Head and Spinal Injuries

Question 1

Present (correct formatting) the GCS score of someone who Obeys commands, is oriented in space/time/person when asked but only opens their eyes to pain?

Answer 1

GCS: 2/4, 5/5, 6/6

Question 2

Present (correct formatting) the GCS score of someone who flexes their arm to pain, is cussing at you, and opens eyes spontaneously

Answer 2

4/4, 3/5, 3/6

Question 3

Present (correct formatting) the GCS score of someone who extends their arm to pain, is confused, and opens eyes only to your voice

Answer 3

3/4, 4/5, 2/6

Question 4

Present (correct formatting) the GCS score of someone who elicits no response to pain and is only mumbling

Answer 4

1/4, 2/5, 1/6

Question 5

Present (correct formatting) the GCS score of someone who localizes to pain, is not making any sounds and eyes closed unless their is pain.

Answer 5

2/4, 1/5, 5/6

Question 6

Present (correct formatting) the GCS score of someone who withdraws their arms to pain, is rambling about their sad days.

Answer 6

4/4, 4/5, 4/6

Question 7

In an emergency situation, when is intubation indicated?

Answer 7

GCS 8 or lower

Question 8

How would you grade the severity of a TBI?

Answer 8

GCS scoring.
Mild 13-15
Moderate 9-12
Severe <9

Question 9

What is the normal range of ICP and at what ICP would you treat it in a TBI?

Answer 9

Normal = 7-15mmHg
Treat if >22mmHg

Question 10

What is normal MAP?

Answer 10

70-100 mmHg

Question 11

What is Cerebral perfusion pressure?
What is the normal amount?
In terms of head injury, what would happen if it is reduced?

Answer 11

CPP = MAP (ABG) - ICP (Probe)
Normal = 60-70 mmHg
Reduced = secondary ischemia

Question 12

How is ICP monitored in TBI?
What are the indications to monitor ICP in TBI?
What is the cutoff to begin treatment?
What are all the lines of management?

Answer 12

Monitored via a probe most commonly inserted intraventricularly. Others include intraparenchymal, subarachnoid, and epidural
Indications for monitoring: Either
1) GCS <8 + CT evidence of Mass effect (midline shift)
2) Normal CT and 2 of: age>40, systolic <90, Motor posturing

Treatment for increased ICP in TBI is indicated when ICP >22mmHg
1) Drainage of CSF
2) Sedation (lowers metabolic demands)
3) Hyperosmolar therapy (mannitol - osmotic diuretic, hypertonic saline)
4) Surgical: Decompressive craniectomy, Ventricular drain (VP shunt), Burr holes, craniotomy

Question 13

How would you determine bleeding risk and coagulopathy? What are the normal values. What would be considered a risk?

Answer 13

Coagulopathy screen/INR
aPTT (normal 30-40/heparin 60-80)/ Normal <1.2
High above those values or INR >1.5

Question 14

Trauma associated with the highest mortality is trauma to the head. What is meant by primary and secondary head injury? Give examples of each

Answer 14

Primary injuries are those that occur at time of injury and are irreversible. These include
1) Cerebral Concussion
2) Cerebral Contusions and laceration
3) Diffuse Axonal Injuries

Secondary injuries are those that occur subsequently. Management focuses on reducing these to prevent neurological deficits, cognitive decline, chronic disability, and death. They include
Intracranial causes: Intracranial hematoma (epi and subdural), raised ICP, Cerebral swelling, post-traumatic seizure, intracranial infection
Systemic causes: Hypoxia, Hypercapnia, Hypotension, Hyperthermia, Hyper/hypoglycemia

Question 15

What is a cerebral concussion?
What symptoms are associated with it?

Answer 15

Cerebral concussion, a primary head injury, is the transient dysfunction most severe immediately after injury and resolves in a variable amount of time

Symptoms: Amnesia, irritability, lethargy, and LOC (sometimes)

Question 16

Cerebral contusions and lacerations are primary head injuries. What do they lead to? Give examples.
What would be your immediate investigation?

Answer 16

These lead to focal brain injuries => epidural, subdural hemorrhages….

Non-contrast CT

Question 17

Diffuse axonal injury occurs via what mechanism of injury?
What finding on non-contrast CT would support this?

Answer 17

Typically from mechanical shearing after deceleration e.g. RTA

a/w intraparenchymal/intracerebral hemorrhage/hematoma. Other findings would include midline shift
Note: This means that intraparenchymal hemorrhage can be caused by both contusions and diffuse axonal injuries. There are also physioplogical causes (SAH lecture) including AV malformations…

Question 18

How do you treat a depression skull fracture?

