Letters to the Editor

Simple Dimple Rule for Sacral Dimples

to the editor: We would like to thank Drs. Fuloria and Kreiter for their review of the newborn examination in American Family Physician.¹ The article was thorough and provided a problem-based approach to the newborn examination. However, we have concerns regarding the last statement of the article: "Dimples should never be probed and should be evaluated with magnetic resonance imaging before neurosurgical intervention."¹ This recommendation could be misinterpreted as stating that all sacral dimples require magnetic resonance imaging (MRI) and neurosurgical consultation.

In the reference cited in this sentence, Drolet states: "Most infants with sacral dimples that fall within the gluteal crease are healthy."² Drolet suggests that only high-risk dimples should undergo evaluation with radiologic imaging. "High-risk" dimples are defined as those that are (1) deep; (2) larger than 0.5 cm; (3) located within the superior portion of the gluteal crease or above (greater than 2.5 cm from the anal verge); or (4) associated with other cutaneous markers.²

Results of a study by Kriss and Desai³ showed that the incidence of cutaneous stigmas in a healthy neonate population was 4.8 percent. This study³ also evaluated 207 neonates with cutaneous stigmas and found that none of the infants with a simple midline dimple (meeting none of the three criteria listed above) had spinal dysraphism. Eight of the 20 (40 percent) atypical dimples (one of the criteria was met) were positive for sacral dysraphism.³

The data in this prospective study reveal that simple midline dimples are the most common dorsal cutaneous stigmata in neonates and pose an extremely low risk for sacral dysraphism. When none of the criteria are met, the negative predictive value for a simple dimple in this study was 100 percent. The cost of screening these dimples or clefts with MRI and neurosurgical consultation would be excessive and unnecessary.

Therefore, we agree with Drolet² and Kriss³ that only atypical dimples associated with a high risk of dysraphism need evaluation with MRI and neurosurgical consultation.

JAMES C. HIGGINS, D.O.
FRANK AXELSEN, M.D.
Jacksonville Naval Hospital
2080 Child St.
Jacksonville, FL 32214

REFERENCES

1. Fuloria M, Kreiter S. The newborn examination: part II. Emergencies and common abnormalities involving the abdomen, pelvis, extremities, genitalia, and spine. Am Fam Physician 2002;65:265-70.
2. Drolet BA. Cutaneous signs of neural tube dysraphism. Pediatr Clin North Am 2000;47:813-23.
3. Kriss VM, Desai NS. Occult spinal dysraphism in neonates: assessment of high-risk cutaneous stigmata on sonography. AJR Am J Roentgenol 1998; 171:1687-92.

Management Guidelines for Sport-Related Concussions

to the editor: I enjoyed reading Dr. Kushner's comprehensive review of sports-related concussions in American Family Physician.¹ As mentioned in the article, the risks of cumulative neurologic injury and fatal cerebral edema following repeated concussions have led to the promulgation of at least 14 management guidelines since 1973 to reduce these risks.² Several points regarding the validity and utility of the current guidelines deserve mention.

The published guidelines rely heavily on expert opinion and anecdotal case reports. Therefore, the guidelines differ in the criteria used to define mild, moderate, and severe degrees (or grades) of concussion. For example, as illustrated in Tables 1 and 2 of the article,¹ the guidelines of the Colorado Medical Society and the American Academy of Neurology (AAN) emphasize loss of consciousness more than any other sign or symptom of concussion in determining the severity of injury. These two guidelines assume that loss of consciousness (even for a period of seconds) portends a worse prognosis than a prolonged period of posttraumatic amnesia. In contrast, the guidelines presented in those tables¹ by Dr. Cantu³ consider prolonged posttraumatic amnesia (more than 30 minutes) as significant as brief loss of consciousness (less than five minutes) in determining the severity of a concussion. Currently, no compelling clinical data favor any single symptom or sign as a better predictor of severity of injury.⁴

