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Case of Fatal Head Trauma Experienced During Japanese Judo

2014; Lippincott Williams & Wilkins; Volume: 13; Issue: 1 Linguagem: Inglês

10.1249/jsr.0000000000000024

1537-8918

Saori Nambu, Masato Noji,

Traumatic Ocular and Foreign Body Injuries

Introduction A total of 118 fatal accidents have occurred during Judo practice and/or tournaments in Japanese schools over the last 29 years (from 1983 to 2011; academic year), and cases of severe after-effects such as a persistent vegetative state or paralysis far exceed the number of fatal cases (24). The most common cause of death was head injury resulting from the inherent manner of judo, i.e., throwing. Case Report On June 15, 2011, a 16-year-old boy was brought to the emergency department of the university hospital in an unconscious state. The boy was a member of his high school judo club and a beginner in the judo practice of randori (free practice). A month and a half prior to admission, at the beginning of May and shortly after he joined the judo club, the boy had hit his head on the tatami during practice and was experiencing headaches for 3 wk after the incident. He underwent computed tomography (CT) examination in a general hospital on May 21, but there was no indication of abnormalities (Fig. 1). Subsequently the attending emergency physician recommended rest and consultation with a neurosurgeon; he also prescribed admission to the emergency room in the event of disturbance in consciousness or vomiting. The boy continued to experience severe headaches and consulted a neurosurgeon on March 26; however he did not receive any other imaging tests because his condition had improved slightly and no abnormality was found in the previous CT images. He did not participate in judo club activities for the 2-wk period during which his school examinations were held after the consultation with the neurosurgeon, thus experiencing a gradual relief from his headaches. However he hit his right parietal region on the tatami when the club activity resumed on June 8. He was once again troubled by headaches and was reexamined by the same neurosurgeon on June 14 (third consultation). Because there were no findings of concussive symptoms, only a painkiller was prescribed and no particular instruction to refrain from judo practice was given. In addition, the judo coach did not capture the facts about his condition and medical history. On the day of admission, the boy's partner, an older club member who was larger (20 cm taller and 25 kg heavier) than him, threw him in ouchigari and knocked the back of his head against the tatami (judo mat). Three minutes later, the boy collapsed onto the tatami in an unconscious state, and his coach immediately called for an ambulance. On examination, the boy was 160 cm in height and 48 kg in weight. His pupils were dilated and vital signs were as follows: Glasgow Coma Scale score, E1V1M2; respiratory rate, 30 respirations per minute; heart rate, 67 beats·min−1; and blood pressure, 175/60 mm Hg. CT revealed an acute subdural hematoma (ASDH) overlying the right parietal to the right temporal region, with a massive shift to the left and swelling in the whole brain (Fig. 2). Emergent craniotomy was performed and the hematoma was evacuated. The source of bleeding was confirmed to be the point at which the bridging veins joined the superior sagittal sinus. Even after surgery, however, the boy remained unconscious and did not recover spontaneous breathing. Although he had received therapeutic hypothermia, brain swelling persisted and cerebral herniation ensued. He died 38 d after the incident.FIGURE 1: CT image 1 h after the catastrophic event. The figure shows SDH in the right parietal lobe (arrow heads) involving significant midline shift (arrows).FIGURE 2: CT image of the patient. (A) After previous head impact, 25 d before the catastrophic accident. The figure shows no abnormality in the right parietal lobe. (B) On the day of the catastrophic accident.Discussion Mechanism of ASDH in Judo Players Over the past several decades, many civil trials on judo accidents have been held in Japan. In these trials, the cases of traumatic head injury typified by ASDH all were attributed to the impact of the victim's head against the tatami or floor. Whether the victims impacted their head directly or not is directly linked to negligence of the obligation to ensure safety by the accused, and the issue frequently becomes a major point of dispute in the court. If there are no external signs on the victim's head, it is assumed that the victim was able to perform ukemi (breaking the fall) appropriately or that the beginners' heads were protected by safe gripping of their lapels at the chest and/or sleeve by their opponents. In such cases, most opponents strongly insist that the cause of the victim's ASDH was not attributed to throwing but to other causes such as the victim's vulnerability, including hydrocephalus or malformation of vessels. In fact, in a civil case wherein a 16-year-old male student of a technical junior college developed ASDH immediately after being thrown by his coach and eventually entered a persistent vegetative state, the victim lost his suit because no evidence of bruises on the surface of his head could be provided soon after the incident (20). Similar injuries attributed to throwing, with no signs of external injuries, occur repeatedly among judo players. Judo is a contact sport that is played on a soft surface (tatami) meant to absorb shocks; therefore it is no wonder that no symptoms are found on the surface of the victim's head, even after he or she has hit his head against the surface of the tatami (15). Recently, however, another theory regarding the mechanism of ASDH, which proposes that acceleration/deceleration forces caused by a combination of both throwing and hikite (pulling one's hand on the opponent's sleeve and controlling the opponent's fall) are involved in head trauma, has begun to be accepted in civil court (16,34). Nevertheless, in the present patient, no signs of external injury were found on