Neurosurgical Trauma

Dr. Taopheeq Bamidele Rabiu

 Introduction
• Overview of clinical problem
• Burden to society
• Urgency of care
• Setting of polytrauma
• Focus
– Head Injury
– Spinal Injury
 Head Injury
• Concept of traumatic brain injury
• Grave consequences without proper care
• Epidemiology
– 1.5 million/year
– 230,000 hospitalization
– 50,000 deaths
– 5.3 million people living with permanent deficits
– Economic burden $37.8 billion/year
• Causes
– Transportation-related
– Firearms
– Falls
• Peak incidence
– young adults aged 15–24 yr
– elderly (>60 yr old)
• Men are twice as likely as women to sustain
and three times as likely to die from a TBI
• Mortality reduced with neuroradiological
advancements and development of NSUs
 Classification of Head Injury
• Mechanism
– Blunt Vs Penetrating
– Open Vs closed
• Pathology
– Diffuse
– Focal
– Primary Vs Secondary
• Functional
– Mild, moderate, severe
 Mechanism of Injury
• Scalp

• Fractures
– Calvarial
• Linear
• Depressed
• Elevated
– Basal
 CELLULAR MECHANISMS OF INJURY
• Cerebral Blood Flow

• Decrease in first few hours

• Later increase (hyperaemia)
– low CBF (< 33 mL/100 g/min)
– Relative hyperemia (33–55 mL/100 g/min)
– Absolute hyperemia (> 55 mL/100 g/min)
• Disruption of the Electron Transport System

– Decreased CBF/hypoxia
– Failure of ETS and oxidative phosphorylation
– Depletion of ATP
– Production of free oxygen radicals
– Cellular swelling and death
• Excitotoxic Neurotransmitters

– Reduced CBF (<20 cc/mL/100 g/min) stimulates

the release of excitatory amino acids
– glutamate, glycine, aspartate
– Glutamate in the synapse (through activation of
NMDA receptors) opens Ca2+ channels
– uncoupling of the oxidative phosphorylation
process and
– production of free radicals
• The Immune Response
• Suppression of the proliferative ability and the
concentration of T cells, IgG/M, and IL-2
responsive cells
• Increased cytokine production
• Elevated levels of inhibitory IL-10 and
excitatory IL-6, IL-8, TGF-ß, TNF
• Activated microglia release factors that
stimulate the production of adhesion
molecules
• Brain Trauma Proteins

• Brain trauma-specific tau proteins

• ELISA testing confirmed a more than 1000-fold
increase in head trauma patients vs controls
• The level of specific CSF tau correlated
inversely with recovery
 Intracranial Pressure
• CPP = MABP – ICP
• CBF= CPP/CVR
• Monro-Kellie doctrine
EARLY EVALUATION AND MANAGEMENT

• Primary survey + resuscitation

• Tracheal intubation
– GCS less than 8
– Inability to protect their airway
– Inability to maintain adequate ventilation
• Fluid resuscitation with isotonic saline
• Immobilization of the spine
• History: mechanism of injury, other medical conditions,
medications, allergies, and illicit substance exposure
• GCS and stratification
• Sedation
 PREVENTION OF SECONDARY INJURY
• Hypoxia • Seizures
• Hypotension • Hyperthermia
• Raised ICP • Infections
• Electrolyte imbalance • Nutrition
• Hyper-/hypoglycaemia • Vasospasm prophylaxis
• Seizures
Management/Prevention of Raised ICP
• Head Position
• Mannitol
• Hypertonic saline
• Hyperventilation
• Barbiturate coma
• Surgery
– Clot evacuation
– Temporal/frontal lobectomy
– Decompressive craniectomy
 Intracranial Haemorrhage
• Extradural
• Subdural
– Acute
– Subacute
– Chronic
• Intracerebral
• Subarachnoid
• Intraventricular
Herniation Syndromes
 Skull fractures
• Fractures
– Calvarial
• Linear
• Depressed
• Elevated
– Basal
• Frontal
• Middle
• Posterior
 Complications of Head Injury
• Infections

• Seizures
– Early
– Late

• Focal/Global neurologic deficits

• CSF leak

• Vascular e.g carotico-cavernous fistula, traumatic

 Rehabilitation
• Physical
• Speech
• Occupational
• Others
 Head Injury Prevention
• Health education

• Traffic regulations
– Seat belts
– Helmets

• Others
Spinal Trauma
 Introduction
• SCI: Highly devastating condition

• Prevalence: 19/million
– Odeku, 1971: 71/10years
– Solagberu, 2002: 39/5years
– Emejulu, 2009: 90 of 1055 neurosurgery cases/30 months
– Udosen, 2007: 14/1 year
– Obalum, 2009: 468/15years

• Initial care has major implications for long-term outcome

 Overview
• Incidence: 2-5/100,000 population
• Majority Spare the cord
• 10%: quadriplegia/paraplegia
• Commoner in adolescents and young adults
• Causes
 Mechanism of Injury
• Types

• Open/Closed

• Parts of spine affected in trauma

• Causes of cord injury

Pathophysiology
 Types of Neurologic deficits
• Complete

• Incomplete

*Cauda Equina &

Conus medullaris syndromes
Assessment
 Think Spinal Injury!
• Consider the potential for SCI

