Brain Injuries & Spinal Injuries Notes

Brain Injuries

  • EXSS 288: Emergency Care of Injury and Illness

  • Quote: “After climbing a great hill, one only finds that there are many more hills to climb”

The Brain: 3 Major Parts

  • Cerebrum / Cortex

    • 4 lobes

  • Cerebellum

  • Brain stem

    • Pons

    • Midbrain

    • Medulla oblongata

  • Meninges

  • Cerebrospinal fluid

Meninges

The meninges are the membranes covering the brain and spinal cord.

  • Dura mater (2 layers)

  • Arachnoid

  • Pia mater

  • Layers:

    • Dura mater

      • Epidural Space

      • Subdural space

    • Arachnoid

      • Subarachnoid Space

    • Pia mater

Cerebrospinal Fluid

  • Contained between the arachnoid and pia mater membranes

Injuries to the Brain

Why talk about concussion?

  • Can have lifelong impacts if not reported and cared for properly

  • Often dismissed as minor

  • Cumulative effects of multiple concussions

  • Topic of much research

  • Guidelines are updated regularly

  • We are learning more about this injury daily

Not Just a Football Problem

  • Injury rate per 10,000 athlete exposures:

    • Football: 10.410.4

    • Girls’ Soccer: 8.198.19

    • Boys’ Soccer: 3.573.57

    • Girls’ Basketball: 4.854.85

    • Wrestling: 4.834.83

    • Girls’ Lacrosse: 4.224.22

    • Boys’ Lacrosse: 4.924.92

    • Competition: 10.3710.37

    • Practice: 2.042.04

  • Data from HS RIO Kerr et al. Pediatrics 2019

What is a Concussion?

  • Sport-related concussion is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities.

  • This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change and inflammation affecting the brain.

  • Symptoms and signs may present immediately or evolve over minutes or hours and commonly resolve within days but may be prolonged.

  • No abnormality is seen on standard structural neuroimaging studies (computed tomography or magnetic resonance imaging T1- and T2-weighted images), but in the research setting, abnormalities may be present on functional, blood flow or metabolic imaging studies.

  • Sport- related concussion results in a range of clinical symptoms and signs that may or may not involve loss of consciousness.

  • The clinical symptoms and signs of concussion cannot be explained solely by (but may occur concomitantly with) drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction) or other comorbidities (such as psychological factors or coexisting medical conditions).

  • Patricios et al. BJSM 2023

  • A concussion is an injury caused by a direct blow that causes an impairment of neural function

What is a concussion?

  • Functional NOT structural injury

  • May be referred to as an mTBI, or mild traumatic brain injury

  • Not identifiable on standard imaging (CT or MRI)

  • This is currently being studied in numerous settings

Head Injuries

  • MOI: direct blow to the head or body

  • Causes the head to “snap”

  • Coup vs Contrecoup

Cerebral Concussion (mTBI)

  • Sport Related Concussion (SRC) induced by biomechanical forces

    • Direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head

    • Results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously

    • In some cases, signs and symptoms evolve over a number of minutes to hours

    • May result in neuropathological changes

    • Acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury

    • Results in a range of clinical signs and symptoms that may or may not involve loss of consciousness

    • Resolution of the clinical and cognitive features typically follows a sequential course

    • In some cases, symptoms may be prolonged

    • McCrory et al. BJSM 2017

mTBI Signs and Symptoms

  • These signs and symptoms may indicate that a concussion has occurred.

  • Signs Observed by Coaching Staff

    • Appears dazed or stunned

    • Is confused about assignment

    • Forgets plays

    • Is unsure of game, score, or opponent

    • Moves clumsily

    • Answers questions slowly

    • Loses consciousness

    • Shows behavior or personality changes

    • Can't recall events prior to hit

    • Can't recall events after hit

  • Symptoms Reported by Athlete

    • Headache

    • Nausea

    • Balance problems or dizziness

    • Double or fuzzy vision

    • Sensitivity to light or noise

    • Feeling sluggish

    • Feeling foggy or groggy

    • Concentration or memory problems

    • Confusion

Observable Red-Flag Items That Warrant Immediate Referral to the Emergency Department via Emergency Medical Transport

  • Decreasing level of consciousness.

  • Increasing confusion

  • Increasing irritability

  • Loss of or fluctuating level of consciousness

  • Numbness in the arms or legs

  • Pupils becoming unequal in size

  • Repeated vomiting

  • Seizures

  • Slurred speech or inability to speak

  • Inability to recognize people or places

  • Worsening headache

Assessing Head Injuries

  • Unconscious Individual

    • Always suspect and treat as a cervical neck injury

    • If no immediate life-threatening conditions are present, maintain in -line stabilization and wait for EMS

History – Conscious Victim

  • Ask the following questions:

    • Can you tell me what happened?