Answer 18

Elevation

Question 19

ATLS guidelines indicates conducting primary, secondary, and tertiary assessment on patients with a traumatic head or spine injury. What do these mean?

Answer 19

Primary assessment: Typical ABCDE, with full GCS and C-spine immobilization
Secondary: Full head to toe assessment + further investigations
Tertiary assessment: After stabilization of the patient. Everything after that including management

Question 20

Without going into detail, what is your management plan for a patient presenting with a head injury?

Answer 20

All patients must have a non-contrast CT brain and, ideally, admitted into hospital for 24 hours for observation.

Primary assessment: Typical ABCDE, with full GCS and C-spine immobilization
Secondary: Full head to toe assessment + Non-contrast CT brain + bloods etc…
Tertiary assessment:
a) Conservative: ICP monitoring (7-15 normal, aim <22), CPP (60-70), Mannitol, Sedation (lowers metabolic demand), Steroids (methyprednislone)
b) Surgical: Ventricular drain (VP shunt), Burr holes, Craniotomy, Elevation (depression skull fracture)

Question 21

Describe the anatomy of the spine in terms of vertebra and curvature

Answer 21

7 cervical (8 nerves) Lordosis
12 thoracic kyphosis
5 Lumbar Lordosis
5 Sacral (fused) kyphosis
5 coccyx (fused)

Question 22

What part(s) of the vertebral column, in general, is most associated with pathologies?

Answer 22

Transitional parts e.g. between C7 and T1 (SNS) and between T12 and L1 (osteoporosis)

Question 23

What vertebra have the highest propensity for injury?

Answer 23

Cervical vertebral
C4-C7

Question 24

What type of injury is most associated with the cervical vertebra?

Answer 24

Translational-type injury

Question 25

Which vertebra are most associated with pathological compression fractures?

Answer 25

Pathological fractures as in from diseases such as osteoporosis
Thoracolumbar region
T12-L2

Question 26

Which vertebra are most associated with high kinetic injury such as RTA or falling from a height?

Answer 26

Thoracic

Question 27

What type of fracture is most associated with the thoracic vertebra?

Answer 27

Burst fractures

Question 28

A patient presents to the ED via ambulence after suffering a RTA. He was wearing his seatbelt and has ecchymosis all over his abdomen. What is the most likely fracture sustained?

Answer 28

Restrained RTA is an example of very high kinetic force
Abdominal pathology likely
Most likely fracture is Distraction (Seatbelt fracture)

Question 29

On MRI of the spine you see a segment of the vertebra displaced posteriorly. What is this called?
What type of spinal fracture is associated with it?

Answer 29

Retropulsed segments
a/w burst fractures of the thoracic spine

Question 30

The stability of a joint (facet joint in spine) is dependent on the three compartments of the vertebrae as seen in the image.
Based on this image, what would need to occur for it to be considered unstable?
What are the 4 different types of spinal fractures along with their management? List them in order of instability.

Answer 30

Instability ensues when 2 or more compartments (or 3 points) are involved in the fracture
dont worry about the extra info you just need to answer the question
1) Compression fracture: Usually minor trauma (fall from standing height) in an elderly patient or one with osteoporosis. Typically stable. T12-L2
Tx: TLSO brace for most. If needed -> Vertebroplasty

2) Burst: High kinetic energy, mostly thoracic, retropulsed segments cause wedge compression leading to neurological deficit.
Tx: Surgical instrumentation

3) Translational/Rotational: Very high kinetic energy, mostly cervical (C4-C7), severe neurological deficit
Tx: Urgent C-spine Stabilization + Surgical instrumentation

4) Distraction: Highest energy fracture (e.g. restrained RTA), a/w abdominal pathology
Tx: Urgent C-spine stabilization + surgical instrumentaion

Question 31

List the major 3 spinal segments in order of most to least likely to be fractured

Answer 31

Cervical (50-60%)&raquo_space; Lumbar (20-25%) > Thoracic (15-20%)

Question 32

How would you stabilize the C-spine?

Answer 32

Collar or blocks

Question 33

A patient presents to the ED after suffering spinal trauma. You immediately begin management with stabilizing the C-spine. How would you examine the body for any additional trauma?

Answer 33

Log rolling to prevent further injury.
Looking for more head, neck and back trauma

Question 34

Spinal trauma at C3

Answer 34

C3 or above: Respiratory arrest

Question 35

Spinal trauma at C5

Answer 35

C5 or above: Paradoxical diaphragmatic breathing

Question 36

What are the causes of paradoxical breathing?

