RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in

Éirinn

Title Head Injury & spinal injury

Class SC1

Course Neurosurgery
 Mr Nek Mazarakis
MSc,DPhil, FEBNS, FRCSEd (SN)
Clinical Lecturer RCSI
Neurosurgeon
LEARNING OBJECTIVES

• List the types of primary and secondary head injuries

• initial assessment and management of HI
• common types of diagnosis with HI and treatment
• prevention of secondary HI
• management options for HI and complications that may
arise post HI
HEAD INJURY – MCQS FROM THIS
SECTION
 HEAD TRAUMA

• 449,000 UK Emergency Department attendances per year

• Trauma is the leading cause of death under the age of 45 and up to

50% of these are due to a head injury

• High morbidity & mortality:

– 50% of inpatient adults have morbidity from HI

Accident and Emergency Statistics – Parliament (2015); Early management of patients with a head injury (NHS; 2009)
PRIMARY HEAD INJURY
(DAMAGE AT TIME OF INJURY)

PERFORATING AND
SCALP SKULL PENETRATING FOCAL DIFFUSE

BLOOD LOSS LINEAR

EDH CONCUSSION
FRACTURES
INTRA CEREBRAL ACUTE SDH
SCALP HAEMORRHAGE
LACERATION BASILAR CHRONIC SDH DIFFUSE
FRACTURES ICH AXONAL
VASCULAR INJURY INJURY
FOREIGN CONTUSION
BODY
LACERATION
DEPRESSED
SAH
PORTAL OF FRACTURES
INFECTION IVH
HYPOTHALAMIC
& PITUITARY
BRAINSTEM
CRANIAL NERVES
 SECONDARY HEAD INJURY
(AFTER INITIAL INJURY)

SYSTEMIC INTRACRANIAL

• HYPOXIA • BRAIN SWELLING

• HYPOTENSION • BRAIN SHIFT & HERNIATION
• HYPERCAPNIA • RAISED ICP
• HYPERTHERMIA • POST - TRAUMATIC FITS
• HYPER GLYCEMIA • INTRACRANIAL INFECTION
• HYPOGLYCEMIA

Prevention of secondary brain injury can prevent death and disability

 INITIAL ASSESSMENT AND MANAGEMENT

• Primary survey and Resuscitation • If GCS ≤ 8  Intubate

– A irway AND C-spine control

– Secondary survey (Head-

– B reathing and ventilation
to-toe)

– C irculation & haemorrhage control

– Revaluation

– D isability (Neurological evaluation-GCS)

– Definitive care

– E xposure / Environmental control

THE GLASGOW COMA SCORE

GCS

Score 3-15

• Verbal Response • Motor Response

• Eye Opening • Obeys commands 6
• Orientated 5
• Spontaneous 4 • Localizes pain 5
• Confused 4
• To voice 3 • Withdraw from pain 4
• Inappropriate words 3 •
• To pain 2 Flexes to pain 3
• Incomprehensible 2 • Extends to pain 2
• None 1
• None 1 • None 1

Know this for the exam

 EXTRADURAL HAEMATOMA
• Usually Blunt Trauma
• Often associated with linear
fracture:

• Usually temporal (70-80%)

• Tear of middle meningeal

artery

• Biconvex due to
attachment of dura to skull
sutures

• Lucid interval
• Treatment
• Requires emergency craniotomy
ACUTE SUBDURAL HAEMATOMA

• Venous tear / Brain laceration

• Covers entire cerebral surface
• Crescent shaped
• Associated Parenchymal Injury
• Morbidity / mortality due to
underlying brain injury
• Mortality 30 - 90 %
• Treatment
• Requires early elective craniotomy
CHRONIC SUBDURAL HAEMATOMA

• Elderly And Infants

• 50 % Present With Raised
ICP

Treatment
• Early burr hole drainage in the
presence of raised ICP or
lateralising signs
INTRACEREBRAL HAEMATOMA

• 15 % of fatal head injuries

Associated with:
• Contusions,
• Diffuse axonal injury
• Subdural Haematoma

Treatment
• Evacuation of haematoma in
the presence of raised ICP or
marked midline shift
POST TRAUMATIC SUBARACHNOID

• Associated With 39%

mortality
• Causes severe post
traumatic headache
• May be associated with
underlying brain injury
and cause major
morbidity
• DO NOT CONFUSE
WITH ANEYRYSMAL
SAH
MANAGEMENT

