Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics

Object. Diagnosing and managing cervical spine trauma in head-injured patients is problematic due to an altered level of consciousness in such individuals. The reported incidence of cervical spine trauma in head-injured patients has generally ranged from 4 to 8%. In this retrospective study the authors sought to define the incidence of cervical injury in association with moderate or severe brain injury, emphasizing the identification of high-risk patients. Methods. The study included 447 consecutive moderately (209 cases) or severely (238 cases) head injured patients who underwent evaluation at two Level 1 trauma centers over a 40-month period. Of the 447 patients, 24 (5.4%) suffered a cervical spine injury (17 men and seven women; mean age 39 years; median Glasgow Coma Scale [GCS] score of 6, range 3–14). Of these 24 patients, 14 (58.3%) sustained spinal cord injuries (SCIs), 14 sustained injuries in the occiput—C3 region, and 10 underwent a stabilization procedure. Of the 14 patients with SCIs, nine experienced an early hypotensive and/or hypoxic insult. Regarding the mechanism of injury, cervical injuries occurred in 21 (8.2%) of 256 patients involved in motor vehicle accidents (MVAs), either as passengers or pedestrians, compared with three (1.6%) of 191 patients with non-MVA-associated trauma (p < 0.01). In the subset of 131 MVA passengers, 13 (9.9%) sustained cervical injuries. Patients with an initial GCS score less than or equal to 8 were more likely to sustain a cervical injury than those with a score higher than 8 (odds ratio [OR] 2.77, 95% confidence interval [CI] = 1.11–7.73) and were more likely to sustain a cervical SCI (OR 5.5, 95% CI 1.22–24.85). At 6 months or more postinjury, functional neurological recovery had occurred in nine patients (37.5%) and eight (33.3%) had died. Conclusions. Head-injured patients sustaining MVA-related trauma and those with an initial GCS score less than or equal to 8 are at highest risk for concomitant cervical spine injury. A disproportionate number of these patients sustain high cervical injuries, the majority of which are mechanically unstable and involve an SCI. The development of safer and more rapid means of determining cervical spine integrity should remain a high priority in the care of head-injured patients.

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An unusual presentation and resolution of syringomyelia after cervical spine injury

Journal of Neurosurgery Spine ◽

10.3171/spi.2005.3.6.0482 ◽

2005 ◽

Vol 3 (6) ◽

pp. 482-484 ◽

Cited By ~ 1

Author(s):

Joseph Cusick ◽

Zvi Lidar

Keyword(s):

Cervical Spine ◽

Cervical Spine Injury ◽

Spine Injury ◽

Type I ◽

Cervical Spine Trauma ◽

Spine Trauma ◽

Resonance Imaging ◽

Chiari Malformation Type I ◽

Content Type ◽

Sequence Of Events

✓ The authors describe a case of noncommunicating syringomyelia associated with Chiari malformation Type I in a patient in whom acute symptomatic exacerbation occurred following cervical spine trauma. Surgical stabilization and realignment of the spine resulted in marked resolution of the neurological abnormalities, and subsequent magnetic resonance imaging demonstrated persistent collapse of the syrinx. The authors review the various factors in the pathogenesis of this unusual sequence of events.

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High-risk mild head injury

Journal of Neurosurgery ◽

10.3171/jns.1997.87.2.0234 ◽

1997 ◽

Vol 87 (2) ◽

pp. 234-238 ◽

Cited By ~ 80

Author(s):

John N. K. Hsiang ◽

Theresa Yeung ◽

Ashley L. M. Yu ◽

Wai S. Poon

Keyword(s):

