillingness to
participate in a placebo-controlled trial of decompression surgery and barriers to participation were explored.
Materials:An online survey.
Methods:Descriptive analyses of demographic and clinical data, and participants' willingness to participate in a
placebo-surgical trial. Logistic regression was used to examine potential predictors of willingness to participate.
Two independent researchers performed a coded framework analysis of patientsbarriers to participation.
Results:68 patients were invited and 63 participants completed the survey (91.3% response, mean (SD) age 69.5
(10.9) years, 52% females), 71% suffered from moderate to very severe pain. Ten participants (15.9%) were
willing to participate in a placebo-controlled trial. Being married was associated with decreased odds of
participating (OR: 0.2; 95% CI, 0.05 to 0.8; P¼0.03), while the main barriers were a lack of information about
the procedure, reassurance of a positive outcome with participation, and concerns about the risks and benets of
placebo surgery.
Conclusions:A minority of patients with lumbar spinal stenosis were willing to participate in a placebo-controlled
trial of surgery. The identied barriers indicate that educating eligible patients about: the need for placebo-
surgical trials, the personal risks and benets of participation, and the importance and potential benets of
placebo trials to others, may be crucial to ensure adequate recruitment into the placebo-controlled surgical trial.
Conclusions should be read cautiously however, given the small sample size present in this study.

An unusual diagnosis of a dural based intracranial lesion. Sonal Sachdev, Gavin A Davis, Chong Zhou, Julie Lokan. Journal of Clinical Neuroscience

A 19-year old man was referred to the Haematology clinic
of a large tertiary hospital in Melbourne, Australia, with an
8-month history of cervical lymphadenopathy, non-drenching
night sweats, and unintentional weight loss of 30 kg. His past
medical history includes depression and regular marijuana
use. He had been recently diagnosed with epilepsy, after
presenting to hospital with a first seizure 3 months prior to
this presentation. He did not undergo any intracranial imaging
at that time.
Clinical examination revealed obvious palpable non-tender
asymmetric cervical and parotid lymphadenopathy. Neurological
examination was unremarkable.
Gadolinium-enhanced MRI Brain demonstrated a 44
41 mm left temporal extra-axial lesion

Does a computerized neuropsychological test predict prolonged recovery in concussed children presenting to the ED? Michael Takagi, Stephen JC Hearps,, Franz E Babl, Nicholas Anderson, Silvia Bressan, Cathriona Clarke, Gavin A Davis, Melissa Doyle, Kevin Dunne, Chloe Lanyon, Vanessa Rausa, Emma Thompson, and Vicki Anderson. Child Neuropsychology.

Computerized neuropsychological tests (CNTs) are widely used
internationally in concussion management. Their prognostic
value for predicting recovery post-concussion is poorly under-
stood, particularly in pediatric populations. The aim of the pre-
sent study was to examine whether cognitive functioning

(measured by CogSport) has prognostic value for predicting
rapid versus slow recovery. This is a prospective longitudinal
observational cohort study conducted at a state-wide tertiary
pediatric hospital. Data were collected at 14, 14, and 90 days
post-injury. Eligible children were aged5 and <18 years pre-
senting to the Emergency Department having sustained
aconcussionwithin48h.Concussionwasdened according
to the Zurich/Berlin Consensus Statement on Concussion in
Sport. Dependent variables were reaction times and error rates
on the CogSport Brief Battery. In total, 220 cases were analyzed;
98 in a rapid recovery group (asymptomatic at 14 days post-
injury, mean age 11.5 [3.2], 73.5% male) and 122 in a slow
recovery group (symptomatic at 14 days post-injury, mean age
12.0 [3.1], 69.7% male). Longitudinal GEE analyses modeled the
trajectories of both mean log10-transformed reaction time and
error rates between groups over time (14, 14 and 90 days).
Both group main and interaction (time by group) terms for all
models were non-signicant (p> .05). Cognitive functioning,
measured by CogSport and assessed within 14daysofconcus-
sion, does not predict prolonged recovery in a pediatric sample.
Further,therewerenosignificant group dierences at any time
point. Considering the widespread use and promotion of CNTs,
it is important that clinicians understand the signicant limita-
tions of the CogSport battery.

Behavioral and emotional difficulties following pediatric concussion. Gornall, A., Takagi, M., Clarke, C., Babl. F. E., Davis, G. A., Dunne, K., Anderson, N., Hearps, S., Demaneuf, T., Rausa, V., Anderson, V. (2019). Journal of Neurotrauma.

Pediatric concussion is a major public health concern. Despite the prevalence of behavior problems following concussion
and their potential role in prolonged symptoms, little is known about how child and adolescent behavior may impact post-
concussion recovery. We sought to examine change in behavioral and emotional functioning in a sample of children ages 5
to<18 years with concussion. This study reports on data collected as part of a larger single-site prospective longitudinal
cohort study. Participants were recruited from the Emergency Department (ED) of a tertiary children’s hospital and
completed the Child Behavior Checklist (CBCL) at 2 weeks (acute; T2) and 3 months (post-acute; T4) post-injury.
Children with concussion (n=231) showed a significant reduction in internalizing (p<0.001,d=0.27), externalizing
(p<0.001,d=0.23), and total behavior problems (p<0.001,d=0.36) at 3 months compared with 2 weeks post-injury.
Multiple regression models found a significant interaction between age and sex with higher rates of internalizing
p=0.02) and total (p=0.040,g2
p=0.02) behavior problems as age increased in females. The results show
that pediatric concussion is associated with temporary behavioral disturbances that are likely to improve considerably in
the months following injury. Nonetheless, as age increases, females may be at increased risk for experiencing ongoing
internalizing problems several months after concussion and may require targeted clinical intervention.

International Consensus Definitions of Video Signs of Concussion in Professional Sports. Gavin Davis, Michael Makdissi, Paul Bloomfield, Patrick Clifton, Ruben Echemendia, Eanna Falvey, Gordon Fuller, Gary Green, Peter Harcourt, Thomas Hill, Nathan McGuirk, Willem Meeuwisse, John Orchard, Martin Raftery, Allen K Sills, Gary Solomon, Alex Valadka and Paul McCrory. British J Sports Medicine.

background The use of video to assist professional
sporting bodies with the diagnosis of sport-related
concussion (SRC) has been well established; however,
there has been little consistency across sporting codes
with regards to which video signs should be used, and
the definitions of each of these signs.
Aim The aims of this study were to develop a consensus
for the video signs considered to be most useful in
the identification of a possible SRC and to develop a
consensus definition for each of these video signs across
the sporting codes.
Methods A brief questionnaire was used to assess
which video signs were considered to be most useful in
the identification of a possible concussion. Consensus
was defined as >90% agreement by respondents.
Existing definitions of these video signs from individual
sports were collated, and individual components of the
definitions were assessed and ranked. A modified Delphi
approach was then used to create a consensus definition
for each of the video signs.
results Respondents representing seven sporting
bodies (Australian Football League, Cricket Australia,
Major League Baseball, NFL, NHL, National Rugby
League, World Rugby) reached consensus on eight
video signs of concussion. Thirteen representatives from
the seven professional sports ranked the definition
components. Consolidation and refinement of the
video signs and their definitions resulted in consensus
definitions for six video signs of possible concussion:
lying motionless, motor incoordination, impact seizure,

tonic posturing, no protective action—floppy and blank/
vacant look.
Conclusions These video signs and definitions have
reached international consensus, are indicated for use by
professional sporting bodies and will form the basis for
further collaborative research.

Towards the development of common demographic data elements for inclusion in future editions of the SCAT and Child SCAT: an international Delphi study. Maxine J. Shanks, Paul McCrory, Gavin A. Davis, Ruben J. Echemendia, Andrew R. Gray, S. John Sullivan. British J Sports Medicine.

background The Sport Concussion Assessment
Tool (SCAT) and Child SCAT are the ’gold standard’
assessment tools for a suspected sport-related
concussion (SRC). A number of ’modifiers’ (eg, previous
history of concussion) of a SRC have been identified.
These may influence how the SCAT/Child SCAT results
should be interpreted.
Objectives To achieve consensus, via an international
panel of SRC experts, on which athlete/player and
parent/caregiver demographic variables should be
considered for inclusion in future editions of the SCAT/
Child SCAT respectively.
Methods A two-round modified Delphi technique,
overseen by a steering committee, invited 41 panellists
to achieve expert consensus (≥80% agreement). The first
round utilised open questions to generate demographic
variables; the second round used a five-point ordinal
item to rank the importance of including each variable in
future editions of the SCAT/Child SCAT.
results 15 experts participated in at least one Delphi
round. 29 athlete/player and eight parent/caregiver
variables reached consensus for inclusion in the SCAT,
whereas two parent/caregiver variables reached
consensus for exclusion. 28 athlete/player and four
parent/caregiver variables reached consensus for the
Child SCAT, whereas two parent/caregiver variables
reached consensus for exclusion. Key categories of
variables included the following: concussion/sport details,
personal medical conditions and family medical history.
Conclusion This study provides a list of athlete/player
and parent/caregiver demographic variables that should
be considered in future revisions of the SCAT/Child SCAT.
By considering (and ultimately likely including) a wider
and standard set of additional demographic variables,
the Concussion in Sport experts will be able to provide
clinicians and researchers with data that may enhance
interpretation of the individual’s data and the building of
larger datasets.

Plasma TNF alpha is a predictor of persisting symptoms post-concussion in children. Georgia M Parkin, Cathriona Clarke, Michael Takagi, Stephen Hearps, Franz E Babl, Gavin A Davis, Vicki Anderson, Vera Ignjatovic. Journal of Neurotrauma.

Mild traumatic brain injury (mTBI)-associated blood proteomics have become an emerging focus in the past decade, with
the U.S. Food and Drug Administration recently approving the use of a blood test to determine the necessity of a computed
tomography scan after adult mTBI. We now also know that the blood proteome of children is different from that of adults,
and new evidence suggests that children may take longer to recover from an mTBI. Despite this, comparatively fewer
studies have analyzed changes in blood protein expression after pediatric mTBI. Concussions, an mTBI subset, often go
underreported, despite the potential for post-concussive symptoms to last more than one month in up to 30% of children.
In the current study, we used a multiplex immunoassay to measure blood protein expression of Apolipoprotein, enolase 2,
glial fibrillary acidic protein, interleukin (IL)-1B, IL-6, IL-8, IL-10, S100 calcium-binding protein B, tau and tumor
necrosis factor alpha (TNFa) at admission, one to four days, two weeks, and three months post-pediatric concussion,
comparing patients with normal recovery (n=9) with those with persisting symptoms (n=9). We identified significant
differences in IL-6 (p<0.001) and tau (p=0.048) protein expression across time post-injury irrespective of clinical
outcome and in IL-8 protein expression (p=0.041) across time post-injury specific to children with persisting symptoms.
Significantly, we have identified an increase in TNFaprotein expression at one to four days post-injury (p=0.031) in
children with persisting symptoms compared with normal recovery. To our knowledge, this is the first study to identify
TNFaas a potential blood biomarker for persisting symptoms post-pediatric concussion.

SUcceSS: Surgery for Spinal Stenosis – protocol of a randomised, placebo-controlled trial. Anderson DB, Ferreira ML, Harris IA, Davis GA, Stanford R, Beard DJ, Li Q, Jan S, Mobbs R, Maher CG, Yong R, Zammit T, Latimer J, Buchbinder R. BMJ Open 2019

Introduction Central lumbar spinal stenosis (LSS)
is a common cause of pain, reduced function and
quality of life in older adults. Current management
of LSS includes surgery to decompress the spinal
canal and alleviate symptoms. However, evidence
supporting surgical decompression derives from
unblinded randomised trials with high cross-over
rates or cohort studies showing modest benefits.
This protocol describes the design of the SUrgery for
Spinal Stenosis (SUcceSS) trial —the first randomised
placebo-controlled trial of decompressive surgery for
symptomatic LSS.
Methods and analysis SUcceSS will be a
prospectively registered, randomised placebo-
controlled trial of decompressive spinal surgery. 160
eligible participants (80 participants/group) with
symptomatic LSS will be randomised to either surgical
spinal decompression or placebo surgical intervention.
The placebo surgical intervention is identical to surgical
decompression in all other ways with the exception of
the removal of any bone or ligament. All participants
and assessors will be blinded to treatment allocation.
Outcomes will be assessed at baseline and at 3, 6,
12 and 24 months. The coprimary outcomes will
be function measured with the Oswestry Disability
Index and the proportion of participants who have
meaningfully improved their walking capacity at 3
months postrandomisation. Secondary outcomes
include back pain intensity, lower limb pain intensity,
disability, quality of life, anxiety and depression,
neurogenic claudication score, perceived recovery,
treatment satisfaction, adverse events, reoperation rate
and rehospitalisation rate. Those who decline to be
randomised will be invited to participate in a parallel
observational cohort. Data analysis will be blinded and
by intention to treat. A trial-based cost-effectiveness
analysis will determine the potential incremental cost
per quality-adjusted life year gained.
Ethics and dissemination Ethics approval has been
granted by the NSW Health (reference:17/247/POWH/601)
and the Monash University (reference: 12371) Human
Research Ethics Committees. Dissemination of results will
be via journal articles and presentations at national and
international conferences.

