Neurosurgeon, Sierra Neurosurgery Group
As snow descends on the Sierra, many of us in the Truckee Meadows turn our attention toward winter activities, including skiing and snowboarding. And, as a practicing Neurosurgeon, skier and father of an avid skier, the frequency of closed head injuries in this community during the winter sports season concerns me deeply.
Closed head injuries (injuries in which the skull remains intact, e.g. concussion) are broadly caused by two sets of circumstances. The first is a direct blow to the head that injures the brain at either the impact site or on the opposite side, as the brain is buoyant in the skull and can move in the direction of impact due to excessive force. The second common cause is rotational trauma. Imagine a spinning top. If the skull rotates too quickly, the force of rotation can cause shearing of neurons (connecting cables) from their cell bodies causing bleeding, among other issues. This type of injury can be devastating to the brain, regardless of a relatively normal-appearing Computer Axil Tomography (CAT) scan or Magnetic Resonance (MRI) image.
Renown Regional Medical Center is the only Level II trauma program in northern Nevada and, due to its location, treats more ski and snowboard-related injuries than any other trauma facility in the world. Resorts depending upon Renown’s trauma services include Mammoth Mountain, Heavenly, Kirkwood, Squaw Valley, Alpine Meadows, Mount Rose and more.
The doctors and nurses at Renown, including myself, care for injuries varying from simple, non-displaced skull fractures, to depressed skull fractures, bleeding on the brain both above and below its wrapper (the dura), and contusions, or bruising of the brain. All of these injuries (less the depressed skull fracture) frequently require surgical intervention in the form of a craniotomy to help restore neurologic function or save the patient’s life.
Fortunately, mild forms of closed head injuries are more common than moderate to severe injury. A patient may present to an ER with a “normal” Glasgow Coma Scale (GCS) rating of 15 but have significant impairment. Many skiers or snowboarders who present to the emergency department, dazed and confused, do not end up being evaluated by a neurosurgeon because a CAT scan of the brain may be normal. However, some of these patients may later be seen by their primary care physician, nurse practitioner or neurologist. Commonly called a concussion, these mild forms of closed head injury can cause lingering and significant problems in the short- to long-term.
Typical signs of concussion include prolonged headache, nausea and vomiting, lack of attention, lethargy, photophobia (sensitivity to light), poor short-term memory, or changes in work or school performance (a B student becoming a C student). Despite the heightened awareness of mild to moderate closed head injury, unfortunately, we in the neuroscience community have little to offer regarding treatment once the concussion has occurred. Since there is no surgical treatment for concussion and there are limited medications available to mitigate a concussion’s cognitive and physical effects, the remedy for this situation clearly is prevention rather than treatment.
The case for helmets
There is nothing more saddening than taking care of an injured person with a closed head injury that could easily have been prevented. I have treated patients from age 4 to age 85 with ski and snowboard-related closed head injuries. And while no concrete proof has been cited that wearing a helmet while skiing or snowboarding changes outcome from injury, I hope that it would be obvious that wearing a helmet is of benefit.
I cared for a 19-year-old snowboarder who hit a tree so hard that his helmet split in two. The helmet was new and of good quality. He did sustain moderate closed head injury, but he ultimately returned to full function. Given the force required to split a helmet into two pieces, I would have to assume that without a helmet, the injury would have been fatal.
In order for a helmet to be effective, it must meet minimum industry standards and fit properly. There is no one-size-fits-all ski or snowboard helmet. Helmets should be fitted by a qualified individual. The Nevada Interscholastic Activities Association (NIAA) requires that all participants in high school skiing competition not only wear a helmet, but wear a helmet that covers the ears, and the United States Ski Association (USSA) has also published guidelines regarding closed head injuries and will undoubtedly revise them in the future.
Resuming activity after concussion
A common question asked by my patients, their parents and referring physicians concerns return-to-play criteria. Nevada high school football programs are required by NIAA rules to provide neurocognitive testing to each student athlete prior to play. That test becomes the baseline for further evaluation should the student have a concussion. The results of the before- and after-injury testing may prevent that student from returning to play. Unfortunately, most recreational skiers and snowboarders don’t have baseline cognitive evaluations on file; therefore, a post-injury evaluation lacks important pre-injury test results. Following concussion, a patient must, at a minimum: be headache free, have completely normal daily activities, show no recurring short-term memory deficits, and have returned to 100% of their work/school/cognitive performance before resuming contact sports.
The physicians, physician assistants, nurse practitioners and staff at Sierra Neurosurgery Group are deeply committed to community education and awareness regarding the seriousness of closed head injuries in skiing and snowboarding. This concern is directed at both youth and adults. As part of this effort, we donate
helmets to the community through ThinkFirst of Northern Nevada activities, in hopes of preventing many potential injuries each winter.
As a person who sees the effects of these injuries on patients regularly, I ask you to please wear a helmet when you’re on the mountain. I don’t want to meet you in the trauma unit.
Dr. Leppla is a board certified neurosurgeon, fellowship trained in spinal surgery, a partner in Sierra Neurosurgery Group, which is the largest private practice neurosurgery group in the western states, he is the chairman of the Department of Neurosurgery at Saint Mary’s Regional Medical Center and is an active member of the Renown neurotrauma program. He and his daughter are active skiers and always wear a helmet.