Can we concuss the lawyers' noggins?

http://www.nejm.org/doi/pdf/10.1056/NEJMcp064645

   A hat tip to Dr. Fuller for an excellent summary article in the New England Journal of Medicine on concussions. While slightly dated at 2007, I have not seen an updated NEJM article on this topic. Please correct me if my search was myopic. For those of you who dislike the NEJM, I do encourage the summary "clinical practice" articles, as they have more a  "real world", non-academic, "in the trenches" utility for practitioners like ourselves.
   The article can speak for itself, but I would offer the following caveats:
- Special focus should be on Table 1, and be sure to read ALL of the footnotes! Note that the New Orleans criteria has higher sensitivity (in other words, you are less likely to miss an important CT abnormality or a lesion needing neurosurgery) than the Canadian CT Head Rule.
-Note that the Canadian rule excluded children under 16, and as such is invalid for pediatrics.
-Remember that these are screening tests, so the sensitivity should be HIGH, but the specificity should be very LOW. As such, note that even when these rules are met and a CT is performed, a significant issue is present only 5% of the time.
-Woe to all who work in the Express Care New Year's Day. Be very aware that the rules do not apply to intoxicated patients, and remember that if the injury occurred while intoxicated your history is very compromised, to put it nicely.
-The article mentions that the old habit of "waking a person up in the middle of the night" to check on lethargy has not been established. However, if one is concerned enough to ask the family to do this, then one should likely consider going on and getting the CT. Reminds one of the old maxim, "if you think a patient may need intubation, then you probably should have intubated 5 minutes ago."
- In the real world, note that the New Orleans criteria says that if someone has a head injury and is over 60, then since one criteria is met (age over 60), that warrants a CT scan. That is a lot of CT scans (and probably a lot of AMA forms), but that is the price of making the lawyers happy with 99% sensitivity.

    Lastly, I think the major reminder here is to be sure to give the patient clear, WRITTEN DISCHARGE INSTRUCTIONS  that explains the major symptoms to watch for and the need for urgent emergency room evaluation via 911 or someone else driving. No clinical imaging rule is 100%. The best combo is a well applied, prudent clinical rule and clear, written discharge instructions.
   Again, the article is a classic, and please comment below, link, or email me if someone has newer criteria.