Protocol for a prospective, longitudinal, cohort study of recovery pathways, acute biomarkers, and cost for children with persistent post-concussion symptoms: the Take C.A.Re Biomarkers study. Michael Takagi, Franz E Babl, Nicholas Anderson, Silvia Bressan, Cathriona J Clarke, Ali Crichton, Kim Dalziel, Gavin A Davis, Melissa Doyle, Kevin Dunne, Celia Godfrey, Stephen JC Hearps, Vera Ignjatovic, Georgia Parkin, Vanessa Rausa, Marc Seal, Emma J Thompson, Katie Truss, and Vicki Anderson. BMJ Open. 2019

Introduction The majority of children who sustain a
concussion will recover quickly, but a significant minority
will experience ongoing postconcussive symptoms,
known as postconcussion syndrome (PCS). These
symptoms include emotional, behavioural, cognitive
and physical symptoms and can lead to considerable
disability. The neurobiological underpinnings of PCS are
poorly understood, limiting potential clinical interventions.
As such, patients and families frequently re-present to
clinical services, who are often ill equipped to address
the multifactorial nature of PCS. This contributes to the
high cost of concussion management and the disability of
children experiencing PCS. The aims of the present studyare: (1) to plot and contrast recovery pathways for children
with concussion from time of injury to 3 months postinjury,
(ii) evaluate the contribution of acute biomarkers (ie, blood,
MRI) to delayed recovery postconcussion and (3) estimate
financial costs of child concussion to patients attending
the emergency department (ED) of a tertiary children’s
hospital and factors predicting high cost.
Methods and analysis Take C.A.Re is a prospective,
longitudinal study at a tertiary children’s hospital,
recruiting and assessing 525 patients aged 5–<18 years
(400 concussion, 125 orthopaedic injury) who present
to the ED with a concussion and following them at 1–4
days, 2 weeks, 1 month and 3 months postinjury. Multiple
domains are assessed: preinjury and postinjury, clinical,
MRI, blood samples, neuropsychological, psychological
and economic. PCS is defined as the presence of
≥2 symptoms on the Post Concussive Symptoms
Inventory rated as worse compared with baseline
1 month postinjury. Main analyses comprise longitudinal
Generalised Estimating Equation models and regression
analyses of predictors of recovery and factors predicting
high economic costs.
Ethics and dissemination Ethical approval has
been obtained through the Royal Children’s Hospital
Melbourne Human Research Ethics Committee (33122).
We aim to disseminate the findings through internationalconferences, international peer-reviewed journals and
social media.
trial registration number ACTRN12615000316505;

The International study of Video review of concussion in Professional Sports. Gavin Davis, Michael Makdissi, Paul Bloomfield, Patrick Clifton, Ruben Echemendia, Eanna Falvey, Gordon Fuller, Gary Green, Peter Harcourt, Thomas Hill, Nathan McGuirk, Willem Meeuwisse, John Orchard, Martin Raftery, Allen K Sills, Gary Solomon, Alex Valadka and Paul McCrory. British J Sports Medicine. 2018,

background Video review has become an important
tool in professional sporting codes to help sideline
identification and management of players with a
potential concussion.
Aim To assess current practices related to video review
of concussion in professional sports internationally, and
compare protocols and diagnostic criteria used to identify
and manage potential concussions.
Methods Current concussion management guidelines
from professional national and international sporting
codes were reviewed. Specific criteria and definitions of
video signs associated with concussion were compared
between codes. Rules and regulations adopted across
the codes for processes around video review were also
results Six sports with specific diagnostic criteria and
definitions for signs of concussion identified on video
review participated in this study (Australian football,
American football, world rugby, cricket, rugby league
and ice hockey). Video signs common to all sports
include lying motionless/loss of responsiveness and
motor incoordination. The video signs considered by
the majority of sports as most predictive of a diagnosis
of concussion include motor incoordination, impact
seizure, tonic posturing and lying motionless. Regulatory
requirements, sideline availability of video, medical
expertise of video reviewers and use of spotters differ
across sports and geographical boundaries. By and large,
these differences reflect a pragmatic approach from each
sport, with limited underlying research and development
of the video review process in some instances.
Conclusions The use of video analysis in assisting
medical staff with the diagnosis or identification of
potential concussion is well established across different
sports internationally. The diagnostic criteria used and
the expertise of the video review personnel are not
clearly established, and research efforts would benefit
from a collaborative harmonisation across sporting

What factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed? A systematic review. Laura K. Purcell, Gavin A. Davis, Gerry A. Gioia. British J Sports Medicine. 2018

Objective To evaluate the evidence regarding (1)
factors affecting return to school (RTS) and (2) strategies/
accommodations for RTS following a sport-related
concussion (SRC) in children and adolescents.
Design A systematic review of original studies
specifically addressing RTS following concussion in the
paediatric and sporting context.
Data sources MEDLINE (Ovid), Embase (Ovid), PsycInfo
(Ovid) electronic databases and the grey literature
OpenGrey, ClinicalTrials. gov and Google Advanced.
Eligibility criteria Studies were included if they were
original research on RTS following SRC in children aged
5–18 years published in English between 1985 and 2017.
Results A total of 180 articles were identified; 17
articles met inclusion criteria. Several factors should
be considered for RTS after concussion, including:
symptomatology; rest following injury; age/grade; and
course load. On RTS after concussion, 17%–73% of
students were provided academic accommodations or
experienced difficulty with RTS. Students were more likely
to obtain academic accommodations in schools with a
concussion policy if they had a medical RTS letter and
had regular medical follow-up after concussion.
Conclusions Schools should have a concussion policy
and offer individualised academic accommodations to
students recovering from SRC on RTS; a medical letter
should be provided to facilitate provision/receipt of
academic accommodations; students should have early,
regular medical follow-up following SRC to help with RTS
and monitor recovery; students may require temporary
absence from school after SRC; clinicians should assess
risk factors/modifiers that may prolong recovery and
require more intensive academic accommodations.

Infographic: Consensus statement on concussion in sport.

  1. Infographic: Consensus statement on concussion in sport. Paul McCrory, Willem Meeuwisse, Jiri Dvorak, Mark Aubry, Julien Bailes, Steve Broglio, Bob Cantu, David Cassidy, Rudi Castellani, Gavin Davis, Ruben Echemendia, Rich Ellenbogen, Carolyn Emery, Lars Engebretsen, Nina Feddermann-Demont, Christopher Giza, Kevin Guskewicz, Stanley Herring, Grant Iverson, Karen Johnston, James Kissick, Jeffrey Kutcher, John Leddy, David Maddocks, Michael Makdissi, Geoff Manly, Mike McCrea, William Meehan, Shinji Nagahiro, Jon Patricios, Margot Putukian, Martin Raftery, Kathryn Schneider, Allen Sills, Charles Tator, Michael Turner, Pieter Vos. British J Sports Medicine. 2017;51:1557-1558.

The Age Variable in Childhood Concussion Management: A Systematic Review. Rosemarie Scolaro Moser, Gavin A. Davis, Philip Schatz. Archives of Clinical Neuropsychology. 2017

Background:Sports-related concussion in young children has become a signicant international public health issue. This paper reviews
the research literature in an effort to shed light on the question,At what age should young children be managed differently than adults or
older adolescents?
Method:A systematic review, registered with PROSPERO and using PRISMA guidelines, was conducted rendering 37 sports concussion
original research studies that examined age as a variable (518 years), and which met specic inclusion/exclusion criteria.
Findings:There are no dened, evidence-based age groups for childhood concussion to substantiate differential management across the
childhood and adolescent age span. There is evidence to support: (1) concussion may present differently across developmental stages; (2)
with increasing age, adolescents may exhibit more symptoms from concussion; (3) the age range of 1213 is the most frequently used cutoff
point between younger and older children; (4) sports concussion research has classied the age variable in children in a number of manners:
educational, developmental, sport level, or as a continuous variable, or matter of sample convenience; and (5) four general groupings of
young versus pre-puberty child and early versus late adolescent are often utilized.
Conclusions:Due to limited measures and challenges of assessing younger children, current research presents a limited understanding of
childhood concussion. Studies in children often lack explained rationales or theories behind age groupings or cutoffs. There is a need for
studies dedicated to the question of how concussion varies developmentally from preschool through late adolescence to guide diagnosis and

Accuracy of the Components of SCAT to Acutely Identify Children with Concussion. Franz E Babl, Diana Dionisio, Lucy Davenport, Amy Baylis, Stephen JC Hearps, Silvia Bressan, Emma J Thompson, Vicki Anderson, Ed Oakley, Gavin A Davis. Pediatrics. 2017;140(2):e20163258

BACKGROUND: The Sport Concussion Assessment Tool version 3 (SCAT3) and its child version (ChildSCAT3) are composite physical and neuropsychological scoring systems used to assess athletes after sport-related concussion. Based on limited validation data, we aimed to evaluate the ability of SCAT3 and ChildSCAT3 to differentiate children aged 5 to 16 years with concussion from controls.
METHODS: Prospective observational study of children in the emergency department with concussion (CONC) and 2 control groups ([1] upper-limb injury [ULI] and [2] well children) with equal-sized subgroups in 3 age bands of 5 to 8, 9 to 12, and 13 to 16 years. ChildSCAT3 was used for participants aged 5 to 12 years, and SCAT3 was used for participants aged 13 to 16 years. Differences between study groups were analyzed by using analysis of variance models and adjusting for age and sex.
RESULTS: We enrolled 264 children (90 with CONC, 90 with ULI, and 84 well) in equal-sized age bands. The number and severity of child- and parent-reported symptom scores were significantly higher in the CONC group than either control group (P < .001). Mean double (ChildSCAT3 P < .001) and tandem stance errors (both P ≤ .01) were also significantly higher, and immediate memory was significantly lower for the CONC group (P < .01). No statistically significant group differences were found for orientation and digit backward tasks. There were no significant differences between ULI and well control groups.
CONCLUSIONS: Overall, SCAT3 and ChildSCAT3 can differentiate concussed from nonconcussed patients, particularly in terms of symptom number and severity.

The Berlin International Consensus Meeting on Concussion in Sport. Gavin A. Davis, Richard G. Ellenbogen, Julian Bailes, Robert C. Cantu, Karen M. Johnston, Geoffrey T. Manley, Shinji Nagahiro, Allen Sills, Charles H. Tator, Paul McCrory. Neurosurgery.

The Fifth International Conference on Concussion in Sport was held in Berlin in October 2016. A series of 12 questions and subquestions was developed and the expert panel members were required to perform a systematic review to answer each question. Following presentation at the Berlin meeting of the systematic review, poster abstracts and audience discussion, the summary Consensus Statement was produced. Further, a series of tools for the management of sport-related concussion was developed, including the Sport Concussion Assessment Tool Fifth edition (SCAT5), the Child SCAT5, and the Concussion Recognition Tool Fifth edition. This paper elaborates on this process, the outcomes, and explores the implications for neurosurgeons in the management of sport- related concussion.

Infographic: Consensus statement on concussion in sport

  • Infographic: Consensus statement on concussion in sport. Paul McCrory, Willem Meeuwisse, Jiri Dvorak, Mark Aubry, Julien Bailes, Steve Broglio, Bob Cantu, David Cassidy, Rudi Castellani, Gavin Davis, Ruben Echemendia, Rich Ellenbogen, Carolyn Emery, Lars Engebretsen, Nina Feddermann-Demont, Christopher Giza, Kevin Guskewicz, Stanley Herring, Grant Iverson, Karen Johnston, James Kissick, Jeffrey Kutcher, John Leddy, David Maddocks, Michael Makdissi, Geoff Manly, Mike McCrea, William Meehan, Shinji Nagahiro, Jon Patricios, Margot Putukian, Martin Raftery, Kathryn Schneider, Allen Sills, Charles Tator, Michael Turner, Pieter Vos. British J Sports Medicine. BJSM Online First, published on September 12, 2017 as 10.1136/bjsports-2017-098065

Consensus Statement On Concussion In Sport – The 5th International Conference On Concussion In Sport Held In Berlin, October 2016.