Answer 36

Normal in children <2
Abnormally: Chest trauma (just happens or injury to phrenic nerve), neuromuscular disorders (myasthenia gravis, ALS, Guillian Barre), COPD, Asthma

Question 37

What type of shock is associated with spinal trauma?
What category of shock does that fall into?
What are the signs of neurogenic shock?
How would you treat it?

Answer 37

Neurogenic shock, a type of distributive shock. Spinal trauma may cause SNS outflow to be disrupted => inability to vasoconstrict => vasodilation and bradycardia (unopposed vagal nerve PNS)

Signs:
1) Hypotension (from vasodilation) + bradycardia
2) Skin warm and flushed (from vasodilation)
3) Priapism (from vasodilation)
4) Respiratory arrest (injury C3)
5) Paradoxical diaphragmatic breathing (C5)

Tx: Fluids, Vasopressors, Atropine

Question 38

What are some vasopressors
Bonus points if you put moa

Answer 38

Vasopressors are also cardiac inotropes. alpha adrenergic receptors vasoconstrict and beta adrenergic deal with cardiac excitability => increase HR

Norepinephrine (mostly alpha agonist) - Fast acting
Epinephrine (both alpha and beta) - Fast acting
Vasopressin (mimics ADH => causes vasoconstriction) - medium acting
Terlipressin (vasoconstricts splanchnic flow, not used here)

Question 39

What is the mechanism of action of Atropine as a tx for neurogenic shock

Answer 39

It is used to treat bradycardia here (note at low doses it can cause bradycardia). It inhibits acetylcholine, in charge of PNS, => increase SNS => increase heart rate

Question 40

A patient presents to the ED after suffering an RTA with suspicion of a fracture to the spine. What is to be included in your initial assessment (primary and secondary assessment). Dont go into detail of ABCD, just the major aspects of each assessment that is relevant to a patient presenting with spinal trauma)

Answer 40

Primary Assessment:
ABCDE +
1) C-spine stabilization
2) Examine for head, neck, back trauma via LOG ROLLING
3) Identify and treat neurogenic shock
4) Aggressive IV fluid Resus at 20ml/kg (2x large bore)

Secondary Assessment:
1) Head to toe exam
2) Neurological assessment: ASIA impairment score and check for Spinal shock
3) CT/MRI
4) Other investigations: Bloods, ABG…

Question 41

As part of the Neurological assessment of spinal trauma, you will be going through your upper and lower limb, motor and sensory examinations. How would you assess their level of impairment?

Answer 41

ASIA Impairment Scale:
A: Complete motor and sensory deficit below level
B: Incomplete: Sensory in tact, complete motor deficit
C: Incomplete: Sensory in tact, Motor <50% power <3/5
D: Incomplete: Sensory in tact, Motor >50% power >3/5
E: Normal function of both motor and sensory

Question 42

As part of the Neurological assessment of spinal trauma, you will be going through your upper and lower limb, motor and sensory examinations. You assess their level of impairment using the ASIA impairment scale. You need to assess the power of the individual across different joints. How would you assess power?

Answer 42

0: No contraction
1: Flickers/trace of contraction
2: Movement without gravity
3: Movement against gravity
4: Movement against gravity + moderate resistance
5: Normal

Question 43

As part of the Neurological assessment of spinal trauma, you will be going through your upper and lower limb, motor and sensory examinations. You would like to assess their reflexes. What is the significance of testing for reflexes in the setting of spinal trauma?
What are you expecting to find in a patient on secondary assessment as part of your initial evaluation on presentation? How will that change over time (be specific)?

Answer 43

Its accepted if you first thought upper motor vs lower motor. A spinal cord injury is an upper motor neuron injury so there you go!
We are checking for Spinal shock. This is the transient loss of sensation + motor paralysis with gradual recovery of reflexes. This occurs in 4 phases:
Phase 1: Areflexia (expected in this case) 0-1days
Phase 2: Initial return (of bulbocavernosus reflex) 1-3 days
Phase 3: Hyperreflexia 1-4 weeks
Phase 4: Hyperreflexia with spasticity 1-12 months
Then starts getting back to normal

Question 44

What is the bulbocavernosus reflex?
What is its significance in spinal trauma?

Answer 44

It is the first reflex to return after spinal trauma (especially sacral for obvious reasons). It is the reflex contraction of the anal sphincter elicited by squeezing the glans penis or touching the clitoris

Question 45

What pattern of spinal cord injury is associated with cervical injuries?

Answer 45

Tetraplegia

Question 46

Paraplegia is associated with trauma to which segment of the vertebrae?

