E. R. Flotte
MD, 2009
Please
send comments and corrections to admin@flotte2.com
Intracranial
pressure (ICP)
·
Cerebral
Perfusion Pressure (CPP) = MAP (Mean Arterial Pressure) – ICP
o Generally recommended to keep CPP 50-70.
·
ICP
monitoring:
o ICP
Waveform: P1
= percussion wave, systolic contraction, decreased with↑ ↑ ICP, ↓ compliance; P2 = tidal wave; P3 = aortic valve closure.
o Lundberg Waves: A (Plateau) = > 50mmHg rise
for > 20min. B = >20mmHg,
lasts 1-2min. C = 4-8Hz.
o Monitors:
§ Intraventricular Catheter: with pressure transducer/
external strain-guage. Allows CSF drainage. May also
have fiberoptic monitor incorporated.
§ Intraparenchymal Monitor
§ Subarachnoid Bolt: less accurate
§ Subdural & Epidural monitors: less accurate
·
General indications:
o
GCS ≤ 8 and abnormal CT or
o
GCS ≤ 8 and normal CT and 2 of:
age >40yrs, posturing, SBP <90
o
Neurologic examinations unavailable
(surgery, pharmacologic paralysis)
·
Signs of increased ICP:
o
Pupilary dilation/ CN3 palsy: 90%
ipsilateral mass.
o
Hemiparesis
(cerebral peduncle compression): 70%
contralateral mass.
o
Cushings
response: Hypertension, bradycardia, and respiratory irregularity due to increased
ICP and brainstem compression.
·
Hypertension is due to peripheral
vasoconstriction and catecholamine release; bradycardia is due to medullary ischemia.
·
Jugular Venous Monitoring
o
Necessary during barbiturate coma.
Normal SjO2 >50%.
·
Brain Tissue Oxygen (PbrO2) monitoring
o
Keep PbrO2 > 15mmHg
·
Cerebral
Microdialysis: measures tissue glucose, pyruvate, lactate, glycerol, glutamate, urea.
Currently used in experimental settings.
o
Systems:
CMA Microdialysis
Raise
head-of bed (HOB) 20-30º
·
Elevation may lower CPP
Sedation/Paralysis
·
Morphine (4mg/hr), Versed, Propofol commonly used.
o
Propofol
is quickly reversible (10 min.), allowing neuro
checks
Ventricular
drainage
·
Continuous or intermittent
Mannitol
·
Improves rheology
(decreased blood viscosity) and has osmotic effect on cerebral edema lasting up
to 6 hrs.
·
Prolonged use may distrupt
BBB increasing edema
·
Contraindications: hypotension, renal
failure.
·
Common dose: 1mg/kg initially, then
0.25-0.5 mg/kg q6hrs. Check Serum Na & Osm before giving. Hold if Na >
150-160, or Osm > 320 (limits can vary depending on the situation).
·
High-dose
(1.4g/kg) given wide open in patients GCS3 & fixed pupils had 33% more favorable outcome. (JN3/04)
·
Alternatives or adjuncts include Lasix,
hypertonic saline (3% continuous or 9-23% bolus through CVL).
o
3%
saline: 7.5% to 30% boluses Benefit is unclear for continuous infusion of 3%.
Withdraw over 24-48hrs
Hyperventilation:
·
Generally keep CO2 30-35. Avoid
prolonged hyperventilation (PaCO2 <25mmHg).
·
Some suggest avoiding prophylactic
hyperventilation (PaCO2 <35) in the first 24hrs to avoid decreasing CPP,
except as a temporizing measure.
·
Use acutely (CO2 to 25 by manual
bagging) only for acute ICP plateaus
·
Monitor SjO2 or PbrO2 for significant
continuous hyperventilation
Decompressive
craniectomy
·
14cm diameter appears optimal.
·
May be done initially with hematoma
removal or within 48 hours of injury
due to refractory increased ICP
·
Hygromas occur, resolve spontaneously
in most (JN4/06)
·
Reconstruction:
Timing controversial.
·
Cochrane
Database: Only one high quality trial was identified;
which involved 27 pediatric patients who received either DC or conventional
treatment. The results indicate that the risk of death and disability was
moderately reduced when DC was used. No trials investigating the effectiveness
in adults were found. However,
the results of non-randomized trials and controlled trials with historical
controls involving adults, suggest that DC may be a useful option when maximal
medical treatment has failed to control ICP.
·
There
are two ongoing randomized controlled trials of DC (Rescue ICP and DECRAN).
·
Pediactric TBI: Has been used
with favorable outcome. See J Jagannathan JN:P4/07
Barbiturate
Coma
·
To burst-suppression on EEG. Serum
levels are used, but have poor correlation to clinical benefit.
·
Pentobarbital: Loading: 10 mg/kg over
60min, then 5mg/kg/hr x3hrs, then 1mg/kg/hr (Thiopental may be substituted).
·
Side-effects: hypotension
Hypothermia:
to 95º is accepted. <95º is controversial. Avoid hyperthermia.
·
NABIS: Hypothermia study showed
reduced ICP but no difference in 6 month outcomes.
Minor Head Injury
·
LOC <1min, normal mental status, no
deficits on initial exam, no skull fracture
·
Guidelines for children with mild head
injury published (Pediatrics, 1999)
·
For LOC (more than seconds), amnesia,
vomiting, lethargy, GCS >13, no focal deficits or seizures, skull fracture
(except across MMA, venous sinuses, or depressed), otherwise normal CT:
observed for 2hrs, if GCS 15, no deterioration, able to hold down liquids, and
reliable caretaker, can discharge (JN:P 8/04)
·
New Orleans Criteria and
o
In predicting the need for
neurosurgical intervention the NOC and the CCHR both had 100% sensitivity but
the CCHR was more specific (76% vs 12%).
·
0.3% incidence of deterioration with
normal CT (delayed EDH, diffuse brain swelling)
Sports-concussion
·
See
Cantu RC N6/07
·
Grading:
Cantu or AAN grades
·
Concussion
in sport consensus statements: “National Athletic Trainers’ Association Position
Statement: Sport-Related Concussion,” Journal of AthleticTraining;
·
Guskiewicz KM, The NCAA Concussion Study. JAMA 290:2549, 2005.