  • Consensus Statement On Concussion In Sport – The 5th International Conference On Concussion In Sport Held In Berlin, October 2016. Paul McCrory, Willem Meeuwisse, Jiri Dvorak, Mark Aubry, Julien Bailes, Steve Broglio, Bob Cantu, David Cassidy, Rudi Castellani, Gavin Davis, Ruben Echemendia, Rich Ellenbogen, Carolyn Emery, Lars Engebretsen, Nina Feddermann-Demont, Christopher Giza, Kevin Guskewicz, Stanley Herring, Grant Iverson, Karen Johnston, James Kissick, Jeffrey Kutcher, John Leddy, David Maddocks, Michael Makdissi, Geoff Manly, Mike McCrea, William Meehan, Shinji Nagahiro, Jon Patricios, Margot Putukian, Martin Raftery, Kathryn Schneider, Allen Sills, Charles Tator, Michael Turner, Pieter Vos. British J Sports Medicine. 2017 doi:10.1136/ bjsports-2017-097699

The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5). Gavin A. Davis, Laura Purcell, Kathryn Schneider, Keith Owen Yeates, Gerard Gioia, Vicki Anderson, Richard G. Ellenbogen, Ruben Echemendia, Michael Makdissi, Allen Sills, Grant L. Iverson, Jiri Dvorak, Paul McCrory, Willem Meeuwisse, Jon Patricios, Christopher C. Giza, Jeffrey S. Kutcher. British J Sports Medicine. 2017

This article presents the Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5). The Sport Concussion Assessment Tool was introduced in 2004, following the 2nd International Conference on Concussion in Sport in Prague, Czech Republic. Following the 4th International Consensus Conference, held in Zurich, Switzerland, in 2012, the SCAT 3rd edition (Child SCAT3) was developed for children aged between 5 and12 years. Research to date was reviewed and synthesised for the 5th International Consensus Conference on Concussion in Sport in Berlin, Germany, leading to the current revision of the test, the Child SCAT5. This article describes the development of the Child SCAT5.
doi:10.1136/ bjsports-2017-097492

The Sport Concussion Assessment Tool 5th Edition (SCAT5). Ruben J. Echemendia,Willem Meeuwisse, Paul McCrory, Gavin A. Davis, Margot Putukian, John Leddy, Michael Makdissi, John Sullivan, Steven P. Broglio, Martin Raftery, Kathryn Schneider, James Kissick, Michael McCrea, Jiri Dvorak, Allen K. Sills, Mark Aubry, Lars Engebretsen, Mike Lossemore, Gordon Fuller, Jeffrey Kutcher, Richard Ellenbogen, Kevin Guskiewicz, Jon Patricios, Stanley Herring. British J Sports Medicine. 2017

This paper presents the Sport Concussion Assessment Tool 5th Edition (SCAT5), which is the most recent revision of a sport concussion evaluation tool for use by healthcare professionals in the acute evaluation of suspected concussion. The revision of the SCAT3 (first published in 2013) culminated in the SCAT5. The revision was based on a systematic review and synthesis of current research, public input and expert panel review as part of the 5th International Consensus Conference on Concussion in Sport held in Berlin in 2016. The SCAT5 is intended for use in those who are 13 years of age or older. The Child SCAT5 is a tool for those aged 5–12 years, which is discussed elsewhere.
doi:10.1136/ bjsports-2017-097506

The Concussion Recognition Tool 5th Edition (CRT5). Ruben J. Echemendia,Willem Meeuwisse, Paul McCrory, Gavin A. Davis, Margot Putukian, John Leddy, Michael Makdissi, John Sullivan, Steven P. Broglio, Martin Raftery, Kathryn Schneider, James Kissick, Michael McCrea, Jiri Dvorak, Allen K. Sills, Mark Aubry, Lars Engebretsen, Mike Lossemore, Gordon Fuller, Jeffrey Kutcher, Richard Ellenbogen, Kevin Guskiewicz, Jon Patricios, Stanley Herring. British J Sports Medicine. 2017

The Concussion Recognition Tool 5 (CRT5) is the most recent revision of the Pocket Sport Concussion Assessment Tool 2 that was initially introduced by the Concussion in Sport Group in 2005. The CRT5 is designed to assist non-medically trained individuals to recognise the signs and symptoms of possible sport- related concussion and provides guidance for removing an athlete from play/sport and to seek medical attention. This paper presents the development of the CRT5 and highlights the differences between the CRT5 and prior versions of the instrument.
doi:10.1136/ bjsports-2017-097508

What is the difference in concussion management in children as compared to adults? A systematic review. Gavin A. Davis, Vicki Anderson, Franz E Babl, Gerry Gioia, Christopher C. Giza, William Meehan, Rosemarie Scolaro Moser, Laura Purcell, Philip Schatz, Kathryn Schneider, Michael Takagi, Keith Owen Yeates, Roger Zemek. British J Sports Medicine. 2017

ABSTRACT Aim To evaluate the evidence regarding the management of sport-related concussion (SRC) in children and adolescents. The eight subquestions included the effects of age on symptoms and outcome, normal and prolonged duration, the role of computerised neuropsychological tests (CNTs), the role of rest, and strategies for return to school and return to sport (RTSp). Design Systematic review. Data sources MEDLINE (OVID), Embase (OVID) and PsycInfo (OVID). Eligibility criteria for selecting studies Studies were included if they were original research on SRC in children aged 5 years to 18 years, and excluded if they were review articles, or did not focus on childhood SRC. Results A total of 5853 articles were identified, and 134 articles met the inclusion criteria. Some articles were common to multiple subquestions. Very few studies examined SRC in young children, aged 5–12 years. Summary/conclusions This systematic review recommends that in children: child and adolescent age- specific paradigms should be applied; child-validated symptom rating scales should be used; the widespread routine use of baseline CNT is not recommended; the expected duration of symptoms associated with SRC is less than 4 weeks; prolonged recovery be defined as symptomatic for greater than 4 weeks; a brief period of cognitive and physical rest should be followed with gradual symptom-limited physical and cognitive activity; all schools be encouraged to have a concussion policy and should offer appropriate academic accommodations and support to students recovering from SRC; and children and adolescents should not RTSp until they have successfully returned to school, however early introduction of symptom-limited physical activity is appropriate.
doi:10.1136/ bjsports-2016-097415

What tests and measures should be added to the SCAT3 and related tests to improve their reliability, sensitivity and/or specificity in sideline concussion diagnosis? Ruben J. Echemendia, Steven Broglio, Gavin Davis, Kevin Guskiewicz, Alix Hayden, John Leddy, William Meehan, Paul McCrory, Margot Putukian, John Sullivan. British J Sports Medicine. 2017

ABSTRACT Objectives Several iterations of the Sport Concussion Assessment Tool (SCAT) have been published over the past 16 years. Our goal was to systematically review the literature related to the SCAT and provide recommendations for improving the tool. To achieve this goal, five separate but related searches were conducted and presented herein. Design Systematic literature review. Data sources Medline, Embase, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, SPORTDiscus and PubMed. Eligibility criteria Original, empirical, peer-reviewed findings published in English and included sports-related concussion (SRC). Review papers, case studies, editorials and conference proceedings/abstracts were excluded. The age range for the ChildSCAT was 5–12 years and for the Adult SCAT was 13 years and above. Results Out of 2961 articles screened, a total of 96 articles were included across the five searches. Searches were not mutually exclusive. The final number of articles included in the qualitative synthesis for each search was 21 on Adult SCAT, 32 on ChildSCAT, 21 on sideline, 8 on video/observation and 14 on oculomotor. Summary/conclusions The SCAT is the most widely accepted and deployable sport concussion assessment and screening tool currently available. There is some degree of support for using the SCAT2/SCAT3 and ChildSCAT3 in the evaluation of SRC, with and without baseline data. The addition of an oculomotor examination seems indicated, although the most valid method for assessing oculomotor function is not clear. Video-observable signs of concussion show promise, but there is insufficient evidence to warrant widespread use at this time.

Ulnar Nerve Submuscular Transposition. Mark Ehlers, Gavin Davis, and Amgad Hanna. In Neurosurgical Operative Atlas: Spine and Peripheral Nerves, 3rd edition (eds. Wolfla, Resnick), Thieme (New York). 2017.


Validation of a score to determine time to post-concussive recovery. Stephen Hearps, Michael Takagi, Franz Babl, Silvia Bressan, Katherine Truss, Gavin Davis, Celia Godfrey, Cathriona Clarke, Melissa Doyle, Vanessa Rausa, Kevin Dunne, Vicki Anderson. Pediatrics. DOI: 10.1542/peds.2016-2003

BACKGROUND: A reliable, developmentally appropriate and standardized method for assessing postconcussive symptoms (PCS) is essential to accurately determine recovery postconcussion and to effectively manage return to normal activities. The aim of this study was to develop an evidence-based, psychometrically validated approach to determining clinically useful cutoff scores by using a commonly administered PCS measure.
METHODS: The current study was a prospective, longitudinal observational study conducted between July 2013 and November of 2015 at a statewide tertiary pediatric hospital. Participants were 120 children (5–18 years of age) presenting to the emergency department with a concussion within 48 hours of injury. PCS were assessed by using the Postconcussion Symptom Inventory (PCSI), acutely, 1 to 4 days postinjury and 2 weeks postinjury. Using comprehensive clinical assessment as gold standard, we assessed the clinical cutoff discrimination ability of PCSI at 2 weeks postinjury by using published approaches, and then varying each approach to optimize their discrimination ability.
RESULTS: Existing and potential clinical cutoff scores were explored in predicting delayed recovery. Receiver operating characteristic curve results returned acceptable discrimination and sensitivity when PCSI items increased in severity from preinjury by 1 or more. Compared with a published cutoff score being 3+ items with increased severity, the current study suggests a more stringent cutoff requirement of 2+ is better able to accurately classify symptomatic children.
CONCLUSIONS: This study provides the first validated index (2+ items, 1+ severity) of concussion recovery for children and youth. Further stud

Using video analysis for concussion surveillance in Australian football. Michael Makdissi and Gavin Davis. Journal of Science and Medicine in Sport. DOI 10.1016/j.jsams.2016.02.014. (2016)

The objectives of the study were to assess the relationship between various player and game factors and risk of concussion; and to assess the reliability of video analysis for mechanistic assessment of concussion in Australian football.

Prospective cohort study.

All impacts and collisions resulting in concussion were identified during the 2011 Australian Football League season. An extensive list of factors for assessment was created based upon previous analysis of concussion in Australian Football League and expert opinions. The authors independently reviewed the video clips and correlation for each factor was examined.

A total of 82 concussions were reported in 194 games (rate: 8.7 concussions per 1000 match hours; 95% confidence interval: 6.9–10.5). Player demographics and game variables such as venue, timing of the game (day, night or twilight), quarter, travel status (home or interstate) or score margin did not demonstrate a significant relationship with risk of concussion; although a higher percentage of concussions occurred in the first 5
min of game time of the quarter (36.6%), when compared to the last 5min (20.7%). Variables with good inter-rater agreement included position on the ground, circumstances of the injury and cause of the impact. The remainder of the variables assessed had fair-poor inter-rater agreement. Common problems included insufficient or poor quality video and interpretation issues related to the definitions used.

Clear definitions and good quality video from multiple camera angles are required to improve the utility of video analysis for concussion surveillance in Australian football.

The reliability and validity of video analysis for the assessment of clinical signs of concussion in Australian football. Michael Makdissi and Gavin Davis. Journal of Science and Medicine in Sport. DOI 10.1016/j.jsams.2016.02.015. (2016)

The objective of this study was to determine the reliability and validity of identifying clinical signs of concussion using video analysis in Australian football.

Prospective cohort study.

All impacts and collisions potentially resulting in a concussion were identified during 2012 and 2013 Australian Football League seasons. Consensus definitions were developed for clinical signs associated with concussion. For intra- and inter-rater reliability analysis, two experienced clinicians independently assessed 102 randomly selected videos on two occasions. Sensitivity, specificity, positive and negative predictive values were calculated based on the diagnosis provided by team medical staff.

