Head, Neck, and Spinal Cord Trauma
last authored: April 2012, David LaPierre
last reviewed:
Introduction
In all acute care settings, healthcare providers will encounter trauma patients. Some of the most common causes of trauma are motor vehicle collisions (MVC), falls, and sports-related injuries (1,2). Trauma is the leading cause of death of people between the ages of 1 and 44 years old in the developed world, and a major cause of death worldwide for all ages (1, 3).
Every year, about 700 teenagers in Canada lose their lives to preventable injuries; this is more than all other causes of death (1). In Canada in 2004, injuries resulted in 13 677 deaths and 67 500 people with permanent disabilities, 5,000 of those classified as total disability (1). Many of these deaths and disabilities are the result of cervical spine (C-spine) injuries (2). Each year more than 4 million patients with potential C-spine injury are seen in emergency departments in Canada and the United States (4). The incidence of C-spine injuries associated with these head injuries and trauma cases is 3-6% in adults and 0.5% in children (<18 years old) (5,6). Up to 10% of unconscious MVC victims will have a C-spine injury (7). C-spine injuries result in a wide range of problems from the fairly benign (ex. neck pain) to the very serious (ex. tetraplegia) to death.
Many of the neurologic injuries occur at the time of the trauma, however, up to 25% of the injuries occur after the trauma during transit to the hospital, care in hospital, or after discharge with a missed diagnosis (5). These statistics show the importance of accurate diagnosis, and subsequent management, of C-spine fractures in the emergency department.
The Case of...
add case illustrating clinical presentation, investigations, and differential diagnosis
Causes and Risk Factors
Causes of trauma include:
Risk factors include:
- young male
- MVC
- alcohol
Pathophysiology
Scalp and skull injury
Layers of scalp spell SCALP:
- skin
- connective tissue (dense)
- aponeurosis (galea)
- loose connective tissue
- periosteum
Brain injury
As mass expands, the CSF is shunted down the spinal cord. As a hematoma continues to grow, venous blood is compressed out, followed by arterial blood.
brain is about 1800 cc - 80% brain, 10% blood, and 10% CSF
Neurologic damage can be caused by the initial force, developing hematoma, and increased intracranial pressure.
Acute epidural hematoma classically occurs following trauma in which the middle meningeal artery is ruptured. It is almost always associated with a skull fracture.
and causes unconsciousness, an awake, alert patient, gradial re-loss of consciousness, a fixed dilated pupil, and contralateral hemiperesis with decerebrate posture.
Acute subdural hematoma is caused by more substantial trauma in which the branches of the superior saggital sinus shear off and spill venous blood across the brain.
Cerebral contusions can be associated with other injuries. Their effects can appear days later, requiring close monitoring following injury.
Spinal cord injury
spinal shock
- somatic motor
- somatic sensory
- autonomic (loss of thoracic sypathetics)
Other injuries include:
- hypoxia
- hypotension
Clinical Evaluation
Stay focused on the basics: ABCs, neurological exam, immobilization
- history
- primary survery
- secondary survey
History
As with all trauma, history largely depends on mechanism of injury
Ask about
- any loss of consciousness
- nausea/vomiting
- headache
- post-traumatic amnesia
- loss os sensation or function
Endeavour to understand the mechanism of injury:
- timing
- objects
- force
- velocity
- blunt or penetrating
- velocity
- safety devices (seatbelts, helmets, airbags, etc)
Also important are past medical history, medications, allergies, alcohol or drug use, last meal, and previous surgeries.
Power of attorney should be identified in case of incapacity of the patient.
Primary survey
Red Flags
Severe head injury may be present if:
- GCS<8
- deteriorating GCS
- unequal pupils
- lateralizing signs
Airway: is the airway patent?
- is the patient speaking?
- is there tongue, teeth, blood, etc occluding the airway?
Breathing: are they ventilating?
- is a jaw thrust possible?
- is a secure airway immediately required?
- is a surgical airway required?
Circulation: are vital signs stable?
- is there large scalp, neck, or facial hemorrhage?
Rapid neurological scan (repeat regularly)
- Glascow Coma Scale
- pupil size, symmetry, and reactivity
- gross motor function (equal movement in all 4 limbs?)
- plantar responses (Babinski)
- sphincter tone
Secondary survey
Neurological scan (repeat regularly)
Head and Neck
General face
Eyes
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Ears
Nose
Oropharynx
Jaw
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Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Bloodwork investigations in the trauma setting are described here.
NEVER do a lumbar puncture.