·
More
than 90% of athletic concussions do not involve LOC. LOC does not correlate
with the severity of concussion symptoms.
·
Management
must be individualized, determining severity of injury after all symptoms and
signs have resolved. Factors that must be considered include age, sport,
previous history of concussion, specific symptoms associated with the injury.
·
No
athlete with postconcussion signs or symptoms should
be allowed to return to competition while symptomatic.
Traumatic Brain Injury (TBI)
·
Guidelines
for the Management of Severe Traumatic Brain Injury, 3rd Edition
(Journal Of Neurotrauma
24Supp1)
·
Guidelines for the Surgical Management of Traumatic Brain Injury, N3/06S
General
TBI Treatment
o
Keeping ICP<20 improves outcome.
o
Keep CPP >50-70. Avoid aggressive
measures to keep CPP >70 (e.g. fluid overload)
o
Note:
Cochrane Database states there are no
data from randomized controlled trials that can clarify the role of ICP
monitoring in acute traumatic coma
·
Normalize BP (SBP >90mmHg),
temperature, oxygen (SaO2>90%, PaO2>60). Keep mildly hypervolemic (CVP
>8). Normalize hematocrit. H2 blocker.
·
Nutrition: paralyzed 100% BME,
non-paralyzed 140% BME
·
Imaging: 3-view c-spine, CXR, pelvis xrays. CT head (uncontrasted) and
abdomen. Labs: BSB, type & cross, BMP, ABG, coags,
urine toxicology
o
Repeat CT head for new ICP spikes.
Delayed hematomas occur in 10-15%
·
AEDs generally discontinued after 1
week if no seizures occur (and patient is stable)
·
Corticosteroids are not indicated in
TBI (Cochrane Database). CRASH
study (Lancet 04) RCT showed worse outcome at 2 weeks for patients receiving
steroids
·
Agents with insufficient evidence to
support routine use according to the Cochrane
Database: aminosteroids,
calcium channel blockers, amino acid inhibitors, hyperbaric oxygen,
hypothermia, magnesium, monoaminergic agonists,
sensory stimulation
·
Agitation/Aggression: propanolol
may be effective (Cochrane Database)
·
Experimental
TBI Treatment
·
Reviews:
Neurosurgical
Focus 10/08
·
AANS
Course: MANAGEMENT OF NON-OPERATIVE HEAD INJURY & INCREASED ICP
·
Audio: Neurotrauma: A 30-year Perspective – Becker DP
·
Audio: Brain Injury Management: Quo Vadis – Valadka AB
Epidural Hematoma (EDH) /
Subdural Hematoma (SDH)
·
Delayed enlargement in 10-30%.
Guidelines:
Indications for Surgery
·
An EDH > 30 cm3 should be surgically
evacuated regardless of the patient’s GCS score.
- An EDH less than 30 cm3 and with less
than a 15-mm thickness and with less than a 5-mm midline shift
(MLS) in patients with a GCS score greater than 8 without focal
deficit can be managed nonoperatively with
serial CT scanning and close neurological observation in a neurosurgical
center.
·
An acute
SDH with a thickness >10 mm or a midline shift greater than 5 mm should be surgically evacuated,
regardless of the patient’s GCS score.
·
All
patients with acute SDH in coma (GCS score less than 9) should undergo
intracranial pressure (ICP) monitoring.
·
A
comatose patient (GCS score less than 9) … should undergo surgical evacuation
of the lesion if the GCS score decreased
between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with
asymmetric or fixed and dilated pupils and/or
the ICP exceeds 20 mm Hg.
Timing
·
It
is strongly recommended that patients with an acute EDH in coma (GCS score
<9) with anisocoria undergo surgical evacuation as
soon as possible.
·
In
patients with acute SDH and indications for surgery, surgical evacuation should
be performed as soon as possible.
Cerebral Contusions/Hematoma
Supratentorial Guidelines:
Indications
·
Patients with parenchymal mass lesions and signs of progressive
neurological deterioration referable to the lesion, refractory intracranial
hypertension, or signs of mass effect on CT scan should be treated operatively.
·
Patients with GCS scores of
6 to 8 with frontal or temporal
contusions > 20 cm3 with
midline shift of > 5 mm and/or cisternal compression on CT scan,
and patients with any lesion greater
than 50 cm3 in volume should be treated operatively.
·
Patients with parenchymal mass lesions who do not show evidence
for neurological compromise, have controlled intracranial pressure (ICP), and
no significant signs of mass effect on CT scan may be managed nonoperatively with intensive monitoring and serial imaging.
Timing and
Methods
·
Bifrontal
decompressive craniectomy within 48 hours
of injury is a treatment option for patients with diffuse, medically refractory
posttraumatic cerebral edema and resultant intracranial hypertension.
·
Decompressive procedures, including subtemporal decompression,
temporal lobectomy, and hemispheric decompressive craniectomy, are treatment options for patients
with refractory intracranial hypertension and diffuse parenchymal injury with
clinical and radiographic evidence for impending transtentorial
herniation.
Posterior Fossa Guidelines
·
Patients
with mass effect on CT scan or with neurological dysfunction or deterioration referable to the
lesion should undergo operative intervention.
o
Mass
effect on CT scan is defined as distortion, dislocation, or obliteration of the
fourth ventricle; compression or loss of visualization of the basal cisterns,
or the presence of obstructive hydrocephalus.
·
Patients
with lesions and no significant mass effect on CT scan and without signs of
neurological dysfunction may be managed by close observation and serial
imaging.
Volume:
V=ABC/2
• A: measure the largest diameter, A.
• B: measure the largest diameter 90° to A on the same
slice, B.
• C: count the number of 10-mm slices.
• Compare each slice with slice 1.
• If the hemorrhage is greater than
75% compared with slice 1, count the slice as 1.
• If the hemorrhage is 25 to 75%,
count the slice as 0.5.
