Head, Neck, and Spinal Cord Trauma
last authored: Sept 2009, David LaPierre
Introduction
Head, neck, and spinal cord trauma is unfortunately very common and often devestating.
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The Case of...
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Causes and Risk Factors
Causes of trauma include:
Risk factors include:
- young male
- MVC
- alcohol
Pathophysiology
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
Basal skull fractures are managed expactantly following CT of C-spine and head. Antibiotics are not normally needed.
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
Stay focused on the basics: ABCs, neurological exam, immobilization
Clinical Evaluation
- history
- physical exam
History
As with all trauma, history largely depends on mechanism of injury
- 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.
Physical Exam
Rapid neurological scan
- Glascow Coma Scale
- pupil size, symmetry, and reactivity
- gross motor function (equal movement in all 4 limbs?)
- deep tendon reflexes (biceps and knee)
- plantar responses (Babinski)
head and neck exam for facial fractures
cervical spine exam: palpate for tenderness.
digital rectal exam to assess tone
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
CT head
- epidural hematoma causes biconvex, lens-shaped blood
- subdural hematoma: semilunar, crescent-shaped hematoma
If C spine tenderness is present, or if distracting injury, perform CT neck or AP, lateral, and odontoid views on plain film.
Management
As in all emergency situations, management of the ABCDEs is of primary importance.
For a mild head injury (GCS 13-15), urgent CT is required if all three of the following are present:
- blunt head trauma within past 24 hours
- LOC, amnesia, or disorientation
- 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
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
- CT exam is deferred prior to transport
Subdural hematoma is treated with ICP monitoring, head elevation, hyperventilation, and mannitol or furosemide to reduce fluid levels.
Do NOT be distracted; hyperventilate patient, treat hypertension, or give mannitol or steroids unless neurosurgery guides
Consequences and Course
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Additional Resources
Trauma Coma Data Bank, Journal Neurosurgery, 1991.
Nova Scotia Head Injury Guideline
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