• Missed Spinal Injuries…..Poonnoose, et al

2002

• High possibilities of SCI

– A road traffic accident
– A fall or jump from a height
– An accident resulting in crush injuries
 – An accident resulting in multiple trauma
– An accident resulting in the patient losing
consciousness

and, if
– Following injury, the patient complains of back or neck
pain and appears to be guarding their back or neck
– The patient complains of any sensory changes or loss
such as numbness or tingling
– The patient is unable to pass urine
 Priorities: ABC

• Airway & Cervical Spine Control

– Neutral supine position
– Observation: airway compromise
– Action
• Clear airway
• Chin-lift technique
• Minimize movements of c-spine
• C-spine immobilization
• Intubation
Breathing
• High risk of deteriorating respiratory function
– Fatigue of innervated muscles
– Chest trauma
– Ascension of the spinal lesion
– Retained secretions
– Abdominal distension splinting diaphragm

• Observations

• Action
Circulation

• Neurogenic shock

• Observations
– Hypotension
– Bradycardia

• Actions
• Neurological assessment

• Early & careful evaluation

• Monitor changes in neurological levels

Motor levels

• Shoulder Elevators C3, 4 • Hip Flexors L2, 3

• Elbow Flexors C5,6 • Knee Extensors L2, 3,4
• Elbow Extensors C7, • Ankle DF L4, 5,S1
8,T1 • Ankle PF S1,2
• Wrist Extensors C6, 7,8 • Toe Extensors L4,5,S1
• Finger Flexors C7, 8,T1
• Abd. Dig. Min C8,T1
 Signs of Spinal Injury
• Examine the whole spine

• Log-roll to turn

• Tell-tale signs of injury

 Grading of SCI
• ASIA Grading
• Frankel Grading
• A= Motor & Sensory complete
• B= Motor complete; sensations preserved
• C=Useless motor residual
• D=Useful motor residual
• E=Normal
Imaging
• Multiple fractures in 5%

• Show whole spine

• Adequacy of imaging

• Modalities
Lines of alignment on lateral radiograph
Initial Care
 Principles of Management
• Prevention of further injury to the spinal cord

• Reduction and stabilization of bony injuries

• Prevention of complications resulting from

spinal cord injury

• Rehabilitation.
Handling of patient
• Flat position

• Logroll

• Spinal boards
DVT Prophylaxis

• Mechanical methods

• Chemical methods
Skin care
• High risk of developing pressure sores
• Pressure sore: sign of neglect
• Methods:
• Pad pressure points
• Regular turning
– < 2 hourly
– > 40o
• Ripple mattresses, etc
Paralytic ileus
• Common in spinal shock
• Observations
– Abdominal distension
– Reduced/absent bowel sounds
• Actions
– Nil-by-mouth
– Nasogastric tube drainage
– Flatus tube
Stress Ulceration
• High risk in acute SCI

• Consider H2RAs/PPIs
Others
• Bladder

• Bowel

• Joints

• Steroid therapy
Penetrating Spinal Injury
 Complications of SCI
• Respiratory
– Aspiration
– Resp insufficiency
– Orthostatic pneumonia
• Cardiovascular
– Neurogenic shock
– DVT/Embolism
• GIT
– Stress ulcers/perforations
– Paralytic ileus
• Joints/MSS
– Stiffness/contractures
– Disuse atrophy
– Para-articular heterotopic calcifications
• Genitourinary
– UTI
– Erectyle dysfunction
– Detrusor hyperreflexia
– Acontractile bladder
• Skin
– Pressure ulcers
• Biochemical
– Hyponatraemia
– Hypercalcaemia
Transfer to spinal centre
• Adequate planning

• Estimate travel time

• Vehicles

• Personnel
Transfer checklist
Prior to transfer, ensure mechanical and
physiological stabilisation

• Immobilisation of the spine is adequate and secure

• Long bone fracture immobilisation
• Airway is clear and can be maintained during transfer
(intubate if PaCO2 is >5.5 KPa or if respiratory failure
is likely to develop during a prolonged transfer)
• Supplemental oxygen
• Chest drainage if pneumothorax or haemothorax
before transfer
• IV is patent and infusing at desired rate

• Naso-gastric tube is in situ, draining freely

• Indwelling foley catheter is in situ and draining

freely

• Skin is protected from injury and apparatus or

debris which may cause pressure sores is cleared
away
• Level of Spinal Cord Injury is documented

• Records and x-rays accompany the individual

• Other injuries – thorax, abdomen, pelvis etc. – are

documented and stabilised

• Any head injury documented and monitored

• Notify time of departure to spinal centre

What we do
All SCIs not traumatic!
 Summary

• Think spinal injury!

• Adequate assessment: ABC
• Document neurological level & grade
• Spinal stabilization
• Nurse flat
• Care of skin, bladder, bowel
• Prevent DVT
• Transfer after physiological/mechanical
 Conclusions
• Prompt and focused evaluation

• Identification of life-threatening conditions

• Prevention of secondary injury

• Rehabilitation

• Preventive measures