Answer 46

Thoraco-lumbar

Question 47

The spinothalamic tract is an ascending pathway responsible for ____ + ____ sensation. It decussates in the ____ => damage to this would cause symptoms _____

Answer 47

Pain and temperature, decussates in the spinal cord => contralateral

Question 48

The Dorsal column(s) is an ascending pathway responsible for ____ + ____ sensation. It decussates in the ____ => damage to this would cause symptoms _____

Answer 48

Vibration and proprioception (and deep tendon reflexes), decussates in medulla => ipsilateral

Question 49

What tract is responsible for the motor pathway. Is it ascending or descending

Answer 49

Descending corticospinal tract

Question 50

List the different patterns of spinal cord injury

Answer 50

1) Complete: Tetraplegia (Cervical), Paraplegia (thoracolumbar)
2) Incomplete: Anterior, Central and Posterior Cord Syndrome, Brown Sequard Syndrome, Conus Medullaris
3) Cauda Equina is lower motor neuron but it is a spinal cord injury

Question 51

What is paraplegia?
What is paraparesis?

Answer 51

Paraplegia = paralysis of lower limbs
Paraparesis = weakness of lower limbs

Question 52

What is tetraplegia?

Answer 52

paralysis of all 4 limbs

Question 53

Anterior Cord Syndrome:
Causes?
Symptoms?

Answer 53

Causes: Hyperflexion injury (RTA, contact sports) or Disruption of anterior spinal artery
Anterior cord => spinothalamic and corticospinal tracts affected bilaterally
Symptoms: Bilateral loss in motor, pain and temp !below level of injury!

Question 54

Central Cord Syndrome:
Causes?
Symptoms?

Answer 54

Causes: Hyperextension injury (fall down stairs) or classically in elderly patients with underlying cervical disease (cervical spondylosis, disc herniation, spinal stenosis)
Affects the central areas of all tracts

Symptoms: Bilateral loss of motor and sensory (upper limb > lower limb) below level! why? Homunculus has upper limb more centrally and lower limb laterally

Question 55

Posterior Cord Syndrome:
Symptoms?

Answer 55

Affects Dorsal Columns
Ipsilateral loss of vibration and proprioception (and deep tendon reflexes) below level!
=> !!Ataxic gait, hypotonia, reduced/absent reflexes!!

Question 56

Brown Sequard Syndrome:
Causes?
Symptoms?

Answer 56

Causes: Penetrating trauma or lateral compression
Affects one side completely (all tracts)
=> Ipsilateral loss of Vibration, proprioception, and deep tendon reflexes below level!
=> Contralateral loss of pain and touch below level!

Question 57

What is Priapism?
In the presence of spinal trauma, what is its relevance?
Damage to which level of the spinal cord will cause priapism?

Answer 57

Prolonged erection of penis
It is a symptom of neurogenic shock.
Although SNS outflow to the penis is through the Conus, damage to any area above it will cause this symptom to occur. Thats why it is a great indicator or neurogenic shock. Thats how the spinal cord works… everything below the level of the insult

Question 58

What is the Conus Medullaris. How is it different from the Cauda Equina?
In the realm of spinal trauma, what are the symptoms of Conus Medullaris and Cauda Equina and what differentiates them?

Answer 58

The Conus Medullaris is the most distal part of the spinal cord (UMN), right before the hair-like structures coming out which are the Cauda Equina (LMN).

Both have: Perianal anesthesia, LL weakness, bowel and bladder incontinence, and sexual dysfunction

Conus is UMN => Symmetrical, Hyper reflexic, and associated with impotence
Cauda is LMN => asymmetrical Hypo reflexic and not associated with impotence

Question 59

What type of drug is Clexane?

Answer 59

LMW, DVT/PE/VTE prophylaxis

Question 60

A patient with spinal cord trauma presents to the clinic 2 weeks post-op complaining of lightheadedness when getting up from bed in the morning. How would you treat it?

Answer 60

Midodrine (Alpha adrenergic agonist) makes sense because vasoconstriction

Question 61

A patient with spinal cord trauma presents to the clinic 2 weeks post-op complaining of pain. How would you treat pain that is somatic?

Answer 61

Paracetamol –> NSAIDs –> Opiates (morphine/oxycontin)

Question 62

A patient with spinal cord trauma presents to the clinic 2 weeks post-op complaining of pain. How would you treat pain that is neuropathic?

Answer 62

Pregabalin, Gabapentin, TCAs, (amitriptyline, venlafaxine)

Question 63

A patient with spinal cord trauma presents to the clinic 11 months post-op complaining of pain. How would you treat pain that is neuropathic in this case?

Answer 63

Spinal cord stimulation. It is an implanted device that prevents ascending signals from reaching the brain

Question 64

A patient with spinal cord trauma presents to the clinic 2 weeks post-op complaining of spasms. How would you treat it?

Answer 64

Baclofen