Do I really need to see the pediatric neurosurgeon?
April 18, 2013 12:31 PM   Subscribe

YANMD, but perhaps you're more free to speak honestly than my doctor. My baby had a simple skull fracture. We have a regular checkup scheduled for a month after the incident, but the pediatric neurosugeon wants to see the baby at around the same time. Would that really offer any additional information?

Details: Following head trauma, a CT scan showed that my baby had a simple skull fracture (linear, no depression) but no intercranial injury. The ER told us to have a 3-day followup with the regular pediatrician, and then come back in a month for a follow-up with a pediatric neurosurgeon. From my internet research, the 1-month seems to be to screen for a leptomeningeal cyst.

The 3-day followup was fine, and the primary-care ped said that because we already had a checkup scheduled for about a month after the accident, a separate appointment with neurosurgeon shouldn't be necessary. But when she asked, they wouldn't let her cancel it. She seemed unconvinced of the usefulness of the additional appointment, but said that "Well, if they want to see the baby, you should let them see the baby." We will ask again at the checkup, but I think the primary care doctor isn't in a position to give her honest opinion. Any informed opinions?
posted by Mr.Know-it-some to Health & Fitness (19 answers total) 1 user marked this as a favorite
 
Wait a minute, your baby had a skull fracture and you are trying to justify not going for a follow-up with a neurosurgeon who specifically asked to see the baby again?

What is the downside here? GO SEE THE NEUROSURGEON!
posted by WinnipegDragon at 12:35 PM on April 18, 2013 [62 favorites]


I am not a doctor, so maybe this opinion isn't very well informed, but why WOULDN'T you want to let a neurosurgeon weigh in? It's your kid's brain. If a neurosurgeon thinks you need to come in again, listen to the neurosurgeon, dude.
posted by Countess Sandwich at 12:37 PM on April 18, 2013 [7 favorites]


Wouldn't you regret it if you opted out of doing this, and then something terrible happened to your child that could have been prevented by following up with the neurosurgeon? Go to the appointment.
posted by something something at 12:40 PM on April 18, 2013 [2 favorites]


Your baby had head trauma. Yes, you ought to keep the appointment with the pediatric neurosurgeon. Why? Because the pediatric neurosurgeon is a SPECIALIST, an expert in their specific field, whereas your primary care pediatrician is a GENERALIST, but not necessarily a 100% expert in every field they have knowledge of. What if your primary care pediatrician missed something? This is your child's brain we're talking about here. Why WOULDN'T you want the specialist to take one final glance over?
posted by These Birds of a Feather at 12:42 PM on April 18, 2013 [6 favorites]


Can you clarify what your concern is? Do you think that there is some significant harm that will come from your child visiting the neurosurgeon, and that the primary doc is being prevented from telling you? What harm could that possibly be?
posted by alms at 12:45 PM on April 18, 2013 [1 favorite]


What comes to mind here, apart from "go to the neurosurgeon!" is that they may be trying to protect you from the possibility of something that isn't, shall we say, good news.

Perhaps there's the potential that this fracture could have more severe repercussions that won't be able to be seen for a month (IANAD, but I know swelling and such can obscure some scans) but they don't want you to spend a month panicking about something that may be extremely unlikely. As such, they may be asking you to go to the neurosurgeon to ensure that everything is okay. If everything's not okay, they'll let you know then and you won't have spent a month worrying about this possibility.

They may be treating it the way they would if you have a strange mole and your GP sends you to a dermatologist to get it checked out. Your GP may not say "OMG SKIN CANCER" so you don't worry in the interim, but once you get there, the dermatologist may say "oh hey, that looks funky, let's get it removed and biopsied, okay?"