the surface of the victim's head, although it was clear that the victim had been thrown by osoto gari (large outer reap) by his opponent, who exceeded the victim in physical build and skill of judo and had struck the back of his head as a consequence of his failure in performing ukemi. Osoto gari is a technique during which the tori (the person who throws) pushes his or her hands and body to the right rear corner of the uke (the person being thrown) and relentlessly drives into the uke using a sweep out of the supporting leg, causing the uke to fall backward. In other words, osoto gari is a throwing move associated with a much higher risk of head injury because the uke can easily hit his or her occipital region. Because judo includes many throwing techniques that make the opponent fall down and backward, it is said that the key essentials to prevent head injury are through toning up of the neck muscles and mastering the skill of ukemi (a skill of self-defense) by the player (2). Concussion and Return-to-Play Before the incident, our patient had struck his head several times by failing to perform ukemi; however there were no abnormalities detected by head CT. On the day preceding the fatal incident, the neurosurgeon did not perform magnetic resonance imaging (MRI) even though the boy complained of continuous headache. Instead he merely excluded the possibility of concussive injury and did not prohibit him from participating in any judo activity. Voller et al. (31) showed that MRI investigation is a very sensitive tool to identify traumatic brain lesions in patients who experience mild traumatic brain injury (MTBI) such as concussion. In the case of concussion, however, MRI investigation is not always the first option (23), and whether or not the patient should undergo MRI after CT is left to the discretion of the attending physician. Gonzalez and Walker (6) emphasized that a normal MRI does not exclude the presence of MTBI. In Japan, attending physicians do not strictly prohibit the patient from returning to play unless the patient shows distinct neurological abnormalities, and the decision of whether or not the victim should return to the sport often is based on the assessment of his or her condition by the sports coach and/or self-assessment. In the United States, at least 14 return-to-play scales had been issued by 1973 (5). Because the signs or symptoms of concussion vary widely, every postconcussive superficial deterioration in athletes is considered to be a sign of disruption of neurological function. Therefore coaches and instructors are required to be careful when treating players who have endured serious impacts to the head and show some symptoms (8,13). In Japan, however, most sports coaches, even physicians, have only a superficial understanding of the severity of concussion. In addition, it should be stated that the crisis management system for children's health and safety is inadequate (22). Although several articles on concussion have been published since 1986, most of them focused on changes in interneuronal systems caused by concussion (11,32) or on first-aid treatment for this condition (21). Some articles published since 2000 have sounded the alarm on repeated concussions (12,28) or a connection between concussion and judo in the field of sports medicine (17); however this knowledge neither has become popular among general physicians nor has it promoted a public understanding of the risk of concussion. Therefore concussion to date has been regarded by most sports coaches (with the exception of those working in rugby, American football, football, and boxing) and general physicians as just one of the trivial head traumas that carry a good prognosis. For example, the Japan Rugby Football Union (JRFU) translated the International Rugby Board Concussion Guidelines and related materials into Japanese and posted the translation on the JRFU official web site in September 2011; these guidelines help players under the age of 19 years who have experienced concussion to accomplish a gradual return to the sport (9). Similar warnings regarding the other contact sports mentioned previously have been issued since relatively early days. With regard to judo, despite the occurrence of numerous fatal incidents, there is no general guideline for returning to practice and/or competition. In junior and senior high school judo club activities, fatal ASDH cases have occurred repeatedly in recent years because the players returned to practice on the day after an accident, even though they had been diagnosed with cerebral concussion and/or were aware of clear symptoms such as headache. The present patient complained of headaches after a head impact as well as temporary symptoms such as numbness in the right hand, nausea, and discomfort in the head. However the victim thought lightly of his own subjective symptoms and was advised by his attending doctor that rest during the examination period in school was sufficient; therefore he was given no particular advice about refraining from judo practice. In the Japanese medical society, to profess to being an official sports doctor, a physician must be accredited by one or more societies such as the Japanese Orthopaedic Association, the Japan Medical Association (JMA), and the Japan Sports Association (JSA). For the accreditation, postulating official sports doctors are required to attend many special lectures and pass the examinations in each of the bodies involved. Within the recognition system for official sports doctors in the JMA and JSA, applicants must attend more than 50 required lectures. However most of the lectures deal with the subjects of exercise physiology, orthopedic surgery, and physical therapy, with only one (90 min) lecture addressing the subject of head trauma. Official sports doctors are primarily responsible for monitoring the physical health of professional or semiprofessional athletes and/or acting as the commission doctor in national or international games. The number of doctors who are experts at sports injury is not sufficient to cover the many students that are injured in school