Two types of brain injury occur

• Closed brain injury

• Open brain injury
 Closed Head Injury
• Resulting from falls, motor vehicle crashes,
etc.
• Focal damage and diffuse damage to axons
• Effects tend to be broad (diffuse)
• No penetration to the skull
 Open Head Injury
• Results from bullet wounds, etc.
• Largely focal damage
• Penetration of the skull
• Effects can be just as serious
 Spectrum of injury

• Laceration
• Contusion
• Fracture
• Haemorrhage - extradural, subdural,
subarachnoid, intraparenchymal
• Diffuse axonal injury
 Diffuse Axonal Injury

• LOC  Coma
• Motor posturing
– Decorticate and decerebrate
• Autonomic dysfunction
– Hypertension and hyperpyrexia
 Extradural haematoma
• Biconvex or lenticular
• Temporal or temporoparietal
• Middle meningeal artery
• 0.5% of all head injured pts
• “Lucid” interval classically
• 9% of those who are comatose
• Outcome related to status prior to surgery
 Subdural haematoma
• 30% of severe head injuries
• Subacute/chronic esp elderly/ETOH
– Trivial or no recognizable injury
• Tearing of bridging veins
• Entire surface of brain
• Underlying brain damage more severe
• Prognosis is worse than extradural
 Physiology
• Monro-Kellie doctrine – closed box
– ICP related to vol. brain + vol. blood + vol. CSF
• Cerebral perfusion pressure
CPP = Mean arterial pressure – ICP
(Normal ICP = 10 mmHg)
• CPP used as proxy indicator of CBF
(50mL/100g/min)
Cerebral Blood Flow Cerebral Autoregulation

60 160

Cerebral Perfusion Pressure (mmHg)

 Glascow Coma Scale

Eye Verbal Motor

6 Obeys
5 Normal Localizes
4 Spontaneous Confused Withdraws
3 Voice Inappropriate abN flexion
2 Pain Incomprehensible Extension
1 Nil Nil Nil
 Paediatric GCS
• Eye opening and < 4 years 4-15 years
Motor response are 5 orientated to 5 orientated and
essentially the same sounds, smiles converses
& interact
• Verbal response is:
4 Consolable 4 disorientated
and converses
3 inconsistently 3 inappropriate
consolable odd words

2 inconsolable 2 incomprehen.
sounds
1 No response 1 No response
 Spectrum of injury

• Mild H.I. GCS 13 – 15 80%

• Moderate GCS 9 – 12 10%
• Severe GCS < 9 10%
GCS features N/surgery
Low risk 15 No LoC/Vom/Amnesia/ha 0.1%

Medium 15 + LoC/Vom/Amnesia/ha 1-3%

High risk 14/15 + #, &/or neuro deficit Up to 10%
 Traumatic Brain Injury

1. Primary Injury : 2. Secondary Injury:

Damage at the time Complications after

of injury initial injury
 Traumatic Brain Injury
Primary damage
• Cerebral laceration
• Cerebral contusion
• Dural sac injury - bleeds
• Diffuse axonal injury
 Traumatic Brain Injury
Secondary damage
• Hypoxia - ischaemia
• Raised intracranial pressure
• Metabolic abnormalities
• Infection
 History - Mechanism
• Height of fall/ speed of impact
• Weapon/ surface
– pointed/ flat
– hard/ soft

• Site of impact
 History - patient

• Alcohol/ Drugs/ pre-trauma state

• Loss of consciousness/ Seizure
• Amnesia/ Headache
• Vomiting
 Examination

• General
• Head/scalp
• PNS/CNS
• Cerebellar signs/gait
 Initial Resuscitation

• Optimise Oxygenation A&B + Cs

• IV access! and avoid hypotension

• BM +/- ABG
 CAUTION
• Other life threatening injuries take precedence
• Treat fits early
• Hypoglycaemia
• Protect from infection including tetanus
 Medical therapies
• Intravenous fluids
• Hyperventilation
• Mannitol/Furosemide
• Steroids
• Anticonvulsants
– 15% epilepsy with severe HI
• Head tilt
 General Overview
• Spinal Cord Injury is damage to the spinal cord that
results in a loss of function such as mobility or feeling
• Frequent causes of damage are trauma and disease
• Spinal Cord is the major bundle of nerves that carry
impulses to/from the brain to the rest of the body
• Spinal Cord is surrounded by rings of bone-vertebra
• They function to protect the spinal cord
 Scale of Motor Strength in SCI
• The American Spinal Injury Association:
– 0 - No contraction or movement
– 1 - Minimal movement
– 2 - Active movement, but not against gravity
– 3 - Active movement against gravity
– 4 - Active movement against resistance
– 5 - Active movement against full resistance
• Assessment of sensory function helps to identify the
different pathways for light touch, proprioception,
vibration, and pain. Use a pinprick to evaluate pain
sensation
 Types of Spinal Cord Paralysis
• Depending on the location and the extent of the
injury different forms of paralysis can occur
• Monoplegia- paralysis of one limb
• Diplegia- paralysis of both upper or lower limbs
• Paraplegia- paralysis of both lower limbs
• Hemiplegia- paralysis of upper limb, torso and lower
leg on one side of the body
• Quadraplegia- paralysis of all four limbs
 Spinal Cord Paralysis Levels
C1-C3
• All daily functions must be totally assisted
• Breathing is dependent on a ventilator
• Motorised wheelchair controlled by sip and puff or chin movements is
required
C4
• Same as C1-C3 except breathing can be done without a ventilator
C5
• Good head, neck, shoulder movements, as well as elbow flexion
• Electric wheelchair, or manual for short distances
C6
• Wrist extension movements are good
• Assistance needed for dressing, and transitions from bed to chair and car
may also need assistance
C7-C8
• All hand movements
• Ability to dress, eat, drive, do transfers, and do upper body washes
 Spinal Cord Paralysis Levels
T1-T4 (paraplegia)
• Normal communication skills
• Help may only be needed for heavy household work or
loading wheelchair into car
T5-T9
• Manual wheelchair for everyday living
• Independent for personal care
T10-L1
• Partial paralysis of lower body
L2-S5
• Some knee, hip and foot movements with possible slow
difficult walking with assistance or aids
• Only heavy home maintenance and hard cleaning will need
assistance
 Complete and Incomplete
Spinal Cord Syndromes can be classified into either
complete or incomplete categories
• Complete – characterized as complete loss of motor
and sensory function below the level of the
traumatic lesion

