HEAD TRAUMA AND SPINAL CORD INJURY

WHAT CAN WE LEARN

ADIGUNO SURYO W, MD
NEUROSURGERY DIVISION
STAY AT HOME AND STAY SAFE….
ONLINE LECTURE MOVE FORWARD….
HEAD TRAUMA
CASE STUDY
Daily activity which we usually see or do in Indonesia….
CONCUSSION NEED CONFUSION…
LEARN FROM BASIC TO CLINIC…….
ANATOMY
PHYSIOLOGY
CEREBRAL BLOOD FLOW

MONRO-KELLIE DOCTRINE

INTRACRANIAL PRESSURE
 Cerebral Blood
Flow
v Adult brain weight is 1200 - 1400 gr
v High CMRO2 and use glucose as
energy source
v Normal Cerebral Blood Flow (CBF) is
50 mL/100 gr brain tissue every
minute.
Irreversible, if CBF < 10-15 cc/100 g/minute
Reversible, if CBF 15-20 cc/100 g/minute

v Adaptive change in size calibre of

cerebral vessels —> cerebral
autoregulation

CPP = MAP - ICP

 MONRO–KELLIE
DOCTRINE
V (IC) = V (brain) + V(CSF) + V (blood)

§ Cranium rigid and

nonexpansiles boxes.
§ Once the limit of
displacement has been
reach, the ICP rapidly
increases
 INTRACRANIAL
PRESSURE
§ Normal ICP is 10-15 mmHg (adult).

§ The classic clinical presentation of

IC-HTN (regardless of cause) is
CUSHING TRIAD :
§ HYPERTENSION
§ BRADYCARDIA
§ IRREGULARITY OF BREATHING
HEAD TRAUMA MECHANISM
 HEAD TRAUMA
MECHANISM
Understanding mechanism of
head trauma thoroughly from
head imaging result.
Then, what we should do…….
 GENERAL NOTES
Primary Goal
Prompt recognition of neurologic
deterioration, and timely
diagnosis and management of pre
and postoperative complications
Secondary Goal
Prevent secondary insults, which
may initiate or exacerbate
secondary damage in a vulnerable
central nervous system

BEGINS AT THE SCENE OF

THE INJURY
 Protocols
1. Initial Triage

2. Primary Survey and Resuscitation

3. Secondary Survey and Stabilisation

4. Definitive Care Phase

( treat intracranial hypertension )
A brief history
Initial Triage
A rapid assesment
Vital func+ons, neurological func+on

In the hypotensive pa0ent, search

major blood loss

In the intubated pa0ent, check the

posi7on and adequacy
 Airway management with cervical spine
Primary Survey protection
and
Resuscitation Breathing and ventilation

Circulation and Control of Hemorrhage

Disability ( neurological evaluation )

Exposure
 Secondary
Survey and
Stabilisation
Principle objectives

Comprehensive evaluation of
head injury and extracranial
injuries

Prioritisation of initial
management of head injury and
extracranial injuries
 Diagnosis
Physical Examination
• Not possible for universal physical exam,
• Major trauma must be assessed rapidly, and must be
individualized based on pa;ent’s condi;on.
• Below features are applied only for craniospinal injuries, and
assumes that general systemic are stable.
§ General physical condi;on
§ Neurologic exam
 Diagnosis
Physical Examination
§ General physical condition
§ Visual inspection of cranium
§ Evidence of basal skull fracture
§ Check for facial fracture
§ Check for periorbital edema, proptosis
§ Cranio-cervical auscultation
§ Physical signs of spinal trauma
§ Evidence of seizure
 Diagnosis
Physical Examination
§ Neurologic exam
§ Cranial nerve exam
§ Level of consciousness
§ Motor exam
§ Sensory exam
§ Reflexes
 Diagnosis
Radiological Examination (Neuroimaging)
1. Skull Radiography
2. CT Scan (Gold Standard)
3. Magnetic Resonance Imaging (MRI)
4. Experimental Modalities for Neuroimaging
Functional MRI (fMRI)
PET Scanning
 Neuroimaging
• Skull Radiography
• Prior to CT, Skull radiography used as triage
tool
• Can evaluate for
• Skull fractures
• Pneumocephalus
• Blood in sinus
• Penetrating foreign body
• Patients with abnormal findings are at
increased risk of intracranial findings
• However, still misses a large number of
patients with normal skull films but extensive
injury
• Limited utility at very rural sites without access
to CT imaging
 §Computed Tomography (CT Scan)
§ Imaging modality of choice
§ Especially good at identifying skull fracture, extra-axial fluid
collection and hemorrhagic contusion