212 incidents resulting in possible concussion were identified in 414 Australian Football League games. The intra-rater reliability of the video-based identification of signs associated with concussion was good to excellent. Inter-rater reliability was good to excellent for impact seizure, slow to get up, motor incoordination, ragdoll appearance (2 of 4 analyses), clutching at head and facial injury. Inter-rater reliability for loss of responsiveness and blank and vacant look was only fair and did not reach statistical significance. The feature with the highest sensitivity was slow to get up (87%), but this sign had a low specificity (19%). Other video signs had a high specificity but low sensitivity. Blank and vacant look (100%) and motor incoordination (81%) had the highest positive predictive value.

Video analysis may be a useful adjunct to the side-line assessment of a possible concussion. Video analysis however should not replace the need for a thorough multimodal clinical assessment.

Use of video to facilitate sideline concussion diagnosis and management decision-making. Gavin Davis and Michael Makdissi. Journal of Science and Medicine in Sport. DOI 10.1016/j.jsams.2016.02.005 (2016)

Video analysis can provide critical information to improve diagnostic accuracy and speed of clinical decision-making in potential cases of concussion. The objective of this study was to validate a hierarchical flowchart for the assessment of video signs of concussion, and to determine whether its implementation could improve the process of game day video assessment.

Prospective cohort study

All impacts and collisions potentially resulting in a concussion were identified during 2012 and 2013 Australian Football League (AFL) seasons. Consensus definitions were developed for clinical signs associated with concussion. A hierarchical flowchart was developed based on the reliability and validity of the video signs of concussion. Ninety videos were assessed, with 45 incidents of clinically confirmed concussion, and 45 cases where no concussion was sustained. Each video was examined using the hierarchical flowchart, and a single response was given for each video based on the highest-ranking element in the flowchart.

No protective action, impact seizure, motor incoordination, or blank/vacant look were the highest ranked video signs in almost half of the clinically confirmed concussions, but in only 8.8% of non-concussed individuals. The presence of facial injury, clutching at the head and slow to get up were the highest ranked sign in 77.7% of non-concussed individuals.

This study suggests that the implementation of a flowchart model could improve timely assessment of concussion, and it identifies the video signs that should trigger automatic removal from play.

Protocol for a prospective,longitudinal,cohort study of post-concussive symptoms in children:the TakeC.A.Re (Concussion Assessment and Recovery Research) study.Silvia Bressan, Michael Takagi, Franz E Babl, Gavin A Davis, Ed Oakley, Kevin Dunne, Cathriona Clarke, Melissa Doyle, Stephen Hearps, Vera Ignjatovic, Marc Seal, Vicki Anderson. BMJ Open. 2016;doi:10.1136/bmjopen-2015-009427

Introduction: A substantial minority of children who sustain a concussion suffer prolonged postconcussive symptoms. These symptoms can persist for more than 1 month postinjury and include physical, cognitive, behavioural and emotional changes. Those
affected can develop significant disability, diminishing their quality of life. The precise prevalence of postconcussive symptoms following child concussion is unclear, with heterogeneous and at times conflicting results published regarding factors that predict children at risk for developing long-lasting postconcussive symptoms. The aim of the Take C.A.Re (Concussion Assessment and Recovery Research) study is to provide an in-depth multidimensional description
of the postconcussive recovery trajectories from a physical, neurocognitive and psychosocial
perspective in the 3 months following concussion, with a focus on the early postconcussive period, and identification of factors associated with prolonged recovery.
Methods and analysis: Take C.A.Re is a prospective, longitudinal study at a tertiary children’s hospital, recruiting and assessing patients aged 5– <18 years who present to the emergency department with a concussion and following them at 1–4 days,
2 weeks, 1 month and 3 months postinjury. Multiple domains are assessed: postconcussive symptoms, balance and coordination, neurocognition, behaviour, quality of life, fatigue, post-traumatic stress symptoms, parental distress and family burden. ‘Delayed recovery’ is operationalised as the presence of ≥3 symptoms on the Post Concussive Symptoms Inventory rated as worse compared with baseline. Main analyses comprise analysis of variance (recovery trajectories, delayed vs normal recovery groups) and regression analyses of predictors of recovery (preinjury, acute and family factors).
Ethics and dissemination: Ethical approval has been obtained through the Royal Children’s Hospital Melbourne Human Research Ethics Committee (33122). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media.
Trial registration number: ACTRN12615000316505.

Cognitive and physical symptoms of concussive injury in children: a detailed longitudinal recovery study. Louise Crowe, Alex Collie, Stephen Hearps, Julian Dooley, Helen Clausen, David Maddocks, Paul McCrory, Gavin Davis, Vicki Anderson. Br J Sports Med doi:10.1136/bjsports- 2015-094663

ABSTRACT Background Recovery from concussion sustained in childhood and adolescence is poorly understood. We explored patterns of recovery for neurocognition and postconcussive symptoms following concussion in children and adolescents. Methods Using a prospective, longitudinal design, we collected baseline data on 728 children and adolescents aged 10–17 years. 10 participants sustained a concussive injury (n=10) in the 12 months following baseline testing and they were reviewed at day 5, 10 and 30 postconcussion. Assessments included the CogSport for Kids computerised test battery to evaluate neurocognitive function and self-report, and parent measures of postconcussive symptoms. At day 30, parents also completed measures rating their child’s quality of life and executive functions. Results Children and adolescents displayed a gradual reduction in postconcussive symptoms over the 30 days following injury. At day 5, 87% of participants were reporting physical and cognitive symptoms, with a generalised reduction in all symptoms by day 10 (40% of participants). On the computerised measure, reaction time was slower after concussion, but returned to baseline levels by day 30. At day 30, 10% of participants demonstrated ongoing postconcussive symptoms. Number of previous concussions was related to speed of symptom resolution. Conclusions At 5 days postconcussion, the majority of children and adolescents experienced debilitating postconcussive symptoms. However, by 30 days postinjury, 90% demonstrated recovery to normal for both neurocognition and postconcussive symptoms.

HeadCheck - a concussion app. Gavin A Davis, Sarva Thurairatnam, Paula Feleggakis, Vicki Anderson, Silvia Bressan, Franz E Babl. Journal of Paediatrics and Child Health. 51 (2015) 830–831.

In a collaboration of child concussion experts at the Murdoch Childrens Research Institute (MCRI), the Royal Children’s Hospital and the University of Melbourne, along with Curve Tomorrow, a software development and design company with expertise in the child health sector, a smartphone app, HeadCheck, was developed to help adults recognise the signs and symptoms of concussion in children. Although the primary
focus of the app was for use in school-aged children and adolescents, the app is sufficiently robust for use in adult players as well. HeadCheck dynamically guides users through a series of concise questions to quickly assist in recognising symptoms of concussion (Figure 1). The HeadCheck algorithm prioritises the information the user needs to understand, ensuring logical steps are followed in a potentially stressful situation. Depending on the severity of the individual’s symptoms, the app may automatically re-direct the user to call the Australian emergency services phone number, ‘000’.

Neurodegeneration and Sport. Gavin A. Davis, Rudolph J. Castellani, Paul McCrory. Neurosurgery. 76: 643-656, 2015


The recent interest in concussion in sport has resulted in significant media focus about chronic traumatic encephalopathy (CTE), although a direct causative link(s) between concussion and CTE is not established. Typically, sport-related CTE occurs in a retired athlete with or without a history of concussion(s) who presents with a constellation of cognitive, mood, and/or behavioral symptoms and who has postmortem findings of tau deposition within the brain. There are many confounding variables, however, that can account for brain tau deposition, including genetic mutations, drugs, normal aging, environmental factors, postmortem brain processing, and toxins. To understand the roles of such factors in neurodegenerative diseases that may occur in athletes, this article reviews some neurodegenerative diseases that may present with similar findings in nonathletes. The article also reviews pathological changes identified with normal aging, and reviews the pathological findings of CTE in light of all these factors. While many of these athletes have a history of exposure to head impacts as a part of contact sport, there is insufficient evidence to establish causation between sports concussion and CTE. It is likely that many of the cases with neuropathological findings represent the normal aging process, the effects of opiate abuse, or a variant of frontotemporal lobar degeneration. Whether particular genetic causes may place athletes at greater risk of neurodegenerative disease is yet to be determined.

Developmental trajectory of information processing skills in children: computer-based assessment. Jacqueline Williams, Louise M. Crowe, Julian Dooley, Alex Collie, Gavin Davis, Paul McCrory, Helen Clausen, David Maddocks, & Vicki Anderson. Applied Neuropsychology: Child. DOI: 10.1080/21622965.2014.939271, 2015


There are significant merits to a comprehensive cognitive assessment but they are also time consuming, costly, susceptible to practice effects and may not detect change in the context of medical interventions or minor brain disruptions. Brief computer-based assessments focused on ‘fluid’ cognitive domains (e.g., information processing skills), which are vulnerable to disruption as a result of a brain injury, may provide an alternative assessment option. This study sought to: i) examine the utility of a well-established, adult-based, computerized tool, CogSport for Kids (CogState®), for evaluating information processing skills in children and adolescents; and ii) to report normative data for healthy children and adolescents. The study was a cross-sectional, community based observational study of typically developing children aged 9-17 years (N=832). Participants completed the CogSport for Kids test battery, which comprises six brief computerized tasks that assess cognitive functions including processing speed, attention and working memory. Results showed an improvement with age for response speed and accuracy. Greatest change occurred between 9 and 12 years with performance stabilizing at 15 years. This brief screening tool is appropriate for clinical and research use in children from 9 years of age, and may be used to track cognitive development from childhood into adulthood, and to identify children who deviate from normal expectations.

Translating guidelines for the diagnosis and management of sports-related concussion into practice. Alex Donaldson, Joshua Newton, Paul McCrory, Peta White, Gavin Davis, Michael Makdissi, Caroline F Finch. Am J Lifestyle Med. doi: 10.1177/1559827614538751

Sports injuries are a significant clinical and public health concern. There is a growing call to improve the translation of available evidence-based and expert- informed sports injury prevention interventions into sustained use in practice by physicians and others (eg, athletic trainers, coaches, and parents) who care for injured athletes. This article provides a brief overview of the current sport injury prevention implementation literature before focusing specifically on the translation of guidelines (including consensus and position statements) developed to assist physicians and others diagnose and manage athletes with sport-related concussion and the associated return-to-play decisions. The outcomes of more than 20 published studies indicate that physician, athletic trainer, coach, parent, and athlete knowledge, use of, and compliance with sport-related concussion guidelines are limited. More concerted, coordinated, and theory-informed efforts are required to facilitate the widespread dissemination, translation, and implementation of such guidelines. An example is provided of how implementation drivers could be used to inform the development of a comprehensive, multilevel implementation strategy targeting the individual, organizational, and system-level changes necessary to support the translation of available sport-related concussion guidelines in both the clinical and sports settings.

Updated guidelines for the management of sports-related concussion in general practice. Michael Makdissi, Gavin Davis, Paul McCrory. Australian Family Physician. 2014; 43(3):94-99.


Concussion is common in many sports and recreational activities. It is thought to reflect a functional rather than structural injury to the brain. The clinical features are typically short-lived and usually resolve spontaneously. Complications, however, can occur and may include prolonged symptoms and/or cognitive deficits in the short term, as well as depression and cumulative deterioration in brain function in the longer term.
This article will provide an updated clinical review of concussion in sport, with an emphasis on assessment and management in general practice.
The critical issues in the clinical management of concussion in sport include making a diagnosis, differentiating between concussion and other pathologies (particularly structural head injury), recognising the presence of any modifying factors (which may increase the risk of complications) and determining when the patient can safely return to competition. The key components of safe return-to-play decisions include rest, neuropsychological testing and a graded program of exertion before return to sport.

Intention to use sport concussion guidelines among community-level coaches and sports trainers. Joshua D. Newton, Peta E. White, Michael T. Ewing, Michael Makdissi, Gavin A. Davis, Alex Donaldson, S. John Sullivan, Hugh Seward, & Caroline F. Finch. Journal of Science and Medicine in Sport. 2014; 17: 469-473.

