SPECIALTY SECTION: NEUROLOGICAL SURGERY A Contemporary Neurosurgical Approach to Sport-Related Head Injury: The McGill Concussion Protocol Karen M Johnston, MD, PhD, FRCSC, Maryse Lassonde, PhD, Alain Ptito, PhD Closed head injury in contact sport is a problem of such magnitude that improvements in diagnosis and manage- ment are now urgent. In the USA, as many as 300,000 concussions are identified each year in athletic activity, and certainly this number underestimates the incidence because this injury is underreported. 1 In the past, neurosurgeons have taken a leadership role in the diagnosis, management, and prevention of sport-related concussion. Indeed, in 1941, Walter Dandy, in an attempt to prevent sport-related head in- jury, designed the first protective baseball cap for the Baltimore Orioles and Brooklyn Dodgers. 2 Important recent contributions from notable neurosurgeons form the very basis of current diagnosis and management guidelines. Robert Cantu, with his expertise as both neu- rosurgeon and team doctor, established the widely used Cantu Concussion Grading System and Return to Play Guidelines, 3 and throughout his career has been a highly respected member of the international sport medicine community. Charles Tator remains on the forefront of progress in the evaluation of ice hockey CNS injuries 4 and leads many of the important scientific studies in this field. Neurosurgeons, working with Think First through the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) neurosurgical associations, have taken proactive roles in sport concussion prevention and education. Neurosurgeons are uniquely positioned to provide leadership in the clinical and scientific dimensions of this important field. Lessons learned from investigation and management of the severely brain injured patient allow for insights into neurosurgical anatomy, physiol- ogy, pathology, and rehabilitation. Through collabora- tive efforts with colleagues from neuroradiology, neuropsy- chology, and neuroscience, a broad, yet comprehensive perspective on the continuum of brain injury from mild to severe is achieved. When brought to the sport medicine “arena” to work with our sport medicine colleagues, these insights and skills become valuable resources with which to undertake this highly specialized care. Concussed athletes represent an ideal population for neurosurgeons interested in the study of head injury. Patients are usually 18 to 30 years of age, male, have 1 to 4 years of postsecondary education, and are involved in contact sport. The study participants described in this paper are well matched by virtue of their college status, age, education level, and sport. In an academic setting they can be followed prospectively for 4 years with con- sistent data input from athletic therapists, physiothera- pists, team doctors, and coaches. Neurosurgical academic training in the scientific method provides a sound basis for research studies in this area. The need to provide evidence-based medicine or objective scientific data with which to measure concus- sive injury severity, effects of intervention, or manage- ment is readily identified in this context. The concussion challenge Important longterm neuropsychologic sequelae conse- quent to mild head injury are documented 5,6 and second impact syndrome, although rare, may be fatal. 7,8 Postconcussive symptoms may become persistent and refractory to treatment. 6,9,10 These findings have impor- tant implications with respect to grading of concussion, management, and return-to-play guidelines. 11-21 Three recurrent problems are identified. The first striking problem is that until recently, there has been no objective way to measure the severity of or recovery from this injury. Second, although recent media attention to this injury through profiling of injured elite athletes has No competing interests declared. Dr Johnston was supported by the Franklin H Martin Faculty Research Fel- lowship Award. Received December 8, 2000; Accepted December 13, 2000. From the Department of Neurosurgery, McGill University Health Center and McGill Sport Medicine (Johnston), Department of Psychology and Neuro- psychology, University of Montreal (Lassonde), and Cognitive Neuroscience, McGill University (Ptito), Montreal, Quebec, Canada. Correspondence address: Karen M Johnston, MD, PhD, Director of Neuro- trauma, Department of Neurosurgery, 1650 Cedar Ave, Montreal, Quebec, Canada H3G 1A4. 515 © 2001 by the American College of Surgeons ISSN 1072-7515/01/$21.00 Published by Elsevier Science Inc. PII S1072-7515(01)00797-9