Neuroimaging
 Neuroimaging
Canadian CT Head Rule

Computed Tomography CT Imaging is only required for patients with minor head injury
with any one of the following findings. The criteria apply to
(CT Scan) patients with minor head injury who present with GCS of 13-15
§ High u'liza'on has led to after witnessed LOC, amnesia or confusion.

clinical decision rules to High Risk for Neurosurgical Intervention

iden'fy appropriate 1. GCS < 15 at two hours after injury
pa'ents requiring 2. Suspected open or depressed skull fracture
evalua'on 3. Any sign of basilar skull fracture (Hemotympanum, Peri-
New Orleans Criteria orbital Eccymosis, Otorrhea or Rhinorrhea, Battle sign)
4. Two or more episodes of vomiting
Canadian Head CT Rule 5. Age > 65 years

Medium risk for Brain Injury Detection by CT Imaging

1. Amnesia before impact of 30 or more minutes
2. Dangerous mechanism (E.g. Pedestrican vs. Motor
vehicle, Ejection from motor vehicle or fall from an
elevation of 3 or more feet or 5 stairs)
 ICP Management
Position
§Optimize head position
Ø 30 to 45 degrees from horizontal
Ø Decreases ICP
Ø Be careful in patients with acute
ischemic stroke, as this may
compromise perfusion to ischemic
tissue at risk
§Neck position - midline

Rosner MJ, Coley IB: Cerebra perfusion, intracranial pressure and head elevation.
J Neurosurg1986;65:636-41.
Oxygenation and Blood Pressure

§Monitor for hypoxemia (Saturation O2 < 90% in the field; pO2 < 60
mmHg from BGA) and hypotension (SBP < 90 mmHg),
§Continuously monitoring of blood oxygen saturation using pulse
oximeter,

SaO2 Mortality Disability

> 90 % 14 % 5%
60 – 90 % 27 % 27 %
< 60 % 50 % 50 %
Oxygenation and Blood Pressure

§Oxygenation and BP should be measured as often as possible, and

continuously if possible,
§SBP and DBP should be measured using the most accurate method
available,
§One episode of hypotension increase mortality risk twofold.
§Target CPP 60 – 70 mmHg, ICP < 20 mmHg,
MAP > 90 mmHg
 ICP Management
Volume, CPP, BP, Seizure Prophylaxis
Euvolemia or mild hypervolemia
Isotonic fluids (NS 0.9 %)
CPP 60-70 mm Hg
Limit BP swings, maintain
SBP ≥100 mm Hg (50 - 69 y.o.)
SBP ≥110 mm Hg or above (15 – 49 y.o. Or > 70 y.o.)
Seizure prophylaxis
Phenytoin is recommended to decrease the incidence of early
PTS (within 7 days of injury), not to prevent late PTS

Raslan A, Bhardwaj A: cerebral edema and intracranial pressure.

In: Torbey MT (Ed): Neurocritical care. New York, NY: Cambridge University Press,
2010:11-19.
 ICP Management
Steroid
§Steroids is not recommended for
improving outcome or reducing
ICP.
§High-dose methylprednisolone
was associated with increased
mortality.
 ICP Management
Fever, Glycemia, Nutrition
1. Normothermia in every patient
§ Acetaminophen
§ Cooling devices
2. Glycemic control
§ TBI worsening outcomes with hyperglycemia
§ Improved outcome with adequate but NOT tight control
3. Nutrition
§ ASAP, enteral ideal,
Bruno A, Williams LS, Kent TA: How important is hyperglycemia during acute brain infarction?
Neurologist 2004;10:195-200
Marik P, Varon J: Intensive Insulin Therapy in the ICU: Is it now time to jump off the bandwagon?
Resuscitation. 2007;74:191-193.
 ICP Management
Osmotherapy
Create an osmotic gradient to cause egress of water from the
brain extracellular compartment into the vasculature, thereby
decreasing intracranial volume and improving cerebral
compliance
Mannitol, 0.25-1 g/Kg , IV
Maximal effects seen 20-40 min post administration, repeat
q 6 hours with 0.25 g/kg, target 320 mOsm/L

Knaap JM: Hyperosmolar therapy in the treatment of severe head injury in children.
Mannitol and hypertonic saline. AACN Clin Issues 2005; 16:1991-211
Diringer MN, Zazulia AR: Osmotic therapy: fact or fiction? Neurocrit Care 2004;1:219-34.
 ICP Management
Safety
§Mannitol
§ Can cause hypotension, hemolysis, hyperkalemia, renal
insufficiency, pulmonary edema
§Hypertonic saline
§ Safety profile better than mannitol
§ Can cause CNS changes, myelinolysis, pulmonary edema,
electrolyte derangements, metabolic acidemia, potentiation of
bleeding, hemolysis, rebound hyponatremia