Head Injury ◽

High Risk ◽

Mild Head Injury ◽

Radiographic Findings ◽

Content Type ◽

Head Injured ◽

Definition Of ◽

Gcs Score ◽

Injured Patients ◽

Fine Print

✓ The generally accepted definition of mild head injury includes Glasgow Coma Scale (GCS) scores of 13 to 15. However, many studies have shown that there is a heterogeneous pathophysiology among patients with GCS scores in this range. The current definition of mild head injury is misleading because patients classified in this category can have severe sequelae. Therefore, a prospective study of 1360 head-injured patients with GCS scores ranging from 13 to 15 who were admitted to the neurosurgery service during 1994 and 1995 was undertaken to modify the current definition of mild head injury. Data regarding patients' age, sex, GCS score, radiographic findings, neurosurgical intervention, and 6-month outcome were collected and analyzed. The results of this study showed that patients with lower GCS scores tended to have suffered more serious injury. There was a statistically significant trend across GCS scores for percentage of patients with positive acute radiographic findings, percentage receiving neurosurgical interventions, and percentage with poor outcome. The presence of postinjury vomiting did not correlate with findings of acute radiographic abnormalities. Based on the results of this study, the authors divided all head-injured patients with GCS scores ranging from 13 to 15 into mild head injury and high-risk mild head injury groups. Mild head injury is defined as a GCS score of 15 without acute radiographic abnormalities, whereas high-risk mild head injury is defined as GCS scores of 13 or 14, or a GCS score of 15 with acute radiographic abnormalities. This more precise definition of mild head injury is simple to use and may help avoid the confusion caused by the current classification.

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Efficacy of hyperventilation, blood pressure elevation, and metabolic suppression therapy in controlling intracranial pressure after head injury

Journal of Neurosurgery ◽

10.3171/jns.2002.97.5.1045 ◽

2002 ◽

Vol 97 (5) ◽

pp. 1045-1053 ◽

Cited By ~ 106

Author(s):

Matthias Oertel ◽

Daniel F. Kelly ◽

Jae Hong Lee ◽

David L. McArthur ◽

Thomas C. Glenn ◽

...

Keyword(s):

Blood Pressure ◽

Blood Flow ◽

Intracranial Pressure ◽

Content Type ◽

Head Injured ◽

Induced Hypertension ◽

Metabolic Suppression ◽

Gcs Score ◽

Injured Patients ◽

Fine Print

Object. Hyperventilation therapy, blood pressure augmentation, and metabolic suppression therapy are often used to reduce intracranial pressure (ICP) and improve cerebral perfusion pressure (CPP) in intubated head-injured patients. In this study, as part of routine vasoreactivity testing, these three therapies were assessed in their effectiveness in reducing ICP. Methods. Thirty-three patients with a mean age of 33 ± 13 years and a median Glasgow Coma Scale (GCS) score of 7 underwent a total of 70 vasoreactivity testing sessions from postinjury Days 0 to 13. After an initial 133Xe cerebral blood flow (CBF) assessment, transcranial Doppler ultrasonography recordings of the middle cerebral arteries were obtained to assess blood flow velocity changes resulting from transient hyperventilation (57 studies in 27 patients), phenylephrine-induced hypertension (55 studies in 26 patients), and propofol-induced metabolic suppression (43 studies in 21 patients). Changes in ICP, mean arterial blood pressure (MABP), CPP, PaCO2, and jugular venous oxygen saturation (SjvO2) were recorded. With hyperventilation therapy, patients experienced a mean decrease in PaCO2 from 35 ± 5 to 27 ± 5 mm Hg and in ICP from 20 ± 11 to 13 ± 8 mm Hg (p < 0.001). In no patient who underwent hyperventilation therapy did SjvO2 fall below 55%. With induced hypertension, MABP in patients increased by 14 ± 5 mm Hg and ICP increased from 16 ± 9 to 19 ± 9 mm Hg (p = 0.001). With the aid of metabolic suppression, MABP remained stable and ICP decreased from 20 ± 10 to 16 ± 11 mm Hg (p < 0.001). A decrease in ICP of more than 20% below the baseline value was observed in 77.2, 5.5, and 48.8% of hyperventilation, induced-hypertension, and metabolic suppression tests, respectively (p < 0.001 for all comparisons). Predictors of an effective reduction in ICP included a high PaCO2 for hyperventilation, a high study GCS score for induced hypertension, and a high PaCO2 and a high CBF for metabolic suppression. Conclusions Of the three modalities tested to reduce ICP, hyperventilation therapy was the most consistently effective, metabolic suppression therapy was variably effective, and induced hypertension was generally ineffective and in some instances significantly raised ICP. The results of this study suggest that hyperventilation may be used more aggressively to control ICP in head-injured patients, provided it is performed in conjunction with monitoring of SjvO2.