• If the hemorrhage less than 25%,
do not count the slice.
• Add up the total C.
Pediatric TBI
·
Barbiturate coma, CSF drainage more
effective than in adults.
Hyperventilation, mannitol may lower ICP without lowering CBF.
·
Increased risk of seizures.
·
Propofol
(continuous IV) for pediatric patients has been banned by the FDA (also in
pediatric TBI guidelines)
·
Diffuse Cerebral Swelling:
Due to venous congestion and hyperemia (not cytotoxic/ vasogenic edema). 50%
mortality.
·
Denny-Brown syndrome:
Bradycardia, agitation, HA due to vagal syncope, mimics EDH
Child abuse (Shaken Baby)
·
Common findings: Interhemispheric SDH,
skull fractures, multiple long-bone fractures of different ages (check skeletal
survey).
Diffuse
Axonal Injury (DAI): Path: Axonal
retraction balls. Locations: White matter, corpus callosum, dorsal brainstem
Traumatic Cranial Nerve
injury
·
Indirect optic
nerve injury: No prospective trial
showing decompression better than steroids except for delayed onset blindness.
o Surgery: Done within 1-3weeks, transethmoidal route
·
Transient cortical
blindness: Children may develop
lasting 1-2d after head injury.
o
Treat with steroids.
o
Immediate onset:
if no improvement on steroids, consider exploration (timing controversial).
o
Delayed onset:
Follow with ENOG (facial EMG). Consider exploration for continuous
deterioration on steroids and <10% function compared to normal side on ENOG.
Controversial.
Posttraumatic Seizures
·
Antiepileptics
prevent early (with 7 days), not late (after 7 days) seizures
·
Consider
beginning AEDs for: GCS <11, any hematoma or contusion, seizures,
penetrating injury, history of alcoholism, open depressed skull fracture
·
If
no seizures after 1 week discontinue antiepileptics.
Skull Fractures
·
Diastatic
fractures separate cranial sutures
·
Mandibular
fracture: think carotid
dissection.
·
Depressed fractures:
o
Closed: Observation is an option. Criteria
to elevate controversial but consider for >1cm or thickness of the skull,
neurologic deficit, cosmesis.
§ Elevation
may improve deficits (equivocal), doesn’t improve seizures.
o
Open fractures: >1cm or table
width, pneumocephalus or CSF leak, frontal sinus (see guidelines below).
Possible dural sinus injury
o
Indications for elevation
(controversial): refractory increased ICP due to sinus occlusion (Binder D N10/04).
§ Also
“gross contamination”, CSF leak, adjacent EDH/SDH/ICH needing evacuation.
§
Generally
felt to avoid elevation if possible
§
Open wounds may be closed with massive
irrigation alone (no elevation) (Geisler FH in Rengachary SS 2005)
o
MRV to assess sinus patency
o
Technique:
§ Have
Fogarty catheter ready. Prep out saphenous vein.
§ Prepare
for air
embolism: CVL, precordial Doppler. Keep head flat if
possible.
§ Expose
sinus on both sides (left/right for SSS or superior/inferior for transverse)
§ Repair
dural will with primary suture, pericranial or
muscular graft or synthetic graft (e.g. Goretex)
Frontal
Sinus fracture:
o
Mucocoeles
may result in a delayed fashion (years later) from obstruction of ostia (e.g. frontonasal duct) by fracture, etc. May cause mass effect on brain.
o
Treatment indications:
§ Anterior
wall fracture: nondisplaced - observe.
Displaced – some recommend
repair/endoscopy to present mucocele and
inspect/repair frontonasal duct.
§ Posterior
wall: Controversial. Repair considered for CSF rhinorrhea
(duration immediate to 7 days), pneumocephalus.
§ If
open or dural tear is suspected (pneumocephalus, CSF leak) then most do intradural exploration (see
below).
§
Consider exploration if displaced >
table width
§
Bifrontal craniotomy for dural
closure and frontal sinus cranialization or obliteration (removal muscoa,
drilling crypts, plugging duct, and filling sinus with bone)
Basilar
skull fracture:
o
Signs: CSF otorrhea or rhinorrhea,
o
In the absence of an open fracture,
pneumocephalus is diagnostic of basilar skull fracture.
o
Give Pneumovax
& Tdt.
o
Get CT with thin cuts.
o
Do not place NG tube with suspected or
proven basilar skull fractures
o
Treatment:
§
If no CSF leak observe and instruct
patient to observe
§
Require treatment: traumatic
aneurysm, carotid-cavernous
fistula, persistent
CSF rhinorrhea,
meningitis/abscess (may occur years later)
§ Prophylactic
antibiotics: Found ineffective with or without CSF leak in
Cochrane Review metaanalyisis (2006) and in several RCT (JN 11/04).
Anterior
Skull Base (frontobasal) fracture:
o
Surgery for CSF
leaks, comminuted fracture with suspected dural
tear, perforating injuries
o
Restore sinus drainage to prevent mucopyocele
o
Case Series:
Piek J
NF7/00
Temporal
fracture:
o
Transverse: Perpendicular to IAC.
Higher risk of CN 7,8 transection.
o
Longitudinal: Parallel to IAC. Delayed
facial palsy is usually due to edema, resolves.
Ping-Pong
Fractures: In infants. Can be treated with observation,
external suction, surgical repair (if severe, disfiguring, neurologic deficit).
Indications
·
Patients with open fractures depressed greater than the
thickness of the cranium should undergo operative intervention to prevent
infection.
·
Patients with open fractures may be treated nonoperatively
if there is no: clinical or radiographic evidence of dural penetration,
significant intracranial hematoma, depression greater than 1 cm, frontal sinus
involvement, gross cosmetic deformity, wound infection, pneumocephalus, or
gross wound contamination.
·
Nonoperative management of
closed (simple) depressed cranial fractures is a treatment option.
Timing
·
Early operation is recommended to reduce the incidence of
infection.
Methods
·
Elevation and debridement is recommended as the surgical method of
choice.
·
Primary bone fragment replacement is a surgical option in the
absence of wound infection at the time of surgery.