• Incomplete – characterized by variable neurological

findings with partial loss of sensory and/or motor
function below the lesion
 Spinal Shock
• An immediate loss of reflex function, called areflexia,
below the level of injury
• Signs:
– Slow heart rate
– Low blood pressure
– Flaccid paralysis of skeletal muscles
– Loss of somatic sensations
– Urinary bladder dysfunction
• Spinal shock may begin within an hour after injury
and last from several minutes to several months,
after which reflex activity gradually returns
 Central Cord Syndrome
• Usually involves a cervical lesion
• May result from cervical hyperextension causing
ischemic injury to the central part of the cord
• Motor weakness is more present in the upper limbs
then the lower limbs
• Patient is more likely to lose pain and temperature
sensation than proprioception
• Patient may complain of a burning feeling in the
upper limbs
• More commonly seen in older patients with cervical
arthritis or narrowing of the spinal cord
 Brown-Sequard Syndrome
• Results from an injury to only half of the
spinal cord and is most noticed in the cervical
region
• Often caused by spinal cord tumours,
trauma, or inflammation
• Motor loss is evident on the same side as the
injury to the spinal cord
• Sensory loss is evident on the opposite side
of the injury location (pain and temperature
loss)
• Bowel and bladder functions are usually
normal
• Person is normally able to walk although
some bracing or stability devices may be
required
 Anterior Spinal Cord Syndrome
• Usually results from compression of the artery that
runs along the front of the spinal cord
• Compression of SC may be from bone fragments or a
large disc herniation
• Patients with anterior spinal cord syndrome have a
variable amount of motor function below the level of
injury
• Sensation to pain and temperature are lost while
sensitivity to vibration and proprioception are
preserved
 Incomplete Spinal Injuries

CLINICAL SYNDROMES:

Conus Medullaris: saddle anesthesia, incontinence (painless, symmetrical)

Cauda Equina: saddle anesthesia, incontinence (painful, asymmetrical)

 Spinal Column Injury
Atlanto-occipital dislocation
• Atlanto-occipital
dislocation (AOD) is a
devastating condition
that frequently results
in prehospital
cardiorespiratory
arrest
• accounts for 1% of
spinal trauma.
• AOD occurs 3 times

Power’s ratio=BC/OA<1
more commonly in
children than adults,
• hyperextension.
• Unstable
 Spinal Column Injury
Atlanto-Axial dislocation
• Lower mortality than
Atlanto-occipital dislocation
• 1/3 of patients have deficit
• Transverse ligament injury
• AAD occurs more commonly
in children than adults
• Non-traumatic in downs
syndrome and Rheumatoid
arthritis
• Unstable ADI> 5mm
 Spinal Column Injury
Atlas (C1) fractures
• Described as Jefferson
fracture
• Axial load
• Usually no neurological
deficit
• 1/3 have C2 fracture
• Usually stable
 Spinal Column Injury
Axis (C2) fracture
• Includes Hangman’s
fracture and Odontoid
process fracture
HANGMAN’S fracture
• Bilateral # of the isthmus of
the pedicles of C2 with
anterior sublaxation of C2-
C3
• Hyperextention and axial
loading
• Usually stable
 Spinal Column Injury
Axis (C2) #
• Includes Hangman’s # I
and Odontoid process #

Odontoid #
• Flexion injury II
• 15% of all cervical
injuries
• II unstable,I & III stable
III
 Spinal Column Injury
Subaxial (C3-C7) #
Whiplash injury:
• Traumatic injury to the soft
tissue in the cervical region
• Hyperflexion,
hyperextention
• No fractures or dislocations
• Most common automobile
injury
• Recover 3-6 months
 Spinal Column Injury
Subaxial (C3-C7) #
Vertical compression injury:
• Loss of normal cervical
lordosis
• Burst fracture
• Compression of spinal cord
• Unstable
• Requires decompression
and fusion
 Spinal Column Injury
Subaxial (C3-C7) #
Compression flexion injury
(teardrop #)
• Classical diving injury
• Posterior elements
involved in >50%
• Displacement of inferior
margin of the body
• Unstable
• Requires stabilization
 Spinal Column Injury
Subaxial (C3-C7) #
flexion distraction injury
(locked facet)
• >50% displacement
• Unstable
• Requires reduction and
stabilization
 Spinal Column Injury
Subaxial (C3-C7) fracture
extention injury (fracture of
posterior elements)
• Fracture of the lamina,
pedicles or spinous process
• With or without
ligamentous injury
• Usually stable
 Spinal Column Injury
Thoracic and lumbar fracture

Stability (three column

model of Denis)
• Injury affecting two or
more column is unstable
 Spinal Column Injury
Thoracic and lumbar fracture

• Compression fracture
• Burst fracture
• Chance fracture (seat belt)
• Flexion distraction
• Fracture dislocation