Diagnostic Imaging
C-spine plain films
C-spine plain films are standard in trauma potentiall involving the head and neck. There are some cases, however, where plain films are not required.
Remember that a C-spine must be cleared both clinically and radiologically. If a patient is intoxicated, or has major distracting injuries, negative X-rays are insufficent.
The Canadian C Spine Rules is one of the most sensitive guidelines for determining X-ray patterns (Stiell et al, 2001):
The patient must have a Glasgow-Coma Scale score of 15, have stable vital signs, and be at least 18 years old.
patient is not “high risk”
AND |
the patient has ONE OF the following low risk factor for safe assessment of range of motion of the neck
AND |
patient can actively rotate neck 45 degrees to the right and 45 degrees to the left. |
If the patient meets all of these criteria, then radiography is not needed.
*A “dangerous mechanism” is any of the following:
- a fall from ≥1 meter/5 steps
- axial load to the head (ex. diving, helmet on helmet impact in football)
- MVC at high speed (>100km/h) or with rollover or ejection from vehicle
- motorized recreational vehicle collision
- bicycle collision.
**A “simple rear-end MVC” does not include the following: Pushed into oncoming traffic, hit by a bus or large truck, hit by a high speed vehicle, resulted in a rollover.
The National Emergency X-Radiography Utilization Study (NEXUS) also has rules for when to order C-spine radiographs, but these will not be discussed in this module. Of the two rules, the CCR have been shown to be more sensitive and specific than the NEXUS criteria (Stiell et al, 2003).
Interpretation of C-spine films is listed here.
Common C-spine fractures are listed here.
CT head and neck
CT head, plus upper C-spine, should be done in all cases of major head injury. For a mild head injury (LOC, amnesia, or disorientation), CT is required if all three of the following are present: (Canadian CT head rule)
- dangerous mechanism leading to head injury
- amnesia before injury lasting >30min
- one or more of the following:
- GCS <15 at 2 hours post-injury
- suspected open/depressed skull fracture
- signs of basal skull fracture
- vomiting 2 or more times
- age >65
CT head and reveal the following:
- epidural hematoma: biconvex, lens-shaped blood
- subdural hematoma: semilunar, crescent-shaped hematoma
- fractures
- loss of mastoid/sinus air spaces
- blod in cisterns
- pneumocephalus
chest/pelvic X ray as indicated
Management
As in all emergency situations, management of the ABCDEs is of primary importance. These are discussed here.
Minor injury
If nothing more than concussion is suspected, observe for 24-48 hours, waking every hour. Use sedatives or analgesics selectively while monitoring.
Severe injury
For major head injury (GSC<12), rapid transport to neurosurgery is of critical importance.
- spine immobilization
- intubate (protecting C-spine) if GCS <8 or deteriorating; provide oxygen otherwise
- maintain BP
- CT exam is deferred prior to transport
- monitor to detect complications
Wounds
Irrigate wounds and remove foreign bodies. Debride noviable tissue.
Drain septal hematoma and pack if epistaxis is present.
Provide teanus prophylaxis and antibiotics as warranted.
Increased intracranial pressure
Manage increased ICP if present; ideally by neurosurgery, or in consultation with them as required
- elevate head of bed
- mannitol or furosemide
- hyperventilate
- paralyzing agents
pharmacotherapy:
- anticonvulsants x7 days
- calcium channel blockers in adults
Basal skull fractures
Basal skull fractures are managed expactantly following CT of C-spine and head. Antibiotics are not normally needed.
Facial fractures
- Mandibular fracture: arch bars wired together, or ORIF
- Maxillary fracture: intermaxillary fixation or ORIF
- Nsal fracture: closed reduction is usual; best done in first 6 hours, or 5-7 days after, when swelling has subsided
- Zygomatic fracture: no treatment for arch fracture; repair if the zygoma is depressed, or the fracture is unstable
- Orbital blow out: urgent decompression
Spine fractures
- reduce dislocation by traction or surgery
- stabilize spine
- MRI if neurological deficit present to rule out compression
Consequences and Course
Resources and References
Trauma Coma Data Bank, Journal Neurosurgery, 1991.
Nova Scotia Head Injury Guideline
Stiell I. et al. 2001. The Canadian Cervical Spine Radiography Rule for alert and stable trauma patients. Journal of the American Medical Association. 286:1841-1848.
Stiell I. et al. 2003. The Canadian C-spine Rule versus the NEXUS low-risk criteria in patients with trauma. New Engand Journal of Medicine. 349:2510-2518.
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