Again, IANAD, but that seems like the most logical reason for the behaviour, so I would definitely go.
posted by juliebug at 12:50 PM on April 18, 2013


Response by poster: I'm not concerned about specific harm from an additional exam, but a possibility is that one doctor (the one who's actually seen the baby) is giving an expert informed judgment, and the other (a specialist, but one who hasn't seen the baby) is just following a protocol that might not apply in this case. I wanted to know what additional diagnostic information, if any, the additional exam would provide. I'm not going to reject the doctors' advice, but I was hoping to get (medically informed) background information to help with the conversation.
posted by Mr.Know-it-some at 1:00 PM on April 18, 2013


If I were in your position, I'd be fretting about time, energy, money and lack of normalcy, and that would make me not want to go because it will probably be fine. Allow me to give you a gentle smack across the face and say: step up. Then you can be annoyed in retrospect about the time, energy and money, because you will have confirmation that your kid is OK. Anything else is letting fear and avoidance get in the way of being the best parent you can be.
posted by chesty_a_arthur at 1:10 PM on April 18, 2013


Best answer: IANYD (and not a neurosurgeon), but my medically informed opinion would be that you should not try to second guess the neurosurgeon. The protocol for skull fracture is to follow up with the neurosurgeon at one month. That protocol exists for a reason and you shouldn't be wasting time trying to get the internet to give you an excuse not to go to the appointment.

No one on the internet can or should tell you that your child does not need to follow up with the neurosurgeon and I think you are reading too much into your primary care physician's statement - it should be taken at face value, "if they want to see the baby, you should let them see the baby". I am sure that when you are at the neurosurgery appointment, you can ask what sorts of issues on the history and physical exam specifically they are looking for, and what those findings might indicate, if you'd like the details.
posted by treehorn+bunny at 1:11 PM on April 18, 2013 [19 favorites]


I wonder if maybe your pediatrician doesn't quite think it's necessary to go to the neurosurgeon, but figures it's not a bad idea? (Basically what people in the thread are saying, only with a) an MD and b) actual knowledge of your child's case.) Unless you have some reason to distrust her judgement, I can't imagine she would tell you to go to the neurosurgeon if she thought it was going to cause any harm.

My best guess would be that your pediatrician *thought* she was going to be able to do the screen that the neurosurgeon would do, but when she called to cancel it turned out to be something else.
posted by mskyle at 1:12 PM on April 18, 2013


So one question would be, why don't you want to go? Is it that you don't have healthcare and are concerned about the cost? Or are you just confused why you need to go to the neurosurgeon if your pedi intially said you didn't need to? I think in both cases, the best answer would be to call the neurosurgeon's office and speak candidly about the appointment and your pedi's thought that it was unnecessary and see what they say. There is a chance that they are just following protocol, but it may also be that a pedi might see your kid and say they are fine, but that the neurosurgeon's office knows that pediatricians often miss things in these sorts of cases. The neurosurgeron's office should be able to explain it to you, and be way more helpful that we on the internet can be.
If the issue is mostly cost, be candid with the neurosurgeon's office about that too, they may be able to help.

When it comes down to it, if it was my kid, even if it would really hurt financially, I would go.
posted by katers890 at 1:15 PM on April 18, 2013


Actually, this page might be helpful to you as well.

"Adults with simple linear fractures of the vault, without any loss of consciousness at the time of initial presentation and with no other complications, do not require long-term follow-up.

On the other hand, infants with similar fractures with dural tears need to be monitored more closely because of the possibility of the skull fracture expanding."
(this is also referred to as a "growing skull fracture")
posted by treehorn+bunny at 1:16 PM on April 18, 2013 [4 favorites]


You should listen to my cousin Treehorn, she is an Emergency Room doctor.
posted by Ruthless Bunny at 1:17 PM on April 18, 2013 [2 favorites]


There have been at least a couple of fairly recent AskMes that described adults who had a head injury, didn't think it was that serious and were seeing longer term consequences. (Example)

With children, it is even easier to miss symptoms of head injury syndrome. I know someone with a screwed up life who fits the profile of someone with a head injury syndrome (terrible temper, poor impulse control, etc). There is anecdotal evidence of a very early head injury. There was never a diagnosis of a brain injury and there was zero intervention for this person's very real problems. At least for a time, they were a drug addict. I have come to believe this was self management for the temper and impulse control that apparently left this idealistic, sensitive person wracked with guilt.