Sporting bodies have developed guidelines for managing community-level players with suspected concussion in response to international consensus statements on concussion in sport. The purpose of this study was to examine the factors that influence the intended use of concussion guidelines among community-level coaches and sports trainers from two popular football codes in Australia: Australian football and rugby league.
Cross-sectional survey.
The survey, based on an extended theory of planned behaviour model, was completed by 183 Australian football coaches, 121 Australian football sports trainers, 171 rugby league coaches, and 142 rugby league sports trainers.
Personal norms and self-efficacy were significant predictors of intention to use concussion guidelines, although the relationship between self-efficacy and intention was stronger among Australian football coaches than rugby league coaches. Analysis of the salient beliefs that underpin self-efficacy found that coaches, irrespective of football code, felt less familiar (χ2 = 25.70, p < 0.001) and less experienced (χ2 = 31.56, p < 0.001) than sports trainers in using the concussion guidelines. At the same time, Australian football personnel, irrespective of their team role, felt that they had insufficient time (χ2 = 8.04, p < 0.01) and resources (χ2 = 12.31, p < 0.001) to implement the concussion guidelines relative to rugby league personnel.
Programmes aimed at increasing the intended use of sport concussion guidelines should focus on enhancing self-efficacy and leveraging personal norms. Increasing coaches’ familiarity and experience in using the concussion guidelines would also be warranted, as would finding ways to overcome the perceived time and resource constraints identified among Australian football personnel.

Knowledge about sports-related concussion: Is the message getting through to coaches and trainers? Br J Sports Med doi:10.1136/bjsports-2013-092785 Peta E White, Joshua D. Newton, Michael Makdissi, S. John Sullivan, Gavin Davis, Paul McCrory, Alex Donaldson, Michael T. Ewing, Caroline F Finch

Aim The need for accurate diagnosis and appropriate return-to-play decisions following a concussion in sports has prompted the dissemination of guidelines to assist managing this condition. This study aimed to assess whether key messages within these guidelines are reflected in the knowledge of coaches and sports trainers involved in community sport.
Methods An online knowledge survey was widely promoted across Australia in May–August 2012 targeting community Australian Football (AF) and Rugby League (RL) coaches and sports trainers. 260 AF coaches, 161 AF sports trainers, 267 RL coaches and 228 RL sports trainers completed the survey. Knowledge scores were constructed from Likert scales and compared across football codes and respondent groups.
Results General concussion knowledge did not differ across codes but sports trainers had higher levels than did coaches. There were no significant differences in either concussion symptoms or concussion management knowledge across codes or team roles. Over 90% of respondents correctly identified five of the eight key signs or symptoms of concussion. Fewer than 50% recognised the increased risk of another concussion following an initial concussion. Most incorrectly believed or were uncertain that scans typically show damage to the brain after a concussion occurs. Fewer than 25% recognised, and >40% were uncertain that younger players typically take longer to recover from concussion than adults.
Conclusions The key messages from published concussion management guidelines have not reached community sports coaches and sports trainers. This needs to be redressed to maximise the safety of all of those involved in community sport.

Prevalence of adjacent segment disc degeneration in patients undergoing anterior cervical discectomy and fusion based on pre-operative MRI findings. KM Lundine, G Davis, M Rogers, M Staples, G Quan. J Clin Neurosci 2014 Jan;21(1):82-5

Anterior cervical discectomy and fusion (ACDF) is a widely accepted surgical treatment for symptomatic cervical spondylosis. Some patients develop symptomatic adjacent segment degeneration, occasionally requiring further treatment. The cause and prevalence of adjacent segment degeneration and disease is unclear at present. Proponents for motion preserving surgery such as disc arthroplasty argue that this technique may decrease the ‘‘strain’’ on adjacent discs and thus decrease the incidence of symptomatic adjacent segment degeneration. The purpose of this study was to assess the pre-operative prevalence of adjacent segment degeneration in patients undergoing ACDF. A database review of three surgeons’ practice was carried out to identify patients who had undergone a one- or two-level ACDF for degenerative disc disease. Patients were excluded if they were operated on for recent trauma, had an inflammatory arthropathy (for example, rheumatoid arthritis), or had previous spine surgery. The pre-operative MRI of each patient was reviewed and graded using a standardised methodology. One hundred and six patient MRI studies were reviewed. All patients showed some evidence of intervertebral disc degeneration adjacent to the planned operative segment(s). Increased severity of disc degeneration was associated with increased age and operative level, but was not associated with sagittal alignment. Disc degeneration was more common at levels adjacent to the surgical level than at non-adjacent segments, and was more severe at the superior adjacent level compared with the inferior adjacent level. These findings support the theory that adjacent segment degeneration following ACDF is due in part to the natural history of cervical spondylosis.

The evaluation and management of acute concussion differs in young children. Gavin A Davis, Laura K Purcell. British Journal of Sports Medicine. 2014;48:98–101.

ABSTRACT Background There are many reasons why concussion in children needs to be considered different from adults. The Zurich (2008) recommendations on the management of concussion in children are restricted to children less than to 10 years of age. It does not include recommendations for children aged 5–10 years. The aim of this study is to review the current literature on (1) concussion assessment at the sideline and during recovery stages, especially in the age group 5–15 years, and (2) the management of concussion in children and adolescents. Methods A literature review using the MEDLINE database was undertaken. Articles were selected that included evaluation and/or management in children aged 5–15 years. Results There are no sideline assessment tools validated for use in this age group. There are a number of different symptom scales that have been validated during different stages of the follow-up assessment in children. No single paediatric concussion assessment tool has been validated for use from sideline through to all stages of recovery. Reliability studies have been published on Balance Error Scoring System in children, but validity studies in this age group have not been published. The management of concussion includes withdrawal from play on the day and cognitive and physical rest. The priority of concussion management in children is to return to learn; while this is usually rapid, there are some children in whom a graduated return to school is required, which should include a number of accommodations. Conclusions A young child is physically, cognitively and emotionally very different from adults, and requires the use of a different set of tools for the diagnosis, recovery- assessment and management of concussion. Age-specific, validated diagnostic tools are required, and management of concussion in children should focus attention on return to learn before considering return to play.

Evidence-based approach to revising the SCAT2: introducing the SCAT3 Kevin M Guskiewicz, Johna Register-Mihalik, Paul McCrory, Michael McCrea, Karen Johnston, Michael Makdissi, Jiří Dvořák, Gavin Davis, Willem Meeuwisse. Br J Sports Med 2013;47:289–293.

The Sport Concussion Assessment Tool 2 (SCAT2), which evolved from the 2008 Concussion in Sport Group (CISG) Consensus meeting, has been widely used internationally for the past 4 years. Although the instrument is considered very practical and moderately effective for use by clinicians who manage concussion, the utility and sensitivity of a 100-point scoring system for the SCAT2 has been questioned. The 2012 CISG Consensus Meeting provided an opportunity for several of the world’s leading concussion researchers and clinicians to present data and to share experiences using the SCAT2. The purpose of this report is to consider recommendations by the CISG, and to review the current literature to identify the most sensitive and reliable concussion assessment components for inclusion in a revised version—the SCAT3. Through this process, it was determined that important clinical information can be ascertained in a streamlined manner through the use of a multimodal instrument such as the SCAT3. This test battery should include an initial assessment of injury severity using the Glasgow Coma Scale, immediately followed by observing and documenting concussion signs. Once this is complete, symptom endorsement and symptom severity, neurocognitive function and balance function should be assessed in any athlete suspected of sustaining a concussion. There is no evidence to support the use of a composite/total score; however, there is good evidence to support the use of each component (scored independently) in a revised assessment tool.

What evidence exists for new strategies or technologies in the diagnosis of sports concussion and assessment of recovery? Jeffrey Scott Kutcher, Paul McCrory, Gavin Davis, Alain Ptito, Willem H Meeuwisse, Steven P Broglio. Br J Sports Med 2013;47:299–303.

ABSTRACT Objective The purpose of this critical review is to summarise the evidence for the following technologies/ strategies related to diagnosing or managing sports-related concussion: quantitative EEG, functional neuroimaging, head impact sensors, telemedicine and mobile devices. Data sources MEDLINE, PubMed, Cochrane Controlled Trials Registers, SportDiscus, EMBASE, Web of Science and ProQuest databases. Primary search keywords were concussion, sports concussion and mild traumatic brain injury. The keywords used for secondary, topic specific searches were quantitative electroencephalography, qEEG, functionalMRI, magnetoencephalography, near- infrared spectroscopy, positron emission tomography, single photon emissionCT, accelerometer, impact sensor, telemetry, remote monitoring, robotic medicine, telemedicine, mobile device, mobile phone, smart phone and tablet computer. Results The primary search produced 8567 publications. The secondary searches produced nine publications that presented original data, included a comparison group in the study design and involved sports-related concussion. Four studies spoke to the potential of qEEG as a diagnostic or management tool, while five studies addressed the potential of fMRI to be used in the same capacity. Conclusions Emerging technologies and novel approaches that aid in sports concussion diagnosis and management are being introduced at a rapid rate. While some technologies show promise, their clinical utility remains to be established.

Revisiting the modifiers: how should the evaluation and management of acute concussions differ in specific groups? Michael Makdissi, Gavin Davis, Barry Jordan, Jon Patricios, Laura Purcell, Margot Putukian. Br J Sports Med 2013;47: 314–320.

ABSTRACT Background One of the key difficulties while managing concussion in sport is that there are few prognostic factors to reliably predict clinical outcome. The aims of the current paper are to review the evidence for concussion modifiers and to consider how the evaluation and management of concussion may differ in specific groups. Methods A qualitative review of the literature on concussion was conducted with a focus on prognostic factors and specific groups including children, female athletes and elite versus non-elite players. PubMed, MEDLINE and SportsDiscus databases were reviewed. Results The literature demonstrates that number and severity of symptoms and previous concussions are associated with prolonged recovery and/or increased risk of complications. Brief loss of consciousness (LOC) and/ or impact seizures do not reliably predict outcomes following a concussion, although a cautious approach should be adopted in an athlete with prolonged LOC or impact seizures (ie, >1 min). Children generally take longer to recover from concussions and assessment batteries have yet to be validated in the younger age group. Currently, there are insufficient data on the influence of genetics and gender on outcomes following a concussion. Conclusions Several modifiers are associated with prolonged recovery or increased risk of complications following a concussion and have important implications for management. Children with concussion should be managed conservatively, with an emphasis on return to learn as well as return to sport. In cases of concussions managed with limited resources (eg, non-elite players), a conservative approach should also be taken. There should be an emphasis on concussion education in all sports and at all levels, particularly in junior and community-based competitions.

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 - Br J Sports Med 2013;47:250–258.

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012
Paul McCrory, Willem H Meeuwisse, Mark Aubry, Bob Cantu, Jiří Dvořák, Ruben J Echemendia, Lars Engebretsen, Karen Johnston, Jeffrey S Kutcher, Martin Raftery, Allen Sills, Brian W Benson, Gavin A Davis, Richard G Ellenbogen, Kevin Guskiewicz, Stanley A Herring, Grant L Iverson, Barry D Jordan, James Kissick, Michael McCrea, Andrew S McIntosh, David Maddocks, Michael Makdissi, Laura Purcell, Margot Putukian, Kathryn Schneider, Charles H Tator, Michael Turner
Br J Sports Med 2013;47:250–258.

To view the statement in full, click here

Practical Management of Head and Neck Injury (Published 2012)

Head and Neck Injury Book
Practical Management of Head and Neck Injury is a unique textbook which comprehensively covers the patient journey from injury to the rehabilitation phase. It includes diagnosis and management of head and neck injury with additional chapters on prognosis and special conditions including head injury in sport, the elderly, children, pregnant women, penetrating head injury, spine and spinal cord injury and brain death. It describes an integrated approach to care from all the relevant specialties with Australian, UK and US experts contributing to many chapters.
Table of Contents
Chapter 1: Epidemiology
Chapter 2: Anatomy
Chapter 3: Pathophysiology of traumatic brain injury
Chapter 4: Pre-hospital management
Chapter 5: Emergency room management
Chapter 6: Spine injury
Chapter 7: Vascular injury
Chapter 8: Operative surgery
Chapter 9: Intensive care management of head injury
Chapter 10: Ward care of the head-injured patient
Chapter 11: Rehabilitation of head injury patients: issues in rehabilitation following traumatic brain injury
Chapter 12: Head injury in children
Chapter 13: Head injury in the elderly
Chapter 14: Head injury in sport -
Gavin A Davis, Michael Makdissi, Paul McCrory
Chapter 15: Pentrating head injury
Chapter 16: Bleeding diathesis and anticoagulants
Chapter 17: Neurotrauma in pregnancy
Chapter 18: Brain death
Chapter 19: Prolonged post coma unresponsiveness (the persistent vegetative state) and minimally responsive state post head injury
Chapter 20: Prediction of outcome and the prognosis of head injury
Chapter 21: Prevention of head injury and trauma systems
Appendices, including evidence-based guidelines

Mild Traumatic Brain Injury in Children and Adolescents From Basic Science to Clinical Management Edited by Michael W. Kirkwood and Keith Owen Yeates (published 2012)

A cutting-edge synthesis of science and practice, this book covers everything from sports-related concussions to less common types of mild traumatic brain injury (mTBI) and related complications. Preeminent authorities review what is known about mTBI in childhood and adolescence—including its biomechanics, pathophysiology, and neurological and neurobehavioral outcomes—and showcase evidence-based clinical evaluation tools and management strategies. Challenging areas such as evaluating complicated mTBI and treating persistent problems after injury are discussed in detail. Also addressed are forensic issues, injury in very early childhood, and other special-interest topics.