    • Can you remember the score or who we played last week?

    • Do you remember walking off the field?

    • Does your head hurt?

    • Do you have any pain in your neck?

    • Can you move your hands and feet? (why?)

    • Have you experienced any tinnitus?

    • Amnesia? Anterograde? Retrograde?

Observation

  • Orientation of the individual

    • Vacant stare? Inability to focus?

  • Memory deficits

  • Cognitive function

  • Slurred speech

  • Delayed verbal and/or motor responses

  • Physical coordination

  • Emotional responses

  • Straw-colored fluid in the ears

Palpation and Special Tests

  • Palpate the skull and cervical spine

    • Points of tenderness

    • Deformities

  • Neurological Exam

  • Eye Function

  • Balance Testing

  • Coordination Testing

  • Cognitive Tests

Eye Function

  • PEARL

  • Eyes should track smoothly

  • Nystagmus

  • Check vision

  • Snellen eye chart

Balance Tests

  • Balance Error scoring system

  • Quantifiable tool of balance

  • 6 total trials

  • Three different stances

  • Two surfaces

  • 20 second trials

  • Count errors

  • Eyes Closed, Hands on hips

Cognitive Tests

  • Standardized Assessment of Concussion (SAC)

  • IV. CONCENTRATION Digits Backwards: If correct, go to the next string length. If incorrect, read second trail. Stop after

  • VI. DELAYED MEMORY RECALL

Neuropsychological Testing

  • Computerized tests (ie. ImPACT)

Suggested Domains of the Clinical History and Examination for Concussion Management

Domains & Features/Examples

  • Previous concussions - Date(s) and circumstances; presence and duration of loss of consciousness, amnesia, and symptoms with each injury

  • Concussion-related personal history - Mood disorder, learning disability, attention-deficit hyperactivity disorder, epilepsy or seizures, sleep apnea, skull fracture, migraine headaches

  • Family history - Mood disorder, learning disability, attention-deficit hyperactivity disorder, dementia (eg, Alzheimer disease), migraine headaches, complications from concussions

  • Symptoms - Current and recurrent

  • Mental status - Level of consciousness, attention and concentration, orientation, memory

  • Eye examination - Eye movements with smooth pursuit (cranial nerves III, IV, VI), nystagmus (VIII), pupillary reflex (CN II, III)

  • Muscle strength - Strength evaluation of deltoids, biceps, triceps, wrist and finger flexors and extensors; pronator drift

  • Motor control - Balance assessment

  • Cognitive function - Reaction time, working memory, delayed recall

mTBI Care

  • “Every concussion is like a snowflake” - Former Chancellor Guskiewicz

  • Any suspicion of mTBI the individual must be removed from activity

  • Treat all unconscious individuals as if they have a cervical spine injury

  • Refer as needed

  • Manage symptoms

  • Predictor of slower recovery

    • Severity of initial symptoms

  • Prior to RTP all signs and symptoms must be resolved

Home Instructions

  • It is OK to:

    • Use Tylenol for headaches

    • Use ice pack for head/neck

    • Go to sleep

    • Rest

  • There is NO need to:

    • Check eyes with flashlight

    • Wake up frequently (unless otherwise noted)

    • Test reflexes

    • Stay in bed

  • Do NOT:

    • Drink alcohol

    • Drive a car or operate machinery

    • Engage in physical activity

    • Engage in mental activity

Return to Play

  • TABLE 1 | 5th International Consensus Statement on concussion in sport return to sport strategy.

    • Rehabilitation Stage Objective Functional exercise at each stage of rehabilitation

      • 1. Symptom-limited activity Daily activities that do not provoke symptoms Gradual reintroduction of work/school activities

      • 2. Light aerobic exercise Walking or stationary cycling at slow to medium pace. No resistance training Increase HR

      • 3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities. Add movement

      • 4. Non-contact training drills Progression to more complex training drills (e.g., passing drills in football and ice hockey). May start progressive resistance training Exercise, coordination, and increased thinking

      • 5. Full contact practice Following medical clearance, participate in normal training activities Restore confidence and assess functional skills by coaching staff

      • 6. Return to play Normal game play.