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Selection of severely head injured patients for mild hypothermia therapy

Journal of Neurosurgery ◽

10.3171/jns.1998.89.2.0206 ◽

1998 ◽

Vol 89 (2) ◽

pp. 206-211 ◽

Cited By ~ 71

Author(s):

Tadahiko Shiozaki ◽

Hisashi Sugimoto ◽

Mamoru Taneda ◽

Jun Oda ◽

Hiroshi Tanaka ◽

...

Keyword(s):

Functional Recovery ◽

Mild Hypothermia ◽

High Dose ◽

Midline Shift ◽

Cerebral Lesions ◽

Content Type ◽

Head Injured ◽

Gcs Score ◽

Injured Patients ◽

Fine Print

Object. The authors have analyzed the efficacy of inducing mild hypothermia (34°C) in 62 severely head injured patients to control fulminant intracranial hypertension. Methods. All 62 patients fulfilled the following criteria: 1) persistent intracranial pressure (ICP) greater than 20 mm Hg despite fluid restriction, hyperventilation, and high-dose barbiturate therapy; 2) an ICP lower than the mean arterial pressure; and 3) a Glasgow Coma Scale (GCS) score of 8 or less on admission. The patients were divided into three groups based on computerized tomography findings: extracerebral hematoma (34 patients with subdural and/or epidural hematoma), focal cerebral lesion (20 patients with localized brain contusion and/or intracerebral hematoma), and diffuse swelling (eight patients with no focal mass lesion). Mild hypothermia prevented ICP elevation in 35 (56.5%) of the 62 patients whose ICP was greater than 20 mm Hg despite conventional therapies. Among those 35 patients whose ICP was controlled by mild hypothermia, 12 (34.3%) achieved functional recovery (good outcome or moderate disability). However, functional recovery was observed in only five (10.9%) of the 46 patients whose ICP was greater than 40 mm Hg after conventional therapies. Of 40 patients with an admission GCS score of 5 to 8, there were 11 (27.5%) who achieved functional recovery. On the contrary, mild hypothermia was not effective in 22 patients with an admission GCS score of 3 or 4. In the patients with focal cerebral lesions, ICP was controlled by mild hypothermia in 17 patients (85%) and patient outcome was intimately related to the extent of the damage. Among 18 patients with extracerebral hematoma who had a midline shift of 9 to 12 mm, raised ICP could be successfully controlled by mild hypothermia in 16 patients (88.9%) and three (16.7%) achieved functional recovery. However, ICP could not be controlled in patients with extracerebral hematoma who had a midline shift of 13 mm or more. In patients with diffuse swelling, ICP elevation could not be prevented at all by mild hypothermia. Conclusions. The authors conclude that mild hypothermia is effective for preventing ICP elevation in patients without diffuse brain swelling in whom ICP remains higher than 20 mm Hg but less than 40 mm Hg after conventional therapies.

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The National Traumatic Coma Data Bank

Journal of Neurosurgery ◽

10.3171/jns.1983.59.2.0285 ◽

1983 ◽

Vol 59 (2) ◽

pp. 285-288 ◽

Cited By ~ 172

Author(s):

Lawrence F. Marshall ◽

Belinda M. Toole ◽

Sharon A. Bowers

Keyword(s):

Common Factors ◽

Data Bank ◽

Operative Intervention ◽

Content Type ◽

Head Injured ◽

The Common ◽

Traumatic Coma ◽

Gcs Score ◽

Injured Patients ◽

Fine Print

✓ The records of the first 325 patients entered into the pilot phase of the National Traumatic Coma Data Bank were reviewed. Thirty-four severely head-injured patients who talked prior to deteriorating to a Glasgow Coma Scale (GCS) score of 8 or less were identified. Of those 34 patients, 18 died or were left vegetative and 16 recovered. While there were certain common factors between those who talked and died and those who talked and recovered, there were also significant differences. The common factors between the two groups were the length of time to deterioration or operative intervention (16 versus 18 hours, respectively), and the initial GCS scores (12.6 versus 12.4, respectively). The primary differences between the groups included the mean age, the degree of midline shift seen on computerized tomography (CT), and the presence of subdural hematoma. Those who talked at some point postinjury, but who subsequently died, had a mean age of 50 years. Those who talked, deteriorated, and then recovered were found to have a mean age of 32 years. Seven of the 18 patients who talked and died had a shift of greater than 15 mm on CT, while this degree of shift was demonstrated in only one of 16 patients who talked, deteriorated, and recovered. Subdural hematomas were significantly more common in the “talk and die” group, as was the overall need for operation. Since the overwhelming majority of patients with marked shift on CT have surgical lesions, early operative intervention is strongly recommended in these patients, prior to their inevitable deterioration.