Table of Contents:

I. Introduction
1. History, Diagnostic Considerations, and Controversies, Elisabeth A. Wilde, Stephen R. McCauley, Gerri Hanten, Gunes Avci, Alyssa P. Ibarra, and Harvey S. Levin
2. Epidemiology and Prevention, R. Dawn Comstock and Kelsey Logan
3. Biomechanics of Sports Concussion, Jason P. Mihalik
4. Animal Models, Andre Obenaus, Lei Huang, Jacqueline S. Coats, Richard Hartman, Jerome Badaut, and Stephen Ashwal
II. Evidence-Based Outcomes
5. Pathophysiological Outcomes, Talin Babikian, John DiFiori, and Christopher C. Giza
6. Neurological Outcomes,
Gavin A. Davis
7. Neurobehavioral Outcomes, Keith Owen Yeates and H. Gerry Taylor
III. Clinical Evaluation
8. Biochemical Markers, Rachel P. Berger and Noel Zuckerbraun
9. Neuroimaging, Stephen Ashwal, Karen A. Tong, Brenda Bartnik-Olson, and Barbara A. Holshouser
10. Physical and Neurological Exam, Joseph A. Grubenhoff and Aaron Provance
11. Balance Testing, Tamara C. Valovich McLeod and Kevin M. Guskiewicz
12. Postconcussion Symptom Assessment, Jennifer A. Janusz, Maegan D. Sady, and Gerard A. Gioia
13. Cognitive Screening and Neuropsychological Assessment, Doug Bodin and Nicole Shay
IV. Clinical Intervention
14. Active Rehabilitation for Slow-to-Recover Children, Grant L. Iverson, Isabelle Gagnon, and Grace S. Griesbach
15. Medical and Pain Management, Pamela E. Wilson and Gerald H. Clayton
16. School-Based Management, John W. Kirk, Beth Slomine, and Jeanne E. Dise-Lewis
V. Topics of Special Interest
17. Sport-Related Concussion, Michael W. Kirkwood, Christopher Randolph, Michael McCrea, James P. Kelly, and Keith Owen Yeates
18. Injury in Preschool-Age Children, Audrey McKinlay
19. Forensic Considerations, Jacobus Donders

Brukner & Khan's Clinical Sports Medicine 4th Edition (published 2012)

The bible of sports medicine. It covers all aspects of diagnosis and management of sports related injuries

Brukner and Khan's Clinical Sports Medicine is the bible of sports medicine. The text explores all aspects of diagnosis and management of sports-related injuries and physical activity such as the fundamental principles of sports medicine, diagnosis and treatment of sports injuries, enhancement of sports performance and dealing with special groups of participants. Each chapter has been comprehensively reviewed and updated and there are 12 new chapters which cover topics such as military medicine, prevention of sudden cardiac death and the integration of evidence into clinical practice. The contributing authors are renowned experts in their field and are based all around the world.

Chapter 17 - Sports Concussion

Paul McCrory, Gavin Davis, Michael Makdissi and Michael Turner

Second Impact Syndrome or Cerebral Swelling after Sporting Head Injury. Paul McCrory, Gavin Davis, and Michael Makdissi. Current Sports Medicine Reports. 11(1) January/February 2012; 21-23

Second impact syndrome is believed to be the catastrophic consequence of repeated head injury in sport. The scientific evidence to support this concept is nonexistent, and belief in the syndrome is based upon the interpretation of anecdotal cases more often than not, lacking sufficient clinical detail to make definitive statements. The fear of this condition has driven many of the current return-to-play guidelines following concussion. Diffuse cerebral swelling (DCS) following a head injury is a well-recognized condition, more common in children than in adults, and usually has a poor outcome.

Concussion in Sport. Makidissi M, Davis G, McCrory P. MedicineToday 2011; 12(7): 75-82

ead trauma is a common occurrence in many sports and recreational pursuits. Recent figures from the USA estimate approximately 1.6 to 3.8 million cases of sports- and recreation-related head injury each year. In Australia, common participation sports such as Australian rules football, rugby league and rugby union have high rates of head injury. The reported incidence of concussion in these sports is in excess of five concussive injuries per 1000 player hours, which equates to over five concussions per team per season. Over the past eight years, three conferences have been held in which the world leading experts have addressed key issues in the understanding and management of concussion in sport. Following each of these meetings, a summary and agreement statement have been published with an aim to ‘improve the safety and health of athletes who suffer concussive injuries during participation in sport’. The most recent conference was held in Zurich, Switzerland, in November 2008. The consensus statement produced from this meeting provides the most up-to-date knowledge on concussion in sport, and outlines the current best practice management guidelines. This article aims to provide an overview of the key concepts arising from the conferences on concussion in sport, including an understanding of the injury, an outline of potential risks and an overview of current management guidelines.

Tibial intraneural ganglia at the ankle and knee: incorporating the unified (articular) theory in adults and children. Davis GA, Cox IH. Journal of Neurosurgery. 2010 April; DOI: 10.3171/2010.3.JNS10427

OBJECT: The etiology of intraneural ganglia has been debated for centuries, and only recently a unifying theory has been proposed. The incidence of tibial nerve intraneural ganglia is restricted to the occasional case report, and there are no reported cases of these lesions in children. While evidence of the unifying theory for intraneural ganglia of the common peroneal nerve is strong, there are only a few reports describing the application of the theory in the tibial nerve. In this report the authors examine tibial nerve intraneural ganglia at the ankle and knee in an adult and a child, respectively, and describe the clinical utility of incorporating the unifying (articular) theory in the management of tibial intraneural ganglia in adults and children.
METHODS: Cases of tibial intraneural ganglion cysts were examined clinically, radiologically, operatively, and histologically to demonstrate the application of the unified (articular) theory for the development of these cysts in adults and children.
RESULTS: Two patients with intraneural ganglion cysts of the tibial nerve were identified: an adult with an intraneural ganglion cyst of the tibial nerve at the tarsal tunnel and a child with an intraneural ganglion cyst of the tibial nerve at the knee. In each case, preoperative MR imaging demonstrated the intraneural cyst and its connection to the adjacent joint via the articular branch to the subtalar joint and superior tibiofibular joint. At surgery the articular branch was identified and resected, thus disconnecting the tibial nerve intraneural cyst from the joint of origin.
CONCLUSIONS: These cases detail the important features of intraneural ganglion cysts of the tibial nerve and document the clinical utility of incorporating the unifying (articular) theory for the surgical management of tibial intraneural ganglia in adults and children.

Consensus Statement on Concussion in Sport – the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. British J Sports Medicine. 2009;43;i76-i84

Consensus Statement on Concussion in Sport – the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Panelists: Broglio S, Davis G, Dick R, Dvorak J, Echemendia R, Gioia G, Guskiewicz K, Herring S, Iverson G, Kelly J, Kissick J, Makdissi M, McCrea M, Ptito A, Purcell L, Putukian M. British J Sports Medicine. 2009;43;i76-i84

Sphenoid Wing Lesion. Journal of Clinical Neuroscience. Lam K, Davis GA, Fitt G, Kalnins R. :2010 May;17(5):606, 677.

J Clin Neurosci. 2010 May;17(5):606, 677.
Sphenoid wing lesion.
Lam K, Fitt G, Kalnins R, Davis G.
Department of Neurosurgery, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia.

Contributions of Neuroimaging, Balance Testing, Electrophysiology, and Blood Markers to the Assessment of Sport-Related Concussion. Davis GA, Iverson GL, Guskiewicz KM, Ptito A, Johnston KM. British J Sports Medicine. 2009; 43 (Suppl_1): i36-i45.

Objective: To review the diagnostic tests and investigations used in the management of sports concussion, in the adult and paediatric populations, to (a) monitor the severity of symptoms and deficits, (b) track recovery and (c) advance knowledge relating to the natural history and neurobiology of the injury.
Design: Qualitative literature review of the neuroimaging, balance testing, electrophysiology, blood marker and concussion literature.
Intervention: PubMed and Medline databases were reviewed for investigations used in the management of adult and paediatric concussion, including structural imaging (computerised tomography, magnetic resonance imaging, diffusion tensor imaging), functional imaging (single photon emission computerised tomography, positron emission tomography, functional magnetic resonance imaging), spectroscopy (magnetic resonance spectroscopy, near infrared spectroscopy), balance testing (Balance Error Scoring System, Sensory Organization Test, gait testing, virtual reality), electrophysiological tests (electroencephalography, evoked potentials, event related potentials, magnetoencephalography, heart rate variability), genetics (apolipoprotein E4, channelopathies) and blood markers (S100, neuron-specific enolase, cleaved Tau protein, glutamate).
Results: For the adult and paediatric populations, each test has been classified as being: (1) clinically useful, (2) a research tool only or (3) not useful in sports-related concussion.
Conclusions: The current status of the diagnostic tests and investigations is analysed, and potential directions for future research are provided. Currently, all tests and investigations, with the exception of clinical balance testing, remain experimental. There is accumulating research, however, that shows promise for the future clinical application of functional magnetic resonance imaging in sport concussion assessment and management.

Clinics in Neurology and Neurosurgery of Sport - Asymptomatic cervical canal stenosis and transient quadraparesis. Davis G, Ugokwe K, Roger E, Benzel E, Cantu R, Rogers M, Dvorak J, McCrory P. British Journal of Sports Medicine. 2009; 43:1154-1158.

The cervical spine is a relatively mobile structure commencing at the base of the skull and finishing at the relatively immobile thoracic spine. The cervical spinal cord and the paired vertebral arteries are critical occupants of the cervical spine, and injury to these structures results in catastrophic quadriplegia (spinal cord injury) or stroke (vertebral artery injury). Trauma to the neck is not uncommon in sport, but only rarely results in neurovascular injury or significant spinal instability. Every physician or trainer entrusted with the care of athletes’ fears that the next neck injury seen may be a catastrophic one and endeavours to seek every opportunity possible to prevent such disaster. The question is: which athletes are at risk? Is asymptomatic spinal canal stenosis a risk factor for spinal cord injury and does an episode of transient quadriparesis predispose an athlete to the development of catastrophic spinal cord injury?
Case study: patient 1
A 26-year-old male footballer sustains a concussion with loss of consciousness lasting 30 seconds. He makes a full recovery, but as a precaution is taken to the local hospital emergency department. He is examined and found to be neurologically intact. A CT scan of the brain is reported as normal. Plain radiographs of the cervical spine suggest narrowing of the spinal canal with a Torg–Pavlov ratio of 0.76 (normal >0.8) measured at C3 ( fig 1 ). Flexion extension radiography of the cervical spine is performed, with no evidence of instability. The managing team physician refers the patient to you for expert opinion.
What recommendations do you make, based on the following considerations?
1. Given that the patient is asymptomatic with respect to the cervical spine and based on these findings, will you allow him to return …

Clinics in Neurology and Neurosurgery of Sport - Benign Brain Tumors. Davis G, Marion D, George B, Le Roux P, Laws E, McCrory P. British Journal of Sports Medicine. 2009; 43:619-622

When athletes are investigated for acute neurological symptoms a brain scan may reveal a tumour or mass lesion. Occasionally, these are incidental findings. The location of the tumour in the brain will critically affect its clinical presentation. A tumour compressing the optic nerve will result in visual loss, a tumour obstructing the cerebral aqueduct will cause hydrocephalus, and a tumour in the hippocampus may cause epilepsy.
The biology of the tumour determines its growth propensity and aggressiveness. Although tectal plate glioma and glioblastoma multiforme are both classified as astrocytomas, the behaviour of each is completely different. A tectal plate i glioma is a very slow-growing, indolent lesion, often remaining stable for many years without the requirement for any treatment, whereas a glioblastoma multiforme is aggressive and invasive, and can grow rapidly within a few weeks. Similarly, the classification of meningiomas includes tumours with a broad spectrum of clinical behaviour. A benign convexity meningioma grows very slowly and is cured with complete resection, whereas a skull base meningioma can invade bone, brain, vascular and neural structures. Tumour biology also affects the brain’s reaction to the tumour, such as the development of cerebral oedema surrounding the lesion.
Treatment of tumours takes these and other factors into account, including patient age and functional level, comorbidity, neurological deficits and seizures. Depending on the tumour type, location and clinical presentation, treatment options include any combination of surgical resection, radiosurgery, radiotherapy, chemotherapy, and treatment of associated phenomena such as hydrocephalus and seizures.
The athlete with a high-grade aggressive tumour with pronounced neurological deficit is unlikely to return to elite sport, but a sportsman with an incidental benign brain tumour will probably want to return and may be able to do so. This forum is inappropriate for a detailed discussion of the management of all brain tumours, …

Clinics in Neurology and Neurosurgery of Sport - Cervical Disc Prolapse. Davis G, Dvorak J, Hamlyn P, Sears W, McCrory P. British Journal of Sports Medicine. 2009; 43:455-459.