Graded Return to Play Protocol

  • Symptom free

    • Player has no symptoms remaining after no activity - Light aerobic exercise - Level 2

    • No recurrence of symptoms within 24 hours (Rugby-specific exercise - no head contact (running drills) Level 3

    • No recurrence of symptoms within 24 hours (Non-contact training skills (passing and resistance training) Level 4

    • No recurrence of symptoms within 24 hours (Medical Practitioner and player agree that player may participate in full contact practice Level 5

    • There can be a return to play - level 6

  • Symptom(s) present

    • Rest until symptom free

    • Recurrence of symptoms - 24 hours rest

    • Recurrence of symptoms - 24 hours rest

    • Recurrence of symptoms - 24 hours rest

    • Recurrence of symptoms - 24 hours rest

Symptom Evaluation

  • How do you feel?
    You should score yourself on the following symptoms, based on how you feel now.

  • Symptoms:

    • Headache

    • "Pressure in head"

    • Neck Pain

    • Nausea or vomiting

    • Dizziness

    • Blurred vision

    • Balance problems

    • Sensitivity to light

    • Sensitivity to noise

    • Feeling slowed down

    • Feeling like "in a fog"

    • "Don't feel right"

    • Difficulty concentrating

    • Difficulty remembering

    • Fatigue or low energy

    • Confusion

    • Drowsiness

    • Trouble falling asleep of applicable)

    • More emotional

    • Irritability

    • Sadness

    • Nervous or Anxious

    • Total number of symptoms (Maximum possible 22)

    • Symptom severity score

    • (Add all scores in table, maximum possible: 22x6=132)

    • Do the symptoms get worse with physical activity?

    • Do the symptoms get worse with mental activity?

Graduated return-to-school strategy

Stage Goal Activity Aim

  • 1 - Daily activities at home that do not give the child symptoms - Typical activities of the child during the day as long as they do not increase symptoms (eg, reading, texting, screen time). - Gradual return to typical activities

  • 2 - School activities - Start with 5-15 min at a time and gradually build up - Increase tolerance to cognitive work

  • 3 - Return to school part-time - Homework, reading or other cognitive activities outside of the classroom - Gradual introduction of schoolwork. May need to start with a partial school day or with increased breaks during the day

  • 4 - Return to school full time - Gradually progress school activities until a full day can be tolerated - Return to full academic activities and catch up on missed work

Exam 3 Statistics

  • High Score: 98%

  • Low Score: 52%

  • Mean Score: 81%

  • Median Score: 82%

  • Mean Elapsed Time: 00:20:26

  • Data Last Updated: Oct 31, 2024, 9:00 AM

Concussion Red Flags

  • S/S lasting longer than 7-10 days

  • Extensive loss of consciousness or amnesia

  • Deterioration over time instead of resolution

  • Compounded by multiple concussions

  • Personality changes

  • Other neurological disorders present

Concussion Prevention

  • It may be inevitable in some sports

  • Education is imperative

  • Teaching proper technique is critical

  • Encourage good sportsmanship

  • Make sure athletes wear proper equipment

Other Head and Face Injuries

Second Impact Syndrome

  • MOI: rapid swelling of the brain following a second head impact occurring before the symptoms of a previous concussion have resolved

  • This second head impact may be very minor

  • May not even be a head impact***

  • Mortality rate of ~50%

Second Impact Syndrome Signs and Symptoms:

  • Usually do not lose consciousness

  • Rapid onset of symptoms

  • Coma

  • Dilated pupils

  • Loss of eye movement

  • Respiratory failure

  • PREVENTION!!

Brain Bleeds

  • Epidural Hematoma

  • Subdural Hematoma

  • Intracerebral Hematoma

Intracerebral Hematoma

  • MOI: impact in which the head hits a stationary object

Intracerebral Hematoma

  • Signs and Symptoms:

    • Vary significantly. Why?

    • Loss of consciousness followed by very alert and talkative

    • Neurological exam is normal

    • Headache, dizziness, and nausea may persist

  • Care:

    • Hospitalization

    • Diagnostic imaging

Epidural Hematoma

  • MOI: blow to the head

  • Tear of the meningeal arteries

  • Signs and Symptoms:

    • Loss of consciousness

    • Symptoms begin to worsen

    • Head pain, dizziness, nausea, unilateral pupil dilation, sleepiness, decreased consciousness, neck rigidity, depression of pulse and/or respiration

Epidural Hematoma Care

  • CT scan is necessary

  • Pressure must be surgically released

  • Craniotomy

Subdural Hematoma

  • More common than epidural hematomas

  • Most common cause of death in athletes

  • Typically involve venous bleeding

  • MOI: acceleration and deceleration forces that tear vessels that bridge the dura mater and brain