·
All management
strategies for open (compound) depressed fractures should include antibiotics.
Traumatic Intracranial or Cervical Vascular
Injury
·
Suspect
with acute or delayed SAH, ICH or stroke after injury
o
Also
unrelenting headache or neck ache.
·
Diagnosis:
CTA, MRA, angiogram
·
Traumatic
aneurysms
(intracranial or extracranial pseudoaneurysms)
o
Suspect
with penetrating brain injury
·
Traumatic
arterial dissection
o
Extracranial:
carotid, vertebral.
§
Suspect
with blunt injury to neck, cervical fractures, Horner’s
syndrome.
o
Intracranial
·
Traumatic
carotid-cavernous fistula
o
Suspect
with delayed proptosis, chemosis, eye pain, ophthalmoplegia.
Traumatic CSF leak
·
May occur through skin laceration, rhinorrhea, or otorrhea (ruptured
TM)
·
CSF Rhinorrhea:
most commonly through fractured cribiform plate into ethmoids. Also into
frontal or sphenoid sinus fractures or mastoids into Eustachian tube
·
May be associated with pneumocephalus
·
Glucose >30, B2-transferrin
positive.
- Classic
“ring sign” of questionable reliability
·
Locate and confirm:
1) Thin-cut CT ±
contrast (look for parenchymal enhancement)
2) CT
cisternography. Iohexol (water soluble contrast) –
inject by LP, requires active clinical leak. May be scanned
prone to enhance leak.
3) MR
Cisternography
4) Radionucleide cisternography
5) Intrathecal injection of fluorescein
with direct endoscopic (e.g. intranasal) inspection
6) Intrathecal injection of indium-DTPA dye with pledgets placed in nares
·
Treatment (traumatic or spontaneous
CSF leak):
·
Prophylactic antibiotics controversial
but not proven helpful
- Conservative:
bedrest?, Diamox?
- After
3-7 days: serial LPs (high-volume) or lumbar drain (position high enough to
avoid pneumocephalus – stop immediately for deterioration)
- Otorrhea
is more likely to resolve than rhinorrhea
- Surgery
if persists > 2wks or meningitis occurs (rhinorrhea).
·
Immediate surgery considered for
depressed fractures into frontal or sphenoid sinuses with dural tear or brain lacertaion
·
Concomitant facial fractures may be
repaired first – may stop leak
·
Frontal exploration:
·
Parasellar
or middle fossa leaks (e.g. sphenoid sinus): pterional
craniotomy
·
Frontal or ethmoidal
leaks: bifrontal
craniotomy
·
Dural defect found intradurally.
Intradural exploration preferred over extradural to avoid creating iatrogenic
dural tears mimicking fistula.
·
Dura then stripped around defect. Bone curetted. Defect packed (muscle, fat) and covered with pericranial flap.
Dura closed over defect.
Chronic SDH
·
Get intermediate CT windows.
·
“Black band” on internal membrane on
T2-MRI may predispose to enlargement
·
There is no evidence (RCTs) that prophylactic
anticonvulsant drugs reduce seizure risk for patients with chronic subdural
hematoma. Non-controlled
studies came up with conflicting results. (Cochrane
Database)
Penetrating Brain Injury (PBI)/
Gunshot Wound (GSW) to the Head
·
Consider giving tetanus toxin (Tdt),
antibiotics (not proven).
·
Consider angiogram for: delayed
hemorrhage, trajectory involving vessels, large hemorrhage in salvageable pt
(on day 2-3).
·
Only remove fragments which come out
with gentle irrigation.
Spine
Trauma
Spinal Cord Injury
·
Guidelines for the Management of Acute Cervical Spine and Spinal Cord
Injuries (N3/02)
·
Level:
motor 3/5 AND pain/temperature sensation intact. Sensation or sacral sparing
(anal motor/sensory) = incomplete.
·
Complete:
3% have recovery w/in 24hrs. After 24hrs no recovery
·
Conversion
disorder (hysterical paralysis): Flex patients knees
and release – conversion disorder will maintain knees in flexed position. Some
authors recommend motor or somatosensory evoked
potentials.
SCI Treatment:
·
Solumedrol (methylprednisolone)
30mg/kg x 1hr then 5.4mg/kg/hr x 24 to 48 hr total for non-penetrating spinal
cord injury
o
Begin only within 8
hours of injury.
o
Controversial. May increase risk of pneumonia and sepsis.
o
NASCIS II: Improved neurological
outcome at 6 weeks, 6 mos, and 12 mos if protocol was started within 8 hours of
injury.
·
>13yo,
non-penetrating injury
·
NASCIS II results were replicated in a Japanese trial but not in
one from
o
NASCIS III: If solumedrol is not
started until three to eight hours after injury, administer for 48 hours.
o
Mechanism: prevent lipid peroxidation of
cell membranes, improve blood flow, increase Na/K-ATPase
– recovering extracellular calcium.
·
MAP
85-90 for 1st 7 days.
·
DVT
prophylaxis for 3 months. Foley catheter/bladder training.
·
No difference in early vs. late surgery (decompression
& fusion) (Vaccaro Spine 97)
· Clinical Trials Review: Tator C N11/06 (Table 6) Prospective RCT in SCI (Table 3) Surgical trials in SCI (Table 4) Recent regeneration trials in SCI (Table 5)
· Hawryluk GWJ NF11/08, Neurosurgical Focus 11/08
·
Audio: Hawryluk G NF11/08
Sequelae:
·
Spasticity: Two studies (14 SCI patients), showed a
significant effect of intrathecal baclofen
in reducing spasticity, compared to placebo, without any adverse effect. The
study comparing tizanidine to placebo (118 SCI
patients) showed a significant effect of tizanidine
in improving Ashworth Score but not in ADL performances, with significant rates
of adverse effects (drowsiness, xerostomia). For the
other drugs (gabapentine, clonidine,
diazepam, amytal and oral baclofen)
the results do not provide evidence for a clinical significant effectiveness. (Cochrane Database)
·
Charcot Spinal Disease after SCI: Destructive spinal lesions
or deformity due to repetitive stress. See Morita M
JN:S11/08
·
Reflex dysenergia: severe hypertension
in patients with SCI and bladder or bowel obstruction
Experimental
Treatments:
·
Gangliosides: The evidence available does not support the
use of ganglioside treatment to reduce the death rate in SCI patients. No
evidence has yet emerged that ganglioside treatment
improves recovery or quality of life in survivors. (Cochrane Database)
Anterior
cord syndrome:
paraplegia + dissociated sensory loss. Must differentiate cord infarct from
surgical lesion (anterior fragment)
Spinal
shock:
Hypotension & bradycardia. Lasts 3d-3wk.