A cervical intervertebral disc can prolapse (hernia or rupture) asymptomatically or may produce neck pain, nerve root compression (radiculopathy) or spinal cord compression (myelopathy). Surgery is indicated in cases of cervical myelopathy. In cases of symptomatic cervical radiculopathy, surgery is indicated in cases that fail to respond to conservative treatment. Surgical approaches to the cervical spine are usually anterior or posterior. Currently, anterior cervical discectomy is the most common procedure used. This may be performed alone or with the addition of fusion (insertion of a bone graft) and with or without instrumentation (an intervertebral prosthesis or use of plates or screws). An alternative to fusion (arthrodesis) is a disc replacement (arthroplasty). There is extensive debate among spinal surgeons as to the most appropriate technique, and as the literature lacks absolute clarity regarding the superiority of one technique over another, most spinal surgeons use the technique that works well in their hands.
A 25-year-old professional soccer player is involved in a motor vehicle crash, sustaining an acute C6–7 disc prolapse with radiculopathy ( figs 1 and 2 ). He undergoes C6–7 anterior cervical discectomy and fusion. Postoperatively he is neurologically intact. Three months have now passed and you are asked to provide your expert opinion. What recommendations do you make, based on the following considerations?
1. Can the patient return to play?
2. If so, when? Do you place any restrictions on him and is there any further follow-up that you require?
3. If you determine that he may not return to play, please explain your reasons for this) If you review him 12 months after surgery and plain x-ray of the cervical spine shows solid fusion, with stable flexion extension x-rays of the cervical spine, would this alter your decision? Are there any other factors that would alter your decision?

Clinics in Neurology and Neurosurgery of Sport - Traumatic cerebral contusion. Davis G, Marion D, George B, Hamel O, Turner M, McCrory P. British Journal of Sports Medicine. 2009; 43:451-454.

This case highlights the difficulties encountered in managing a sports player with traumatic brain injury. Fortunately, most head injuries in sport are minor and recover completely. Although the consensus definition 1 of sports concussion emphasizes the lack of structural brain injury, this is not the case with more severe injuries.
The presence of acute abnormalities (eg, contusion, haemorrhage) on CT or MRI scans in such patients inherently pushes the nature and consequences of the injury higher up the spectrum of traumatic brain injury and standard sports concussion management guidelines may no longer apply.
The case described is one of mild TBI and not simple concussion. However, many elements of the management are common to both conditions, and for the sake of simplicity, we will accept, as have the faculty, that this is a case of concussion with a cerebral contusion.
Patient 1
A 26 year-old professional ice hockey player was celebrating his team’s victory at a local nightclub. He was hit over the head with a beer bottle and lost consciousness for 3 minutes. In the emergency department, he had neurologically fully recovered. His scalp laceration was sutured and a CT scan of the brain was performed, revealing a small frontal contusion. There was no associated skull fracture and the CT scan was otherwise unremarkable. He was advised to rest for 6 weeks and then underwent formal neurological and neuropsychological testing, which were normal. Repeat CT scan of the brain showed complete resolution of the contusion ( fig 1 ). What recommendations do you make, based on the following considerations?
(1) Can he return to ice hockey?
1. If so, when?
2. Are there any extra precautions you would take when he returns to competition?
3. If he sustains a …

Clinics in Neurology and Neurosurgery of Sport - Extradural and subdural haematoma. Davis G, Marion DW, Le Roux P, Laws E, McCrory P. British Journal of Sports Medicine. Jun 2008; doi:10.1136/bjsm.2008.048215

Although concussion is the most common type of brain injury seen in athletes, there is always the possibility that head impact may cause a more severe structural brain injury. This is a complication that is feared by all sports physicians and others involved in athletic care.
Acute subdural haematoma (ASDH) results from traumatic laceration to the brain, from bleeding from the cortical vessels into the subdural space or from acceleration–deceleration injury to the head that causes tearing of the bridging veins, resulting in clot formation in the subdural space between the arachnoid and dural meningeal layers. A subdural haematoma is often associated with some underlying parenchymal (brain) injury, including diffuse axonal injury. In contrast, extradural haematoma usually results from a skull fracture causing damage to a meningeal artery, which is situated between the dura and the skull. Classically, there is no significant parenchymal injury in extradural haematoma.
Subdural and extradural haematomas are distinct clinical entities that share some common elements in sports medicine yet also have certain individual peculiarities that are important in return-to-sports decision making.
Case 1: subdural haematoma
A 31-year-old professional boxer has won all 26 fights he has contested. He sustained a small subdural haematoma in a fight he won ( fig 1 ). There was mild mass effect from the subdural haematoma, and it was observed with serial CT scans, without the requirement for surgical drainage. Spontaneous resolution of the subdural collection was noted on a repeat CT scan at 6 weeks. It is now 1 year later, and he has a normal neurological examination and formal neuropsychological testing is normal. The result of his brain MRI scan is also normal (including magnetic resonance venogram (MRV) and magnetic resonance angiogram (MRA) sequences).
What are …

Clinics in Neurology and Neurosurgery of Sport - Lumbar spine - sequestrated disc prolapse and disc bulge. Davis G, Johnson E, McCormick P, Roger E, Ugokwe K, Benzel E, Sears W, McCrory P. British Journal of Sports Medicine. 2009; 43:796-801.

Focal degenerative disc disease in the lumbar spine is broadly categorized into three clinical types: (1) asymptomatic disc degeneration, (2) degenerative disc disease resulting in low back pain (LBP) and (3) focal disc prolapse resulting in compression of the spinal nerve root producing the clinical picture of radiculopathy or sciatica. Whenever possible, non-surgical management is the favoured option, but when persistent nerve root compression does not respond to conservative measures, surgical decompression of the nerve root is required. A variety of operative procedures and approaches exists to deal with focal disc prolapse. Such procedures include open discectomy, microdiscectomy and endoscopic percutaneous discectomy. In some situations, in addition to discectomy, a vertebral fusion procedure is also required.
Although the fine details of surgical technique are beyond the scope of this paper, two cases have been selected for discussion because they represent common clinical scenarios encountered by the spinal surgeon, but there is limited published information specific to the athlete with such an injury. We have therefore addressed the issues specific to return to sport rather than focus on the myriad surgical procedures that can be performed on the lumbar spine.
Case study: patient 1. Lumbar: sequestrated disc prolapse
A 29-year-old American footballer was tackled to the ground and instantly felt a “twinge” in his lower back. He got up from his fall, and over the next few hours the pain intensified and then radiated into his right thigh, calf and foot. Treatment over the following 4 weeks included physiotherapy, acupuncture, non-steroidal anti-inflammatory medication, and hydrotherapy. The leg pain intensified and MRI of the lumbar spine showed a right L5–S1 sequestrated disc prolapse ( figs 1 and 2 ). A microdiscectomy was performed, with complete resolution of pain. He was discharged from hospital the day after surgery and has remained free of pain. You review him 6 weeks postoperatively and he is …

Clinics in Neurology and Neurosurgery of Sport - Mass lesions: Cavernoma. Davis G, Fabinyi G, Le Roux P, McCrory P. British Journal of Sports Medicine. 2009; 43:866-868.

The advent of widespread access to MR scanning has meant that a wide spectrum of incidental findings are now detected and referred for advice and management. Although cavernous haemangiomas (or cavernomas) are one of the most common types of benign vascular malformations, their precise incidence is unknown. They can occur as single or multiple lesions and provide a real dilemma for an athlete who wishes to participate in contact sports. Before the advent of modern neuroimaging techniques, such lesions would typically present as haemorrhage or seizures rather than as incidental findings on brain scans. In this patient, their risks and suggested management is discussed.
Case study: cavernoma
A footballer is involved in a motor vehicle accident. The patient incurs a head injury and loses consciousness for 30 seconds. The patient attends the emergency department, where is found to be asymptomatic, with normal systemic and neurological examination findings. A CT scan of the brain is performed, which shows a lesion in the anterior right frontal lobe. And MRI scan of the brain confirms this as a solitary cavernous haemangioma (cavernoma) ( fig 1 ). The treating clinicians order formal neuropsychology assessment and EEG, which are both normal. One week later, the patient attends your office seeking medical clearance to resume playing professional rugby. What recommendations do you make, based on the following considerations?
1. Does the presence of the cavernoma preclude the patient from returning to rugby or other contact sports?
2. Would you recommend any other treatment (eg, gamma knife) in order to allow him to return to sport?
3. If you permit him to play, is there any benefit from wearing a helmet and if so, does …

Clinics in Neurology and Neurosurgery of Sport - Peripheral Nerve Injury. Davis G, Kline D, Spinner R, Zager E, Garberina M, Williams G, McCrory P. British Journal of Sports Medicine. 2009; 43:537-540.

Peripheral nerve injuries are not uncommon in sports. Typically, these are associated with orthopaedic injury (eg, axillary nerve injury with glenohumeral joint dislocation) rather than the transection or gunshot-type injuries often seen in emergency departments.
The classification of nerve injuries is complex, 1 2 but the underlying principle is that the simplest of nerve injuries is a physiological loss only (neurapraxia) and the most severe form is complete anatomical transection of the nerve and its coverings (neurotmesis). Between these two extremes are varying degrees of injury to the axon and its covering sheath.
With all degrees of nerve injury, the greater the degree of preservation of anatomical structures, the greater the chance of neurological recovery. Thus a neurapraxic injury will recover spontaneously, whereas a neurotmetic injury will not recover without surgical intervention. Between these two ends of the spectrum is a large group of nerve injuries in which the capacity for spontaneous recovery cannot be accurately assessed clinically and may require surgical exploration with or without nerve repair.
On the sports field, the most common mechanism of nerve injury is a stretch or traction type of injury. In the first few weeks following a stretch injury, clinical observation is required. and after sufficient time has elapsed for Wallerian degeneration to occur (at least 2 weeks), then nerve conduction studies (NCS) and electromyography (EMG) can be performed. Over the following 6–8 weeks, a nerve injury is then followed by clinical examination and repeat NCS/EMG, with the objective being to determine whether spontaneous recovery will occur. If there is failure of neurological recovery at 3 months after the injury, then surgical intervention is required to facilitate recovery before irreversible fibrosis in the denervated muscle results.
The principles used by the peripheral nerve surgeon include neurolysis, intraoperative nerve action potentials (NAP), primary repair, …

Pancoast Tumors. Davis GA, Knight SR. Neurosurgery Clinics of North America. 19:545-557, October 2008.

Pancoast tumors (superior sulcus tumors or apical lung tumors) typically invade structures at the thoracic outlet, including the inferior elements of the brachial plexus (C8, T1 nerve roots and lower trunk). Historically, these tumors are rapidly fatal, but newer treatment with induction chemotherapy and radiotherapy, followed by surgical resection of the tumor has resulted in improved patient survival. To accomplish oncologic excision, resection of the involved brachial plexus elements is still standard practice in most centers, resulting in loss of hand function and/or development of neuropathic pain. We present a modification of this protocol that incorporates induction chemoradiation, surgical resection of the lung tumor by a thoracic surgeon, and neurolysis and preservation of the brachial plexus by a neurosurgeon. Improved survival outcome, especially in patients demonstrating a pathologic complete response, with preservation of hand function, supports our hypothesis that involved brachial plexus does not need resection in these patients.