sports activities. In addition, serious discrepancies have been reported in the number of sports doctors among different regions (33). The physicians who examine patients who have experienced concussion during judo practice should take special notice of the risk of subsequent serious head injury and provide cautious opinions about returning to the sports activity in question. Concomitantly an appropriate follow-up observation of the patient and a gradual return to judo practices, about which the coaches, students, and their guardians are aware, are required urgently. Second Impact Syndrome In the case presented here, the report prepared by the accident investigation commission pointed out that the boy had experienced ASDH corresponding to the second impact syndrome (SIS), i.e., the reception of an impact by the brain that has experienced previous damage. SIS greatly increases the risk of catastrophic brain damage. Although the pathophysiology of SIS is controversial, it generally is believed to be caused by a loss of autoregulation of the cerebrovasculature (3,4,26). Our patient had experienced uncontrollable acute brain swelling just after the incident, which was consistent with SIS (4); however the possibility that he may have experienced a small subdural hematoma at some stage of bruising before the impact cannot be excluded because he had been experiencing long-lasting headaches (19,25). Tsuduki et al. (30) reported a judo accident that had occurred in 2002 and was similar to the one reported here. A 16-year-old girl who struck her head in judo practice complained of sustained headaches and developed ASDH because of a second impact to her head after being thrown by a female judo instructor. In the civil case filed by the parents of the girl, who had entered a vegetative state, the judge mentioned that her head injury had resulted from SIS on the basis of her surgeon's opinion, and the parents won the suit (10). The court found that her bridging vein had been stretched (perhaps they meant vascular engorgement) by a prior impact, resulting in profuse bleeding after the second impact (10). Although SIS may not always occur with intracranial hemorrhage, several cases in which the athletes received a second injury while still clinically symptomatic from the first have been reported; these athletes developed acute hemispheric swelling in association with SDH (19,27). As mentioned above, cerebral concussion has been assumed to be a trivial injury associated with Japanese judo until recently; therefore little attention is paid to head bruises without loss of consciousness. The athletes return immediately to judo practice even if they are aware of their own headaches and/or lethargy. In 2013, a court ruling went against a 16-year-old male high school student who developed ASDH on being thrown after having concussion during the previous day's practice in his school judo club and entered a vegetative state (14,35). The court found that the coach, who had failed to notice the student after his concussive injury, could not have predicted the outcome of ASDH because the knowledge regarding cerebral concussion had been unpublicized. The judgment was based on the fact that the risk of head injury had been neglected among Japanese judo players and coaches at the time of the accident (2008). Regardless of the fact that similar injuries had been occurring repeatedly in schools over the past years, this information was never transmitted among judo coaches. Such a flawed crisis management system in the judo society and education board has produced repeatedly the same outcome in Japan. In our case, a detailed report of the accident was issued by the accident investigation commission (third-party organ), and the parents of the victim acknowledged the case as an accident and did not file any lawsuits. However it can be said that the present patient experienced the worst possible outcome, similar to the others, because of undervaluation of the magnitude and severity of his headaches by his attending physicians and coach. His death could have been prevented if the physicians, coaches, and parents had been aware about the risk of concussion and its nature. Conclusions The large number of tragic accidents resulting in traumatic brain injury among children and adolescents involved in the sport of Japanese judo, which is an unparalleled sport worldwide, results primarily from ignorance about the risk of head injury. As in the female judoka abuse case (1,29), practicing in the society of Japanese judo is old-fashioned and the value of guts and sweat overrides trainings with scientific rationality (18). Gronwall and Wrighton (7) published warnings in 1975; doctors have a duty to convince controlling bodies and participants of sports frequently associated with concussion that the effects are cumulative and that the acceptance of concussion injury, though gallant, may be very dangerous. In our case, the patient underwent physical and CT examinations, but those concerned did not have access to the correct medical information and underestimated the fact that the boy had exhibited postconcussive symptoms. The All Japan Judo Federation revised their prior teaching guideline and issued The Safety Instruction of Judo (3rd edition) in 2011 (2). The new guideline explicitly states that adequate care and attention to concussion are necessary because it relates to ASDH. Moreover the guideline states that players who show symptoms of concussion should be examined by a neurosurgical expert and undergo CT or MRI and that the coach should take the diagnosis into account to judge whether the player can return to the sports activity. In the future society of Japanese judo, coaches and instructors have to exercise improved, adequate, and safe practices. In addition, coaches, physicians, teachers, parents, and students should have correct knowledge regarding head injury, especially concussion. Finally, with regard to not only judo but also other activities, it is imperative to collect information of similar head injury cases and establish common head injury guidelines in schools.