All concussion guidelines agree that an athlete should not return to play if still symptomatic from a previous concussion. Returning an athlete prematurely to sport presumably exposes the athlete to the threat of second-impact syndrome and cumulative brain injury. However, the guidelines differ in their recommendations for returning players to competition once they are asymptomatic. For example, under the Colorado guidelines, an athlete who is completely asymptomatic following several seconds of loss of consciousness would immediately be transported to the hospital and kept from play until asymptomatic for two weeks (grade 3 concussion). Under the AAN guidelines, this same athlete may return to play after being asymptomatic for one week (grade 3, brief loss of consciousness). The Cantu³ guidelines return this athlete to play after two weeks, if asymptomatic for one week (grade 2 concussion).

Questions remain regarding the universal applicability of the current concussion management guidelines. In the published cases of the second-impact syndrome, all victims have been adolescents.⁵ This implies some age-related differences in vulnerability and response to brain injury. Nor do the return-to-play guidelines consider the different inherent risks of further head trauma among sports.

Concussion management guidelines have undoubtedly increased awareness of the signs, symptoms, and potential sequelae of concussion; however, more definitive, evidence-based information is needed to validate current recommendations. Newer diagnostic tools, such as neuropsychologic testing, may offer more sensitive means of determining the presence and severity of cerebral concussion.⁶ Ideally, optimum management of the head-injured athlete will occur through a synthesis of scientifically based guidelines and the physician's clinical judgment.

NICHOLAS J. SOLOMOS, M.D.
Kelsey-Seybold Clinic Family Medicine Residency Program
Baylor College of Medicine
Department of Family and Community Medicine
2727 W. Holcombe
Houston, TX 77025

REFERENCES

1. Kushner DS. Concussion in sports: minimizing the risk for complications. Am Fam Physician 2001;64: 1007-14.
2. Collins MW, Lovell MR, Mckeag DB. Current issues in managing sports-related concussion. JAMA 1999;282:2283-5.
3. Cantu RC. Guidelines for return to contact sports after a cerebral concussion. Physician Sports Med 1986;14:75-6, 79, 83.
4. McCrory P, Johnston KM, Mohtadi NG, Meeuwisse W. Evidence-based review of sport-related concussion: basic science. Clin J Sport Med 2001;11:160-5.
5. Cantu RC. Second-impact syndrome. Clin Sports Med 1998;17:37-44.
6. Grindel SH, Lovell MR, Collins MW. The assessment of sport-related concussion: the evidence behind neuropsychological testing and management. Clin J Sport Med 2001;11:134-43.

Corrections

The article "Charcot Foot: The Diagnostic Dilemma" (November 1, 2001, page 1591) contained an error in Figure 6, an algorithm showing how to distinguish Charcot foot from osteomyelitis, on page 1595. The two final decision points at the bottom of the algorithm were inadvertently reversed: "Negative for osteomyelitis" should have been placed on the right side of the figure, and "Consistent with osteomyelitis" should have been placed on the left side of the figure. The corrected figure is available at: www.aafp.org/afp/20011101/1591.html.  

The article "Treatment of Hypothyroidism" (November 15, 2001, page 1717) contained two errors in the dosage of levothyroxine. On page 1720, in the first sentence of the right-hand column, the dosage of levothyroxine should have been given as 0.075 mg per day. In Figure 1, in the first decision point on the right-hand side of the algorithm, the dosage of levothyroxine should have been 0.075 mg per day.

Information in the article "Preventive Strategies in Chronic Liver Disease" (November 1, 2001, page 1555) regarding seroconversion rates in hepatitis immunization was misleading. The first full paragraph in the left column on page 1557 should have been worded this way: "In patients without chronic liver disease, seroconversion occurs in 94 percent of patients following hepatitis A vaccination and 100 percent of patients following hepatitis B vaccination. Vaccination of adults with chronic liver disease of viral or nonviral etiology produced seroprotection rates similar to those observed in healthy adults.²² However, seroconversion rates are lower in patients older than 40 years, in those with end-stage renal disease, alcoholism, and decompensated cirrhosis, and in those with a liver transplant.⁷"