Granular Cell Tumour - A rare tumour of the ulnar nerve. Davis G. Neurosurgical Focus. 22(6):E25, June 2007.

Granular cell tumors of the ulnar nerve are extremely rare, with only two cases previously reported in the English literature. The author presents a case of granular cell tumor of the ulnar nerve, in which the tumor was resected and the nerve was repaired with a nerve graft. The histopathological characteristics, imaging findings, and clinical data regarding these tumors are reviewed, and based on all the available evidence, a new treatment paradigm is proposed, which differs from that used in the earlier reported cases and takes into account the reported rate of tumor recurrence after incomplete resection.

Pancoast tumour resection with preservation of brachial plexus and hand function. Davis GA, Knight S. Neurosurgical Focus. 22(6):E15, June 2007.

OBJECT: Pancoast tumors are aggressive bronchogenic lesions of the lung apex that are rapidly fatal if untreated. Modern treatment includes induction chemotherapy and radiotherapy prior to resection, but many authors also resect the T-1 nerve root (with or without the C-8 nerve root and the lower trunk of the brachial plexus) as part of the therapy, causing significant loss of hand function in many patients. The current authors determined whether a different approach allowing preservation of the brachial plexus and hand function could be adopted without compromising patient survival. An extensive historical review of Pancoast tumors is presented as a baseline for clinical comparison.
METHODS: Five patients harboring Pancoast tumors with brachial plexus involvement underwent surgery performed by both a neurosurgeon and thoracic surgeon. In all cases the tumor was resected from the brachial plexus using neurolysis while preserving the C-8 and T-1 nerve roots and lower trunk of the brachial plexus.
RESULTS: One patient died 3 years posttreatment; the other four patients remain alive and well 2 to 5 years postoperatively. Hand function improved or remained normal in all four survivors, with postoperative intrinsic hand muscle function being Louisiana State University Medical Center Grade 5 in each patient. These results (2-year survival rate of 100%) compare favorably with the Southwest Oncology Group Data (overall 2-year survival rate of 55%; 70% in patients who had undergone complete resection). With a minimum 2-year follow-up, 80% of patients remained alive and well, with normal hand function.
CONCLUSIONS: Although this patient series is small, the findings are extremely encouraging and suggest that the described treatment paradigm preserves survival as well as hand function in patients with Pancoast tumors.

Ulnar Nerve Volar to Medial Epicondyle – An important anatomical variation. (Case Illustration) Davis GA. Journal of Neurosurgery. 104: 625, 2006.

The details of this case highlight the fact that anatomical variation, whatever its cause, may complicate a surgery that is otherwise regarded as simple and must always be considered when operative findings are unexpected.

Long-term seizure outcome following surgery for dysembryoplastic neuroepithelial tumour. Chan CHP, Bittar RG, Kalnins RM, Davis GA, Fabinyi GCA. Journal of Neurosurgery. 104: 62-69, 2006.

OBJECT: Resection of dysembryoplastic neuroepithelial tumor (DNET) is thought to result in favorable seizure outcome, but long-term follow-up data are scarce. The authors present a review of 18 patients who underwent surgical removal of a DNET: 12 via temporal lobectomy and six via lesionectomy.
METHODS: The mean long-term follow up was 10.8 years (median 10.4 years, range 7.8 to 14.8 years), and results obtained during this time period were compared with previously reported short-term (mean 2.7 years) seizure outcome data. In the current study, 66.7% patients had an Engel Class I outcome and 55.6% had an Engel Class IA outcome compared with 77.8% and 55.6%, respectively. Temporal lobectomy (Engel Class I, 83.3%; Engel Class IA, 66.7%) led to a better seizure outcome than lesionectomy (Engel Classes I and IA, 33.3%). Two patients (11.1%) required repeated operation and both had an incomplete lesionectomy initially.
CONCLUSIONS: Results indicated that complete resection of a DNET leads to a favorable seizure outcome, with epilepsy cure in those who had experienced early postoperative seizure relief. Long-term seizure outcome after surgery is predictable based on the result of short-term follow up.

Value of neuropsychological testing after head injuries in football. McCrory P, Makdissi M, Davis G, Collie A. British J Sports Medicine. 39(Supp 1):i58-i63, 2005.

This paper reviews the pros and cons of the traditional paper and pencil and the newer computerised neuropsychological tests in the management of sports concussion. The differences between diagnosing concussion on the field and neuropsychological assessment at follow up and decision making with regard to return to play are described. The authors also discuss the issues involved in interpreting the results of neuropsychological testing (comparison with population norms versus player’s own baseline test results) and potential problems of such testing in football. Finally, suggested recommendations for neuropsychological testing in football are given.

Can we manage sport-related concussion in children the same as in adults? McCrory P, Collie A, Anderson V, Davis G. British J Sports Medicine. 38:516-519, 2004.

Br J Sports Med. 2004 October; 38(5): 516–519.
doi: 10.1136/bjsm.2004.014811.
Can we manage sport related concussion in children the same as in adults?
P McCrory, A Collie, V Anderson, and G Davis
Centre for Health, Exercise and Sports Medicine and the Brain Research Institute, University of Melbourne, Parkville, Victoria 3010, Australia.

Submuscular Transposition of the ulnar nerve : review of safety, efficacy and correlation with neurophysiological outcome. Davis GA and Bulluss KJ. Journal of Clinical Neuroscience. 12(5): 524-528, 2005.

The surgical management of ulnar nerve entrapment at the elbow is a controversial topic, with each surgeon believing his/her technique to be the best. The authors routinely perform submuscular transposition (SMT) of the ulnar nerve to treat entrapment neuropathy at the elbow. The aims of this review are (1) to review the results of SMT with respect to safety and complications, (2) to compare the efficacy of SMT with other studies previously published, and (3) to compare the clinical results with the neurophysiological outcome.
A retrospective review of patients who underwent SMT for ulnar nerve entrapment between April 2000 and May 2003 was performed. Forty-five ulnar nerves in 44 patients were operated, of which 40 nerves were first time operation (primary group), and 5 nerves had previously undergone a simple decompressive procedure elsewhere (redo group). All patients were graded using the Louisiana State University Medical Centre (LSUMC) system for grading of ulnar nerve entrapment. Pre- and post-operative nerve conduction studies were performed, and these results compared to clinical recovery post-operatively.
For the primary group, function improved by one grade in 32.5%, two grades in 37.5% and three grades in 12.5% of patients. There was no change in 17.5%, and no patient deteriorated post-operatively.
In the redo group there was improvement of at least one grade in 60% of patients. When clinical improvement was compared with electrophysiological improvement, no clear correlation was demonstrated.
Submuscular transposition of the ulnar nerve is a safe, effective treatment for ulnar nerve entrapment at the elbow. When performed by trained peripheral nerve surgeons, good results are achievable for both primary and redo surgery.
Keywords: anterior transposition; cubital tunnel syndrome; ulnar nerve

Brachial Plexus Surgery and Apical Lung Tumours. Davis GA, Knight S. Cancer Forum. 28 (1): 11-12, 2004.

Historically, management of apical lung tumours (superior sulcus tumours or Pancoast tumours) that involve the brachial plexus has been very limited, and usually all that was offered was palliative care.1 However, several advances have been made in the management of these tumours, such that the aim of treatment now is complete clearance of macroscopic tumour. The surgical approach, as well as changes in the use of induction radiotherapy and chemotherapy have resulted in improved functional and survival outcome in these patients. Based on our experience in treating these patients at the Austin Hospital, we present the following overview of our strategy in managing these difficult tumours.

Cerebral Metastases in a Patient with Malignant Mesothelioma : Mah E, Bittar RG, Davis GA. Journal of Clinical Neuroscience. 11:917-918, 2004.

Malignant mesothelioma is an uncommon tumour with an inevitably poor outcome. Statistics from the US National Cancer Institute reveal a steady rise in its incidence over the past 25 years. It typically arises from the pleura, but can also originate in the peritoneum, pericardium, genital tracts and tunica vaginalis. Previously considered a local disease with low incidence of metastasis, there is increasing evidence suggesting otherwise. Reported cases of cerebral metastasis are rare and the vast majority are postmortem findings. This report documents a patient with symptomatic cerebral metastasis from malignant mesothelioma, who underwent craniotomy and excision of two cerebral lesions. It is one of a handful of case reports in the literature in which histological confirmation has been obtained ante-mortem and where surgical treatment of the intracranial mesothelioma was undertaken.

Increased perivascular spaces mimicking frontal lobe tumour. Davis GA, Fitt GJ, Kalnins RM and Mitchell LA. Journal of Neurosurgery. 97:723, 2002.

J Neurosurg. 2002 Sep;97(3):723.
Increased perivascular spaces mimicking frontal lobe tumor.
Davis G, Fitt GJ, Kalnins RM, Mitchell LA.
Department of Neurosurgery, Austin and Repatriation Medical Centre, Heidelberg, Victoria, Australia.

Acute onset non-traumatic paraplegia in childhood: Fibrocartilagenous embolism or acute myelitis? Davis GA, Klug GL. Child's Nervous System. 16( 9), 551-554, 2000.

Fibrocartilaginous embolus causing acute spinal cord infarction is a rare cause of acute-onset paraplegia or quadriplegia. Few cases of survivors have been reported in the neurosurgical literature, with most reports involving postmortem or biopsy findings. There is little information on MRI findings in such patients. We present the youngest patient ever reported, and discuss the important differences between fibrocartilaginous embolus and acute myelitis of childhood. A 6-year-old girl with a history of back pain presented with sudden-onset nontraumatic paraplegia, with a clinical anterior spinal artery syndrome. Initial MRI scan revealed intervertebral disc disease at L1-2 and an incidental thoracic syrinx, but no cause for her acute-onset paraplegia was identified. Cerebrospinal fluid and other investigations were all negative. Sequential MRI scans revealed development of spinal cord expansion from T10 to the conus medullaris, with increased cord signal in the anterior aspect of the spinal cord. The intervertebral disc disease was unchanged. The imaging and clinical findings were caused by fibrocartilaginous embolus, which meant there was no need for spinal cord biopsy. The report describes the clinical and imaging criteria for diagnosis of fibrocartilaginous embolus, highlighting the case for avoiding an unnecessary biopsy. The clinical pattern in the paediatric group is discussed, with features differentiating it from acute myelitis of childhood.

Delayed presentation of transorbital intracranial pen. Davis GA, Holmes AD, Klug GL. Journal of Clinical Neuroscience. 7(6):545-548, 2000.

A 13 year old Fijian boy sustained a stab wound to the left orbit 3 years ago. It was not appreciated by the treating physicians in Fiji that the plastic pen had crossed from the left orbit, through the nose, right orbit and right optic nerve, into the right middle cranial fossa and lodged in the right temporal lobe and that the pen remained in situ for the past 3 years. The boy presented to Australia with a discharge from the entry wound in his left lower eyelid. The retained foreign body was not detected on computed tomography imaging, but was detected on subsequent magnetic resonance image. A combined neurosurgery/plastic surgery craniofacial approach was undertaken with successful complete removal of the retained pen, and preservation of vision in his only seeing eye.

Dysembryoplastic Neuroepithelial Tumour and Mixed DNET-Ganglioglioma - Seizure Outcome Following Surgery. Davis GA, Kalnins RM, Fabinyi GCA. Journal of Clinical Neuroscience 4(4):451-457,1997.

Dysembryoplastic neuroepithelial tumour (DNET) is a recently recognized tumour occurring in patients with epilepsy of early onset. Long-term seizure outcome following resection is not well known. A review of 18 patients with DNET is presented. There were 13 temporal lobe, 3 frontal lobe and 2 parietal lobe DNETs. Of the 13 temporal lobe tumours, there were 3 mixed DNET-gangliogliomas. Resection in all 18 patients produced an overall class 1 seizure outcome of 78%. Class 1 outcomes for the subgroups of mixed DNET-ganglioglioma and anterior temporal lobe DNETs were 100% each. Although the number of patients is statistically small, comparison with other reported series is made.

Concurrent Adjacent Meningioma and Astrocytoma - A report of three cases and review of the literature. Davis GA, Fabinyi GCA, Kalnins RM, Brazenor GA, Rogers MA. Neurosurgery 36:599-605,1995.

Three patients presenting with an adjacent meningioma and astrocytoma are described. A review of the literature discusses several modes of neuroimaging and the difficulties in diagnosing simultaneous adjacent tumors. Aspects of the pathology and etiology of these tumors are also reviewed.

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