·
Bulbocavernosus
1st reflex to return (pinching glans penis/ clitoris > anal
contraction, lowest available reflex).
SCIWORA
(Spinal Cord Injury Without Radiographic Abnormality)
·
Diagnosis: X-rays (including
flexion/extension) negative with neurologic deficit. Most common 1-16yo.
o
SSEPs obtained by some for
questionable myelopathy
o
MRI may show spinal cord contusion –
may aid prognosis (Guidelines N3/02S)
·
Myelography
and angiography are not recommended (Guidelines N3/02S)
·
Treatment: C-Collar until normal flex/ext
xrays are obtained. (Guidelines N3/02S)
o
Consider external immobilization of up
to 12 weeks (Guidelines N3/02S)
o
24 hours of steroids given although no
hard data exists (N12/04)
o
Guilford brace for 2-3mos or halo for
1-3wks recommended by some (Pang). Discontinue if flexion/extension X-rays
normal at 3mo.
o
No sport participation for 3-6mos. (Guidelines N3/02S)
·
Guidelines: N3/02S
·
Reviews: N12/04
·
Patients with transient SCI during
sports and no cord compression (including cervical stenosis but CSF signal is
preserved) may return to sports. Others must refrain from play (Bailes
JE JN:S1/05)
Whiplash:
Grade I = pain/stiffness, Grade II = limited ROM, point tenderness. Both: ROM
exercises, II = c-collar < 72hrs (hard only)
·
The same NACIS methylprednisolone protocol for SCI has been found
effective in whiplash injuries.
Central
Cord Syndrome
·
Arm weakness (more than leg) (due to orientation of corticospinal tracts), variable sensory loss, and bladder
dysfunction
·
Most
commonly post-traumatic in patient with baseline cervical stenosis
·
Timing of surgery is controversial
·
Marshall
1956 suggested early surgery for central cord syndrome was harmful had a small
number of patients who underwent laminectomy only
·
Others
have found early surgery for traumatic CCS was “safe and more cost effective” (Guest J JNS7/02)
·
Patients with myelopathy may fare
better with fusion
·
Reviews:
Aarabi B
NF11/08
Spine
fractures
·
Clinical clearance (no x-rays): alert,
not intoxicated, no pain/tenderness, no focal deficits, no distracting injuries
·
Guidelines: Canadian C-Spine Rules
(CCR) (Stiell AG JAMA
2001), NEXUS
·
“5 Nexus Nos”:
no midline tenderness, no focal deficits, normal alertness, no intoxication, no
distracting injury (Hoffman JR NEJM 2000)
·
Cervical Spine X-rays: A/P, lateral,
odontoid.
·
Must see to C7/T1 disc.
·
Odontoid
xray not useful in patients < 9yo
·
If no fractures or instability on X-ray
but has neck pain or tenderness, then get flexion/extension X-rays.
·
Don’t get flexion/extension X-rays if
≥ 4mm subluxation or ≥ 11o angulation
(unstable by White-Panjabi
guidelines)
·
If cervical muscle spasm is present
then keep in c-collar and repeat flexion/extension films in 1 week.
·
Obtain CT cervical spine (with
reconstructions) for fracture on Xray, non-visualized
areas on X-ray, level of neurologic deficit, comatose patient
·
MRI for neurologic deficits,
instability or suspected ligamentous injury, C1
injury (to evaluate transverse ligament)
·
Posterior ligamentous
injury may be suspected with localized tenderness, inter-spinous
process widening, kyphosis, or ligamentous
injury on MRI
·
Vertebral
artery injury: obtain angiogram, CTA or MRA if: severe
dislocation, facet dislocation, complete SCI, fracture through foramen transversarium
·
D/C collar after: normal flexion/extension
x-rays (under flouro if obtunded) OR normal MRI
(within 48hrs)
·
Thoracic and Lumbar spine xrays obtained for significant mechanism, neurologic
deficits, multiple injuries, unable to be examined, cervical fracture
·
If a spine fracture is found (i.e.
cervical) – image the entire spine.
5-20% will have other spine fractures.
·
Bone scan to delineate old versus new
fractures (remain hot for 24-48hrs up to year).
·
Timing:
·
No evidence urgent decompression
improves fixed neurologic deficits
·
Emergent decompression for: incomplete
SCI and progression, complete CSF block, decompression of vital cervical root,
compound/penetrating fracture, acute anterior cord syndrome, nonreducible fracture
·
Delayed neurologic deterioration (months-years)
– consider posttraumatic
syrinx (occur in 3%).
·
AANS
Course: Management of the Patient with Spinal Instability
(Moquin RR)
·
AANS
Course: Evaluation of Cervical Spine Injury (Vives K)
Cervical fractures
·
Guidelines for the Management of Acute Cervical Spine and Spinal Cord
Injuries (N3/02)
Cervical traction
·
Cervical
Traction Guidelines
·
Used for:
1)
Reduction of fractures for
decompressing spinal cord and nerve roots and obtaining proper alignment
2) Immobilization
·
Reduction usually accomplished ASAP
with unstable displaced/subluxed fractures – jumped
facets, fracture-dislocation
·
Pre-reduction MRI:
o Non-awake
patient: obtain MRI first to rule out herniated disc.
o Awake patient: Controversial.
Some advocate MRI only if reduction is not urgent (e.g. no or minor deficits)
·
Consider MRI 1st if placing
non-MRI compatible tongs and non-urgent
o MRI
recommended if closed reduction fails.