Varon J, Marik PE: The management of head trauma in children.Crit Care Shock. 2002;5:133-143.
Schwarz S, Georgiadis D, Aschoff A, Schwab S: Effects of hypertonic (10%) saline in patients with
raised intracranial pressure after stroke. Stroke 2002;33:136-40.
 When to involve the neurosurgeon

Regardless of imaging, other reasons for discussing

a patient’s care plan include:
§ persisting coma (GCS ≤ 8) after initial resuscitation
§ unexplained confusion for more than 4 hours
§ deterioration in GCS after admission
§ progressive focal neurological signs
§ seizure without full recovery
§ definite or suspected penetrating injury
§ cerebrospinal fluid leak
Prescription (Do)
1. Maintain mean BP > 90 mm Hg
2. Maintain PaCO₂ between 25 - 35 mm Hg
3. Use isotonic solution for euvolemia
4. Frequent neurologic exams
5. Liberal use of CT scans
6. Early neurosurgical consult
Proscription (Don’t)
1. Allow patient to become hypotensive
2. Over-aggressively hyperventilate
3. Use hypotonic IV fluids
4. Use long acting paralytics
5. Paralyze before performing complete exam
6. Depend on clinical exam alone
SPINAL CORD INJURY
ANATOMY
VERTEBRAE

SPINAL CORD
CONUS MEDULARIS
FILUM TERMINALE
MOTORIC TRACT
(CORTICOSPINAL TRACT)
SENSORIC TRACT (DCML
SYSTEM AND ALS SYSTEM)
DERMATOME AND MYOTOME
DEFINITION
Dermatome is the area of skin
innervated by the sensory axons within a
particular segmental nerve root
Myotome is representation for a single
spinal nerve segment which innervate
certain muscles or muscle groups,
eventough each segmental nerve root
innervates more than one muscle, and
most muscles are innervated by more
than one root (usually two).
 NEUROGENIC SHOCK VS SPINAL SHOCK

Spinal shock refers to the flaccidity (loss of muscle
tone) and loss of reflexes that occur immediately
after spinal cord injury.
After a period of time, spasticity ensues.
Neurogenic shock results in the loss of vasomotor
tone and sympathetic innervation to the heart.
Injury to the cervical or upper thoracic spinal cord (T6
and above).
 DOCUMENTATION OF SPINAL CORD INJURIES

The bony level of injury refers to the specific

vertebral level at which bony damage has occurred.

The neurological level of injury describes the most

caudal segment of the spinal cord that has normal
sensory and motor function on both sides of the
body. The neurological level of injury is determined
primarily by clinical examination.

The term sensory level is used when referring to the

most caudal segment of the spinal cord with normal
sensory function.
 DOCUMENTATION OF SPINAL CORD INJURIES

The motor level is defined similarly with respect

to motor function as the lowest key muscle that
has a muscle-strength grade of at least 3 on a 6-
point scale.

The zone of partial preservation is the area just

below the injury level where some impaired
sensory and/or motor function is found.
Spinal Cord Syndromes

Central cord syndrome is characterized by

a disproportionately greater loss of
motor strength in the upper extremities
than in the lower extremities, with
varying degrees of sensory loss.
Central cord syndrome can occur with or
without cervical spine fracture or
dislocation.
These injuries are frequently found in
patients, especially the elderly, who have
underlying spinal stenosis and suffer a
ground-level fall.
Spinal Cord Syndromes

Anterior cord syndrome results from

injury to the motor and sensory
pathways in the anterior part of the
cord.
Characterized by:
Paraplegia
Bilateral loss of pain and
temperature sensation.
Preservation of intact dorsal column
(i.e., position, vibration, and deep
pressure sense)
 Spinal Cord Syndromes

Brown-Séquard syndrome results from

hemisec.on of the cord, usually due to
a penetra.ng trauma.
Consists of :
Ipsilateral motor loss (cor.cospinal
tract)
Ipsilateral loss of posi.on sense
(dorsal column),
Contralateral loss of pain and
temperature sensa.on beginning one
to two levels below the level of injury
(spino-thalamic tract).
RADIOGRAPHIC EVALUATION
CERVICAL SPINE
RADIOGRAPHIC EVALUATION
LUMBAL SPINE
 MANAGEMENT
General management of spine and spinal cord trauma includes:
1. Restric<ng spinal mo<on,
2. Oxygena<on,
3. Intravenous fluids,
4. Medica<ons, and
5. Transfer