Subdural Hematoma Signs and Symptoms:

  • Develop slowly

  • Almost always unconscious

  • Dilation of one pupil

  • Headache

  • Dizziness

  • Nausea

  • Sleepiness

  • Care:

    • CT Scan or MRI

    • Need to determine location and severity of bleeding

    • Surgery to remove hematoma

    • Craniotomy

Skull Fracture

  • Blunt trauma MOI

  • Severe headache and nausea

  • Palpation may reveal defect in skull

  • May be blood in the middle ear, ear canal, nose, ecchymosis around the eyes (raccoon eyes) or behind the ear (Battle’s sign) S/S

  • Cerebrospinal fluid may also appear in ear and nose S/S

  • EMS, Immediate hospitalization and referral to neurosurgeon Care and Action

Mandible Fracture

  • MOI: direct blow

  • Signs and Symptoms:

    • Deformity

    • Malocclusion

    • Pain with biting

    • Bleeding around teeth; discoloration of gums

    • Lower lip anesthesia

Mandible Fracture Care

  • Referral for reduction and fixation (4-6 weeks at a minimum)

  • Full return takes 2-3 months

  • Light activity can be maintained

  • Specialized headgear or mouthpieces

Orbital Fracture MOI

  • Direct trauma to the eyeball

  • Signs and Symptoms

    • Blurred vision

    • Diplopia

    • Restricted eye movement

    • Downward displacement of the eye

    • Soft-tissue swelling and hemorrhaging

    • Numbness

    • Infraorbital nerve entrapment

  • Care and Action

    • X-ray will be necessary to confirm fracture

    • Antibiotics

    • Decrease risk of infection (due to proximity of maxillary sinus and bacteria)

    • Treat surgically or allow to resolve spontaneously

Retinal Detachment

  • MOI: blow to the eye

  • Signs and Symptoms:

    • Relatively painless

    • Seeing specks floating in front of the eye

    • Blurred vision

    • “Curtain”

  • Care:

    • Patch both eyes

    • Immediate referral

    • Surgery may be required

Nasal Fracture MOI

  • Direct trauma

  • Signs and Symptoms

    • Profuse bleeding and hemorrhaging,

    • Immediate swelling and deformity

  • Care and Action

    • Control bleeding and refer to a physician for X-ray, examination and reduction

    • Refer Immediately or wait 3-5 days

    • Uncomplicated and simple fractures will pose little problem for the athlete’s quick return

    • Splinting may be necessary

Epistaxis

  • MOI: generally the result of a direct blow

  • Sinus infection

  • Low humidity

  • Allergies

  • Foreign body lodged in nose

  • Other facial injuries

Epistaxis Care

  • Have athlete lean forward****

  • Place cold compress over the nose and ipsilateral carotid artery

  • Apply light pressure to the affected side (~5 min)

  • Place gauze between upper lip and gum***

  • Plug the nostril; leave ½ inch sticking out

  • Afrin

Tooth Fracture Types

  • Uncomplicated crown fracture: pulp chamber not exposed

  • Complicated fracture: pulp chamber exposed

  • Root fracture: below gum line

Tooth Fracture Care

  • Complicated and uncomplicated fractures: may continue to play

    • Use gauze to stop bleeding

    • Place missing part of tooth in plastic bag

    • Refer to dentist within 24-48 hours

  • Root fracture: may continue to play but refer to dentist ASAP

    • If tooth is out of place do not attempt to reposition

    • Dentist will brace the tooth 3-4 months

Tooth Subluxation, Luxation, Avulsion

  • MOI: impact to the upper or lower jaw

  • Signs and Symptoms:

    • Subluxation

      • Little pain, but tooth may feel different

    • Luxation

      • May be displaced forward or backward

    • Avulsion

Tooth Subluxation, Luxation, Avulsion

  • Care:

    • Subluxation: refer to dentist within 48 hours

    • Luxation: move tooth back to normal position

      • Refer to dentist ASAP

    • Avulsion: safe to attempt to put tooth back in place

      • Save-A-Tooth

      • Refer to dentist immediately (good chance of saving the tooth if re-implanted within 30 minutes)