CONSERVATIVE SURGICAL

OBSERVATION
VENTRICULAR DRAIN
VENTILATION

FLUIDS BURR HOLES

MANNITOL
CRANIOTOMY
STEROIDS

ICP MONITORING ELEVATION SKULL

FRACTURE
MAINTAIN CPP
SPINAL CORD INJURIES: AN OVERVIEW

Not as high yield

BASIC ANATOMY

• 33 bony vertebra
– 7 cervical
– 12 thoracic
– 5 lumbar
– 5 sacral (fused)
– 4 coccygeal (fused)
GMT/LGI/02
 Definition of spinal stability
Panjabi & White: the ability of the spine under physiologic loads to limit patterns of
displacement so as not to damage or irritate the spinal cord and nerve roots and, in
addition, so as to prevent incapacitating deformity or pain due to structural changes

In other words: instability refers to excessive displacement of the spine that would

result in neurologic deficit, deformity, or pain
SPINAL CORD INJURY: DEMOGRAPHICS

#1 : Male teenagers and young adults

Relative increase in 60-70 y/o
RTA (44.5%)
Falls (18.1%)
Violence (16.6%)

Summa 1999
SPINAL CORD INJURY: DEMOGRAPHICS

Cervical 50-64%
Thoracic 17-19%
Lumbar (cauda equine)
20-24%
EPIDEMIOLOGY

• ~ 40 % of all spinal trauma is found in the polytrauma patient

• 2-3 % of all polytrauma victims have associated cervical spine injuries

PATHOPHYSIOLOGY OF SCI

• Primary mechanical insult

Rapid compression due to bone displacement

from burst or dislocation
Distraction ***
Shear ***
Penetration

• Primary injury leads to cascade of secondary injury mechanisms

INTERVENTIONS TO MINIMIZE
SECONDARY RESPONSES

• Aggressive field resuscitation

Maintain systemic BP
Maintain optimal oxygenation

• Steroids (NASCIS – no evidence of benefit)

• Surgical decompression? Timing ?

SPINAL CORD INJURIES
TERMINOLOGY

• Neurological level = most caudal segment with normal

sensorimotor exam

• Complete SCI = absence of sensorimotor function below

neurological level

• Incomplete SCI = partial preservation of sensory and/or motor

below the defined neurological level
PATTERNS OF SCI

• Complete
– Cervical tetraplegia
– Thoracic and lumbar paraplegia

• Incomplete syndromes – high yield for MCQ

– Anterior cord
– Central cord
– Brown-Sequard
– Posterior cord
– Conus medullaris
SPINAL CORD INJURIES
TERMINOLOGY

• Neurogenic shock = immediate loss of sympathetic tone after SCI.

Loss of vasomotor and cardiac innervation.

Clinically:hypotension w/out tachycardic response

Fluid resus.: may need vasopressor

•  Spinal shock = transient period of areflexia. While in shock, unable to

predict  likelihood of recovery.
    Usually lasts for 48h (but can last for weeks...)
C1 - 4 TETRAPARESIS

• Absent limb function

• Ventilator dependence
C5 - 8 TETRAPLEGIA

• C5 deltoids, biceps
• C6 biceps
• C7 wrist extension,
triceps
4
• C8 functional grasp
5
• T1 intrinsic hand
muscles
THORACIC PARAPLEGIA

• Better respiratory and trunk

control with injury at more caudal
levels

• Thoracolumbar most common

12
L1

L1

T12
LUMBAR PARAPLEGIA

• L2 hip flexion
• L3/4 knee extension
• L4 foot dorsiflexion
L2
• L5 EHL
• S1 gastroc.soleus
(plantarflexion)

L2
SPINAL CORD ANATOMY REMINDER
INCOMPLETE SCI
CAUDA EQUINA SYNDROME

• Lower motor
neuron lesion (not
cord)
• Sacral segments
more affected than
lumbar
• Saddle anesthesia
with incontinence
INITIAL EVALUATION

• ATLS guidelines (collar /blocks)

• Examine for head, neck, or back trauma –need to logroll – to keep

spine straight when checking back

• Paradoxical diaphragmatic breathing

• Priapism

• Neurogenic shock: hypotension and bradycardia

– Loss of sympathetic tone – can’t get HR up to
compensate for loss of BP
ASIA WORKSHEET
SPINAL SHOCK

• Temporary loss of all or most spinal reflex activity below level of

injury
• Lasts around from 24h to weeks.
• Ends when bulbocavernosus reflex and/or anal wink returns
• An injury cannot be considered complete until resolution of spinal
shock
RADIOLOGICAL EVALUATION
 SUMMARY

• Always assume that spinal injury is present until

you prove it isn’t
• You need a very high index of suspicion that
spinal trauma may be present (we still miss them
in the severe polytrauma)
• Assessment is easy – you don’t need to be a
neurologist
• Accurate charting and frequent assessment
makes the assessment of prognosis easier

GMT/LGI/02
LET’S SEE SOME CASES!
Thank you for listening!