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Normal computerized tomography scans in severe head injury

Journal of Neurosurgery ◽

10.3171/jns.1986.65.6.0784 ◽

1986 ◽

Vol 65 (6) ◽

pp. 784-789 ◽

Cited By ~ 87

Author(s):

Ramiro D. Lobato ◽

Rosario Sarabia ◽

Juan J. Rivas ◽

Francisco Cordobes ◽

Servando Castro ◽

...

Keyword(s):

Computerized Tomography ◽

Ct Scans ◽

Consecutive Series ◽

Good Recovery ◽

Permanent Disability ◽

Content Type ◽

Head Injured ◽

Gcs Score ◽

Injured Patients ◽

Fine Print

✓ The authors analyze the clinical course of 46 severely head-injured patients who had completely normal computerized tomography (CT) scans through the immediate posttraumatic period (1 to 7 days after trauma). These patients represent 10.2% of a consecutive series of 448 cases of severe head injuries and two-thirds of the cases showing a normal CT scan on admission (the other one-third of the cases developed new pathology). The usual course in these 46 patients after the initial coma was toward progressive neurological improvement, and 35 patients (76%) achieved a functional level of survival. Nine patients (19.5%) remained comatose for several weeks and developed severe disability. There were two fatalities due to medical complications. The final outcome was more closely related to the duration of coma (the longer the duration the worse the result) than to the initial Glasgow Coma Scale (GCS) score. In fact, 26% of the patients in the lower GCS score ranges (3 to 4 points) made a good recovery and 46% developed moderate disability only. These findings indicate that the grim prognostic significance of deep posttraumatic coma is tempered in the presence of a normal scan. However, the absence of CT abnormalities in severely head-injured patients cannot be equated with a good prognosis because in one-fifth of the cases serious permanent disability develops. Sustained elevation of the intracranial pressure (ICP) was not seen in these patients, indicating that ICP monitoring may be omitted in cases with a normal scan. However, since one-third of the patients with a normal admission scan developed new pathology within the first few days of injury, a strategy for control scanning is recommended. Control CT scans performed more than 6 months after injury showed a significantly higher incidence of brain atrophy in patients developing permanent disability than in those who made a good recovery.

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Contribution of CSF and vascular factors to elevation of ICP in severely head-injured patients

Journal of Neurosurgery ◽

10.3171/jns.1987.66.6.0883 ◽

1987 ◽

Vol 66 (6) ◽

pp. 883-890 ◽

Cited By ~ 116

Author(s):

Anthony Marmarou ◽

Angelo L. Maset ◽

John D. Ward ◽

Sung Choi ◽

Danny Brooks ◽

...

Keyword(s):

Severe Head Injury ◽

Ventricular Catheter ◽

Outflow Resistance ◽

Content Type ◽

Relative Contribution ◽

Temporal Course ◽

Head Injured ◽

Predominant Factor ◽

Injured Patients ◽

Fine Print

✓ The authors studied the relative contribution of cerebrospinal fluid (CSF) and vascular parameters to the level of intracranial pressure (ICP) in 34 severely head-injured patients with a Glasgow Coma Scale score of less than 8. This was accomplished by first characterizing the temporal course of CSF formation and outflow resistance during the 5-day period postinjury. The CSF formation and outflow resistance were obtained from pressure responses to bolus addition and removal of fluid from an indwelling ventricular catheter. The vascular contribution to the level of ICP was assessed by withdrawing fluid at its rate of formation and observing the resultant change in equilibrium ICP level. It was found that, with the exception of patients with subarachnoid hemorrhage, CSF parameters accounted for approximately one-third of the ICP rise after severe head injury, and that a vascular mechanism may be the predominant factor in elevation of ICP.