Neck and Spine Injuries

Anatomy

  • 33 individual vertebrae

    • 24 movable

    • 9 immovable

  • Anterior

    • Location of sacrum and coccyx

  • 7 Cervical vertebrae

  • 12 Thoracic vertebrae

  • 5 Lumbar vertebrae

Vertebrae

  • Vertebral Bodies

  • Nerve root

  • Vertebral canal

  • Disc

  • Spinal cord

  • Pedicle

  • Lamina

  • Spinous

  • Transverse process process

Vertebrae Differences

  • SIZE DIFFERENCES

  • CERVICAL

  • THORACIC

  • LUMBAR

Brachial Plexus

  • Network of nerves originating at the spinal cord

  • Innervates chest, shoulder and arms

The Cervical Region

  • Atlas (C1)/Axis (C2)

  • 7 vertebrae

    • C1: atlas

    • C2: axis

    • C7: sticks out with flexion

The Thoracic Region

  • 12 vertebrae

  • Articulate with the ribs

The Lumbar Region

  • 5 vertebrae

  • Support the low back

  • Largest and thickest

The Sacrum and Coccyx

  • Sacrum

    • Fusion of 5 vertebrae and two hip bones

    • SI joints

    • “Keystone” of the pelvic girdle

  • Coccyx

    • AKA “tailbone”

    • 4+ fused vertebrae

Intervertebral Discs

  • Lie between each vertebrae

  • 2 parts:

    • Annulus fibrosus

    • Nucleus pulposus

  • Act as shock absorbers

Spinal Injuries

  • Prevention is key

  • Best way to prevent injury

    • Avoid axial loading

    • Maintain good “core” strength and posture

    • Strength and flexibility

Cervical Fractures

  • Relatively uncommon in athletics

  • Gymnastics, ice hockey, diving, football, rugby are most common

  • MOI: axial loading

  • Rotation of the head can increase severity

Cervical Fractures Signs and Symptoms:

  • Point tenderness over cervical vertebrae

  • Restricted ROM

  • Cervical muscle spasm

  • Numbness in the trunk and/or extremities

  • Weakness/paralysis in the trunk and/or extremities

  • Loss of bladder and/or bowel control

  • Care:

    • If suspected fracture, individual should only be moved by TRAINED professionals

    • Spine boarding

Brachial Plexus Injury

  • AKA "stinger" or "burner"

  • Etiology

    • Stretching

    • Compression

Brachial Plexus Injury

  • Signs and Symptoms

    • Burning, numbness, tingling, and pain down the arm into the hand

    • May last seconds to several days

  • Care

    • Once symptoms have resolved athlete may return to participation

    • Stretching and strengthening neck musculature

    • May add additional padding to shoulder pads

Low Back Pain

  • One of the most common and disabling ailments in humans

  • More common in older individuals

  • MOI:

    • Congenital anomalies

    • Mechanical defects

    • Faulty posture

    • Sprains

    • Strains

    • Contusions

Low Back Muscle Strains

  • MOI:

    • Sudden extension

    • Improper lifting mechanics

    • Chronic condition (faulty posture)

  • Signs and Symptoms:

    • Pain/discomfort may be diffuse or localized

    • Pain with activation of the muscle and passive stretching of it

  • Care:

    • Rule out more serious injury

    • Rest, Ice, Compression

    • May require complete bed rest

    • Rehab

Lumbar Vertebrae Fracture

  • Compression fractures and fractures of the transverse and spinous processes

  • MOI:

    • Compression Fracture

    • Transverse and Spinous Process Fracture

Lumbar Vertebrae Fracture

  • Signs and Symptoms:

    • Pain with palpation of transverse and spinous processes

    • Point tenderness

    • Localized swelling

    • Muscle guarding

  • Care:

    • X-ray (especially for diagnosis of compression fractures)

    • Spine boarding

Spondylolysis and Spondylolisthesis

  • MOI: common in people/athletes who commonly go into hyperextension

  • Direct blow may cause the vertebral body to slide forward

Spondylolysis and Spondylolisthesis

  • Signs and Symptoms:

    • Persistent aching pain and/or stiffness

    • Increased pain after physical activity

    • Individual feels the need to change positions commonly or “pop” his/her back

    • Potentially point tenderness over affected vertebrae

  • Care:

    • Bracing and rest help alleviate symptoms

    • Rehab focusing on controlling hypermobile segment

Herniated Lumbar Disc

  • Most commonly occurs between L4 and L5

  • May occur acutely or chronically

  • MOI: forward flexion with rotation

Herniated Lumbar Disc

  • Signs and Symptoms:

    • Centrally located pain that radiates down one LE

    • Symptoms are typically worse in the morning

    • Individual will typically lean backward and away from side of herniation

    • Sitting usually worse

  • Care:

    • Rest and ice

    • Rehab

    • Surgery

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