·
Contraindications:
o Age
<3 yrs.
o Significant
HNP in not awake patient (OK in awake patient)
o AO dislocation
or Hangman’s
fractures type IIA,III (traction may be used but 10% risk of neurologic decline)
o Relative:
significant kyphosis (e.g. ankylosing spondylitis) - keep traction in the
plane of the c-spine (avoid hyperextension).
·
Procedure:
o Place
Garder-Wells tongs or halo 1cm above pinna. Place anterior to EAC for extension, posterior for
flexion.
·
MRI-compatible Gardner-Wells tongs are
preferred but may not have the weight capacity for lower cervical dislocations.
o Use
analgesics and muscle relaxants (e.g. valium).
o May
be done with flouro or serial x-rays.
o Begin
at 3-5lbs per level of weight. 10lbs/level maximum. Lower weight when reduced.
o Stop
for: reduction, neurologic deterioration, or disc distraction (any disc height
>1cm or increased compared to adjacent discs or Ocippital-C1 >5mm.)
External
immobilization
·
Orthoses
·
Cervical collar (C-collar). Soft: for
comfort only, no stability. Hard.
·
Cervical-thoracic orthoses (CTO):
·
Halo vest
o Recheck
alignment/halo periodically (e.g. every 2 weeks)
·
Radiologic
Criteria:
·
Basion-Dental Interval (BDI) > 10-12mm.
·
Basion-atlantal interval (BAI – to
posterior body C2 line) <12mm.
·
Powers
ratio >1.
·
Pang D N9/07: Occipital
condyle–C1 facet interval (CCI) obtained on reconstructed CT. Normal <2mm. Abnormal
>4mm.
·
Suspect
with upper cervical prevertebral swelling
·
More
common in pediatrics
·
Assess
vertebral artery with MRA
·
No
traction (usually) – 10% risk of neurologic deterioration.
·
Immediately
apply halo until stabilization (or immediate stabilization),
·
Treatment:
Occipitocervical
stabilization
Occipital
Condyle Fractures
·
Suspect
with: blunt trauma patients sustaining high-energy craniocervical injuries,
altered consciousness, occipital pain or tenderness, impaired cervical motion,
lower cranial nerve paresis, or retropharyngeal soft tissue swelling
·
MRI to evaluate transverse ligament
·
Treatment: C-collar unless alar ligament has avulsed fragment of condyle
- then treated with halo (rule out associated AO dislocation)
C1
fractures:
·
Isolated Anterior or Posterior arch:
collar.
·
Lateral mass fracture: >2mm
displacement = halo, <2mm = collar.
·
Combined C1-C2 fractures treatment
based on C2 component
Jefferson’s
Fracture: Anterior and posterior ring fractures of C1
·
MRI to look at transverse ligament.
·
Transverse ligament disruption: ADI
>3mm, >7mm overhang C1/2 lateral masses (Rule of Spence), or based on MRI
o
TL disruption may be bony avulsion or
purely ligamentous
·
If TL is intact: immobilization
(collar or SOMI)
·
If TL disrupted:
o
Halo immobilization (if bony tubercle
of TL avulsed)
o
Occipitocervical stabilization
or C1-2 posterior
stabilization
(if purely ligamentous TL injury, halo
contraindicated or unsuccessful)
·
Usually due to odontoid
fracture or TL disruption
·
ADI >3mm (5mm in kids).
·
MRI to look at transverse ligament.
·
Treatment:
o
If TL intact: reduce & halo.
o
If TL disrupted: C1-2
posterior stabilization.
Atlantoaxial Rotatory Subluxation
·
Effendi classification: I = non-displaced;
II = body displaced >4mm, >11° angulation; III = Displaced with facet
dislocation (locked facets) and >50% subluxation
·
Francis Grade
·
Treatment:
o
≤ 3mm subluxation:
c-collar/SOMI.
o
≥ 4mm subluxation:
except for below, reduce with traction, then halo x
8-12wks. If fails then surgery.
·
Effendi IIA: halo without traction
·
Surgery for >11° angulation, >50% subluxation, disc
disruption, HNP with deficits, locked facets (Effendi class III)
·
Locked facets (Effendi type III): do
not reduce, proceed to surgery
o
Surgical options: C1-C3
posterior stabilization, C2/3 ACDF (if not reduced), C2
pedicle screw (if reduced)
Odontoid
fracture
·
Obtain MRI to evaluate transverse
ligament
·
Type I:
very rare (<1%). Generally treated with collar.
·
Type II:
Treatment depends on displacement and age.
o
<7yo: immobilization only (halo,
SOMI, collar)
o
>7yo: immobilization or surgery
·
70% successful fusion in halo for
30-50yo.
·
Some use cervical collar (Polin RS N3/96)
or SOMI brace – no class I data
·
Relative surgical indications: >5mm
subluxation (78% fail halo), age >50-60yo (39%
fail halo), type IIA (85% fail halo), instability in halo (Hadley MN N1988).
·
Type IIA: Have significant comminution at the base of the dens.
Higher rate of nonunion. Favor surgery. (Hadley
MN N1988)
o
Surgical
options: C1/2 stabilization, odontoid screw.
·
Contraindications
for odontoid screw:
C1 fracture (atlantoaxial joints, Jefferson fractures)
or disrupted transverse ligament on MRI; fracture > 6 months old, pathologic
fractures, significant odontoid displacement, retropharyngeal infections,
severe osteoporosis (relative); obese/barrel-chest
·
Type III: halo or cervical
collar/SOMI (Polin
RS N3/96).
C2
fracture:
·
Lamina: collar.
·
Facets, body, lateral mass: collar, CTO
or halo.
·
Combined C1-C2 fractures treatment
based on C2 component
Anterior
wedge: CTO/collar if mild, halo if severe
Teardrop:
·
“True Treardrop”
associated with: sagittal body fracture, retrolisthesis,
anterior wedge, facet disruption, prevertebral swelling,
loss of disc height inferiorly, neurologic deficit. Requires
stabilization.