Please see the neurosurgeon and, if anything, push for more examination, not less. Take any precautions available. One study found that upwards of 90% of people on death row had a history of severe head injury -- so severe you could find evidence of it with an x-ray even if there were zero medical records, so I am not suggesting your child is doomed to wind up a criminal. I am just saying head injuries can really mess up a person's life in ways that make losing a leg or arm look good by comparison (at least to me).

I am also saying if an adult hits their head and thereafter has poor impulse control, it is more likely to be appropriately attributed to the brain injury. If a child does so, it is much, much harder to distinguish poor impulse control in a child from normal childhood social gaffes. Even with adults, the evidence from recent AskMes is that people often underestimate the impact a head injury has had. Head injuries can be very permanently impairing. This is not the kind of thing to blow off or make light of.

Just go to the appointment. Soft tissue injuries can be hard to pin down. By comparison, a broken bone is much easier to clearly see. They probably aren't hiding anything from you. They just need to see what it looks like a month later, like they said they did.
posted by Michele in California at 2:14 PM on April 18, 2013


Best answer: I suspect your concern is that you consider your pediatrician to be the world's foremost medical expert on your child and feel that a random pediatric neurosurgeon who had never seen your child could never have the depth of understanding that your pediatrician does.

But the truth is that your pediatrician has thousands of patients and takes care of front line issues. Pediatric surgery is a highly specialized field, and when dealing with head trauma to a child, you want to have the child examined by someone who has seen thousands upon thousands of these kinds of cases and knows all the subtleties to look for and possibilities to be aware of. Protocol calls for a follow up with a pediatric surgeon because the surgeon has seen thousands and thousands of children for head trauma follow ups.

To a degree, this is not a case where you are supposed to use your own judgment and weigh pros and cons. You're supposed to follow the lead of the medical professionals.
posted by deanc at 7:18 PM on April 18, 2013 [1 favorite]


Neuro deficits can be incredibly subtle. Especially in children. See the specialist.
posted by brevator at 8:50 PM on April 18, 2013


Best answer: I completely get where you're coming from with the question so please don't feel people are piling up on your here or suggesting you're a bad parent.

There is evidence that additional / routine testing, screening, etc., causes some damage in that you may discover other stuff that really was n't causing an issue but this is not one of those situations I believe.

A post-injury protocol for infants is different to routine screening. Basically the generalist doesn't see all the weird, whacky and wonderful variety of presentations that the specialist gets to see, even if s/he never saw your baby before.

That's why this step is really valuable, sheer volume means in a few minutes they can spot if something small is "off" and take any necessary steps to invesitigate or not.

In this case the protocol is very well thought out and I would absolutley get that reassurance.
posted by Wilder at 5:23 AM on April 19, 2013


When one of my sons was 13 months old, he also fractured his skull. Like with your child, there was no bleeding or depression. In fact, the first radiologist who looked at the x-rays missed it (it was Christmas day, so I don't know if a doctor even looked at it that day) but the next day, we got a call back to go back in because the radiologist on duty that day saw something on the x-ray.

He then had a CT scan which confirmed the fracture but no other issues. We were never told to follow up with anyone.

As it happens, a friend of a friend is a pediatric neurologist and he said if there was no bleeding it was no big deal, so I kind of put it out of my mind.

I know this doesn't answer your question, but just wanted to share our experience.

That was four years ago now, and nothing about my son seems off. He's just as smart as his (identical triplet) brothers.
posted by pyjammy at 8:55 AM on April 19, 2013 [1 favorite]


Response by poster: For the record, the results: After speaking with a second primary-care pediatrician at the practice, an aquaintance who is a primary care pediatrician at a different practice, the neurosurgeon, and after further internet research, I still don't know the answer. The primary care pediatricians basically said they had no idea what the neurosurgeon would do that would differ from what they would do, and the neurosurgeon implied that he didn't trust the primary care pediatricians. The exam for all the doctors consisted of carefully and thoroughly touching the skull, but I expected the neurosurgeon to give the entirely understandable explanation that he was a better diagnostician with more experience. Instead he just said, "Well, I don't know what they did."

So although I'm hugely thankful that we received excellent medical care from dedicated doctors, I'm still a bit disappointed about the lack of coordination of care.
posted by Mr.Know-it-some at 12:11 PM on May 6, 2013


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