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Impairment of helper T-cell function and lymphokineactivated killer cytotoxicity following severe head injury

Journal of Neurosurgery ◽

10.3171/jns.1991.75.5.0766 ◽

1991 ◽

Vol 75 (5) ◽

pp. 766-773 ◽

Cited By ~ 37

Author(s):

Keith B. Quattrocchi ◽

Edmund H. Frank ◽

Claramae H. Miller ◽

Asim Amin ◽

Bernardo W. Issel ◽

...

Keyword(s):

T Cell ◽

Head Injury ◽

Severe Head Injury ◽

Cell Cytotoxicity ◽

Content Type ◽

Lak Cell ◽

Head Injured ◽

Injured Patients ◽

Fine Print

✓ Infection is a major complication of severe head injury, occurring in 50% to 75% of patients who survive to hospitalization. Previous investigations of immune activity following head injury have demonstrated suppression of helper T-cell activation. In this study, the in vitro production of interferon-gamma (INF-γ), interleukin-1 (IL-1), and interleukin-2 (IL-2) was determined in 25 head-injured patients following incubation of peripheral blood lymphocytes (PBL's) with the lymphocyte mitogen phytohemagglutinin (PHA). In order to elucidate the functional status of cellular cytotoxicity, lymphokine-activated killer (LAK) cell cytotoxicity assays were performed both prior to and following incubation of PBL's with IL-2 in five patients with severe head injury. The production of INF-γ and IL-2 by PHA-stimulated PBL's was maximally depressed within 24 hours of injury (p < 0.001 for INF-γ, p = 0.035 for IL-2) and partially normalized within 21 days of injury. There was no change in the production of IL-1. When comparing the in vitro LAK cell cytotoxicity of PBL's from head-injured patients and normal subjects, there was a significant depression in LAK cell cytotoxicity both prior to (p = 0.010) and following (p < 0.001) incubation of PBL's with IL-2. The results of this study indicate that IL-2 and INF-γ production, normally required for inducing cell-mediated immunity, is suppressed following severe head injury. The failure of IL-2 to enhance LAK cell cytotoxicity suggests that factors other than decreased IL-2 production, such as inhibitory soluble mediators or suppressor lymphocytes, may be responsible for the reduction in cellular immune activity following severe head injury. These findings may have significant implications in designing clinical studies aimed at reducing the incidence of infection following severe head injury.

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Role of intracranial pressure monitoring in severely head-injured patients without signs of intracranial hypertension on initial computerized tomography

Journal of Neurosurgery ◽

10.3171/jns.1994.80.1.0046 ◽

1994 ◽

Vol 80 (1) ◽

pp. 46-50 ◽

Cited By ~ 79

Author(s):

Michael G. O'Sullivan ◽

Patrick F. Statham ◽

Patricia A. Jones ◽

J. Douglas Miller ◽

N. Mark Dearden ◽

...

Keyword(s):

Blood Pressure ◽

Ct Scan ◽

Intracranial Hypertension ◽

Mass Lesion ◽

Midline Shift ◽

Pressure Monitoring ◽

Content Type ◽

Head Injured ◽

Injured Patients ◽

Fine Print

✓ Previous studies have suggested that only a small proportion (< 15%) of comatose head-injured patients whose initial computerized tomography (CT) scan was normal or did not show a mass lesion, midline shift, or abnormal basal cisterns develop intracranial hypertension. The aim of the present study was to re-examine this finding against a background of more intensive monitoring and data acquisition. Eight severely head-injured patients with a Glasgow Coma Scale score of 8 or less, whose admission CT scan did not show a mass lesion, midline shift, or effaced basal cisterns, underwent minute-to-minute recordings of arterial blood pressure, intracranial pressure (ICP), and cerebral perfusion pressure (CPP) derived from blood pressure minus ICP. Intracranial hypertension (ICP ≥ 20 mm Hg lasting longer than 5 minutes) was recorded in seven of the eight patients; in five cases the rise was pronounced in terms of both magnitude (ICP ≥ 30 mm Hg) and duration. Reduced CPP (≤ 60 mm Hg lasting longer than 5 minutes) was recorded in five patients. Severely head-injured (comatose) patients whose initial CT scan is normal or does not show a mass lesion, midline shift, or abnormal cisterns nevertheless remain at substantial risk of developing significant secondary cerebral insults due to elevated ICP and reduced CPP. The authors recommend continuous ICP and blood pressure monitoring with derivation of CPP in all comatose head-injured patients.

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