·
“Simple teardrop”: If none of the
above are present then obtain flexion/extension X-rays.
If normal then keep in c-collar and repeat in 4-7d.
·
May occur from extension (ligament
avulsion) or flexion (type of compression fracture)
Quadrangular
fracture: Oblique fracture through body
(anterior-superior to inferior), retrolisthesis,
anterior wedge, disruption of disc & ligaments. Treatment: Anterior &
Posterior stabilization.
C3-C7
fractures:
·
Subaxial
cervical spine trauma classification – Patel AA
NF11/08
·
Allen and Ferguson mechanistic
classification (Allen BL Spine 1982)
·
Site
of injury
·
White-Panjabi
guidelines for cervical instability: ≥ 4mm subluxation, ≥ 11o angulation
(inferior endplates).
·
Don’t get flexion/extension X-rays if
unstable
·
If unstable: Immobilize (collar or
halo) for 6-12 weeks until stable on flex/ext
·
Collar (or halo): minor avulsions,
minor compressions, nondisplaced lateral mass,
lamina, spinous process
·
Indications for surgery: failure of closed
reduction, significant ligamentous injury, kyphosis >15°, vertebral body compression >50%,
fracture-dislocation, spinal cord or nerve root compression with progressive
neurologic deficits (including herniated disc or hematoma)
·
Cervical traction for closed
reduction: See above.
Immediate reduction for canal compromise with neurologic deficits: locked
facets, burst fractures
·
Anterior or posterior or combined approach
may be favored on the basis of whether there is more anterior (extension) or
posterior (flexion) bony or ligamentous disruption
- Anterior
stabilization: ACDF
or corpectomy
(for significant vertebral body fracture)
·
May need to be supplemented by
posterior stabilization if posterior tension band is disrupted.
·
ACDF may be used for posterior
fractures (Woodworth
RS JN:S2/09)
Locked
facets:
·
Facets dislocated, with superior facet
anterior to inferior
·
May be unilateral or bilateral:
o
Unilateral: neck pain, rotation of
spine and <25% subluxation on imaging
o
Bilateral: spinal cord injury, >50%
subluxation
·
Manual reduction in traction:
Unilateral: torque towards locked side. Bilateral: axial distraction and
flexion
·
Once reduced leave in 5-10lbs for
stabilization.
·
Surgery – anterior and/or posterior.
Halo x 3mos may be tried if facet surface fracture fragments are present.
Clay
shoveler’s: C7 spinous process fracture. Collar prn
pain.
Traumatic
Vertebral Artery Injury (VAI)
·
Assess vertebral artery with
angiogram, CTA or MRA for: severe dislocation, facet dislocation, complete SCI,
fracture through foramen transversarium
·
Treatment:
o Stoke:
anticoagulation (heparin)
o Ischemic
symptoms: observation or anticoagulation
o Asymptomatic:
observation
·
Carotid/vertebral
dissection
Mechanisms:
·
Flexion:
bilateral locked facets (neck flexed w/ flexing force), wedge, clay-shoveler, teardrop (neck flexed w/ compression).
·
Flexion-Rotation:
unilateral locked facet
·
Extension-Rotation:
pillar fracture (neck flexed, compressing force)
·
Axial
compression:
·
Extension:
hangman’s (distracting force, neck extended), posterior fracture-dislocation,
laminar fracture
Pediatric Spinal Trauma
·
<9yo odontoid
xray not useful due to persistent synchondrosis
·
On backboard elevate patients <8yo
to prevent cervical flexion
·
MRI to evaluate ligamentous
injury (common in peds) with significant pain,
deficits, mechanism
·
Odontoid
injuries – injury to epiphysis at base of odontoid –
most common
o
Also common: atlantooccipital
dislocation (due to large head size)
·
Thoracolumbar
fractures which are purely bony generally heal will with bracing. Burst
fractures show more bone remodeling and less progressive kyphosis
than adults. Circumferential fusions rarely necessary.
·
Limbus
fractures (avulsion of apophysis at endplate) most
common at L4/5, L5/S1. Present like HNP.
·
Radiographic mimics of trauma
o
C2/3
pseudosubluxation: C2
posterior spinal line should be less than 2mm posterior to a line between C1
& C3 posterior spinal lines
o
Odontoid synchondrosis
(fuses at 7yrs)
o
ADI normally wider than adults – up to
5mm
o
Pseudospread
of the atlas: C1 lateral masses may overlap C2 by up to 8mm until 4yo
·
C2 epiphysiolysis
(synchondrosis injury at odontoid
base): occurs <7yo. Treatment: closed reduction & halo
·
See
Neurosurg Focus 2/06
Thoracic
fractures
·
Decompression and stabilization by corpectomy
(anterior/burst) or pedicle screws (posterior).
·
Upper thoracic:
o
Anterior approach (sternotomy
or manubriotomy) limited to T3 by aortic arch.
o
Pedicle screw fixation of upper
thoracic (T1-T5) fractures: Fisher C
JN:S3/09
Thoracolumbar fractures
·
Evaluate
for abdominal injuries
·
Widening
of interspinous distance suggest unstable injury
·
Classification:
o
Denis three-column
model
(Spine 1983)
o
Holdworth’s two-column model
(anterior/posterior) (JBJS 1963, 1970)
o
McAfee’s
mechanistic classification (below) (JBJS 1983)
o
AO/ASIF
Modified Comprehensive Classification (A compression, B distr
action, or C multidirectional with translation)
o
Thoracolumbar Injury
Classification and Severity Score (Spine Trauma Study Group, 2005): Patel AA JN:S3/09 – Table
1
·
Cobb angle: measurement of kyphosis,
angle between by lines drawn perpendicular to the superior end plate of the
vertebral level cephalad to the fracture and the
inferior end plate of the vertebral body caudal to it.
Compression/Wedge
fracture: Involve anterior
column only.
o
TLSO
if severe.
o
May
require surgery if: anterior height <50% of posterior height, angulation >30-40°, progressive
kyphosis, or 3+ fractures in a row.
·
Anterior
(corpectomy) and/or posterior stabilization depending on severity (anterior for
severe angulation/kyphosis)
Burst fracture:
o
Involve
anterior and middle columns (i.e. fracture through posterior vertebral body)
o
Surgery
indicated for (type IB): neurologic deficit, >50% loss of body height, angulation >20-25°, progressive kyphosis, or >50% canal compromise.
·
50%
height loss was popularized in a clinical study suggesting that when these patients
are treated non-operatively, late progression of kyphosis and spinal stenosis
tend to develop
·
Others
(neurologically intact): No difference between TLSO and surgery by systematic
review (JN:S5/06)
·
Anterior
or posterior approach – anterior for more canal compromise, compression
o
If
non-operative (type IA): avoid early ambulation, TLSO bracing (3-6mo), serial X-rays
to look for progression.
o
L5
(rare): L4-S1 posterior stabilization and/or 2wks bed rest, TLSO w/thigh cuff x
4-6mos, serial X-rays.
Seat-belt/Chance
fracture:
o
Flexion-distraction
injury.
o
Fracture
through anterior and posterior bony or ligamentous elements with no
subluxation.
o
45%
have associated intra-abdominal injuries (obtain CT abdomen)
o
Axial
CT shows “empty facet” sign because of facet joint dislocation. Increased interspinous distance. No or mild
anterior compression.
o
Treatment:
posterior stabilization (or TLSO for bony Chance)
o
Soft-tissue Chance variants and most
bony variants in adults require operative stabilization.
o
Pure Chance fractures with
disruption through the bone may heal in a hyperextension orthosis,
mostly in young patients.
Fracture-dislocation: Involves translation
or rotation through the middle column
o
Generally
require posterior (± anterior) stabilization
o Spondyloptysis: Complete (>100%) dislocation of 2 or more vertebral bodies. Require long posterior stabilization. (Yadla S JN:S8/08
– Figure 1 3D CT)
·
Surgical
Options
o
Posterior decompression
& stabilization:
·
Decompression
·
Ligamentotaxis: posterior
longitudinal ligament distraction pulls fragments out of canal. Limited with
PLL disruption, canal compromise >66%, injuries >3 days old
·
Transpedicular
decomopression performed if ligamentotaxis
is insufficient for decompression or PLL disrupted
·
Laminectomy not used usually
·
Stabilization:
Pedicle screws ≥2 levels above & below & posterolateral fusion
·
Some
recommend 1 level above & below (short-segment) but some report 20-50%
screw failure, worsening kyphosis.
·
Balanced
construct: 3 above, 2 below.
·
Can
skip or include level of fracture in screw placement.
·
If
patient is wheelchair-dependent, some avoid fusing sacrum if possible.
·
Spondyloptysis, or significant
coronal or sagittal misalignment: posterior long construct
·
Consider
adjunctive vertebroplasty (Cho DY N12/03 – short segment)
o
Anterior - Corpectomy: T11-L3. Superior
for substantial kyphosis, anterior canal compromise,
three column injuries.
o
Combined
anterior/posterior
·
Surgical
Indications
o
Canal
compromise with stable neurologic deficit has not clearly been shown to be
improved with early or late decompression.
o
Progressive
neurologic deficit is generally felt to benefit from decompression.
o
Relationship
between canal compromise and neurologic deficit is inconclusive. Canal
compromise may improve with immobilization alone and remodeling.
o
Relationship of kyphosis to chronic back pain is inconclusive
·
Osteoporotic:
Bed rest x 7-10d then PT, TLSO
·
Lumbar
unilateral locked facets: Reddy SJ
JN:S12/08
·
Lamina
fractures may incarcerate dura with CSF leak
·
See Vaccaro AJ JBJS
2003
Sacral
Fractures
GSW
Spine
·
Surgery for: neurologic deterioration,
cauda equina injury w/compression, neural compression, CSF leak, instability,
debridement, vascular injuries, migration, plumbism.
- Fixed
neurologic deficit (i.e. due to concussive effect) managed non-operatively
- Trans-abdominal
injuries (especially with colon penetration) generally managed with antibiotics
(but debridement is performed by some)
- Early
vs delayed surgery controversial but believed to be equivalent
·
Give antitetanus.
·
Steroids not indicated
Cervical
Cord Neurapraxia
·
Transient
(<48hr) motor or sensory deficits
·
See
Bell GR CSS 8/03
Spinal
Orthoses
Cervical Orthoses
·
Cervical
Collars
o
Soft
cervical collars do not immobilize. They
may help support the cervical musculature and remind the patient to be careful.
o
Hard
Collars: Philadelphia, Miami J, Aspen. Mostly stabilize lower spine (C5-T1)
Cervicothoracic Orthoses (CTO)
·
Guilford
Brace
·
SOMI
Brace: has mandibular and occiput
support. Reduces flexion in upper cervical spine
·
Yale
Brace
·
Minerva
Brace
·
Halo-vest
o
Children:
Head CT scan may guide pin placement. <2yo use 10-12 pins to 2in-lb. 2-7yo use 6-8 pins to 5in-lb. Adults: 8in-lb.
Thoracolumbar Orthoses (TLSO)
·
Used
for minor, stable fractures:
o
Jewett
Brace
o
CASH
Brace
o
Knight-Taylor
Brace
·
Custom-molded
TLSO: Immobilizes T8-L4.
o
May
have cervical extension (T2-T7) or thigh-cuffs (L4-S1 immobilization)
·
Hyperextension
cast
Lumbosacral Orthoses (LSO)
·
Elastic
Binder
·
Binder
with supports
·
Corset
·
Custom-molded
Cervicothoraciclumbar Orthoses (CTLSO)
·
Milwaukee
Brace
Revised
6/1/09
Copyright
2009
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send comments and corrections to admin@flotte2.com
Disclaimer:
This outline is complied, not original. Sources are being added retrospectively.
It is
intended for personal educational use by students and residents. It is not intended to guide clinical decision
making. Accuracy and timeliness cannot be guaranteed.
Sources
for figures are embedded as hyperlinks within the figures.