Head and Neck Pathologies

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Head and Neck Pathologies

• Orthopedic Assessment III Head, Spine, and
  Trunk with Lab
• PET 5609C

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Head and Neck Pathologies

• Sports related concussions 300,000 mild
  traumatic brain injuries/yr
• 3-8 of all high school and collegiate football
  players sustain concussions each year
• NCAA Injury Surveillance System had reported
  concussions constitute 12.2 and 4.8 of all
  injuries occurring in collegiate hockey and soccer

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Head and Neck Pathologies

• Concussions Mild traumatic Brain Injuries
• Immediate (but transient) posttraumatic
  impairment of brain function
• Immediate effect brain cell loss
• Secondary damage (? risk of brain cell death)
• Diagnosis
• Duration of symptoms (i.e. loss of consciousness)
• Neuropsychological findings

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Head and Neck Pathologies

• Concussion Cognitive Features
• State of unawareness (i.e. team opponent)
• Mental confusion
• Difficulty concentrating
• Loss of Consciousness
• Amnesia
• Anterograde
• Retrograde

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Head and Neck Pathologies

• Concussion Subjective Symptoms
• Headache
• Dizziness
• Nausea
• Loss of Balance
• Feeling dinged
• Seeing stars/flashing lights
• Hearing problems
• Irritability
• Double Vision

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Head and Neck Pathologies

• Concussion Objective Signs
• Loss of or impaired conscious state
• Poor coordination/balance
• Gait unsteadiness
• Poor concentration
• Vomiting
• Vacant stare/glassy eyed appearance
• Slurred speech
• Personality changes

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Head and Neck Pathologies

• Response to Trauma Biochemical Changes with
  Concussion
• Excitatory Neurotransmitters are Released
• Influx of extracellular potassium
• Altered ionic balance
• Brain enters state of Hypermetabolism
  (Hyperglycolysis)
• Can last up to 7-10 days
• During this state, Brain needs extra nutrients,
  sensitive to inadequate blood flow
• Biochemical changes
• Implicated in neuronal loss and Cell Death
• Potential Mechanism for Lifelong Depression due
  to Neuronal Death??

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Head and Neck Pathologies

• Standardized Assessment of Concussion (SAC)
• Abbreviated neuropsychological test
• Immediate objective data
• Presence and severity of neurocognitive
  impairment
• On or off field evaluation
• Tests
• Orientation
• Immediate Memory Recall
• Concentration
• Delayed Recall
• Glasgow Coma Scale
• Severe brain injury
• Normal score 15
• gt 11 Excellent prognosis for recovery
• lt 7 Serious brain dysfunction

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RESPONSE POINTS ACTION
Eye Opening
Spontaneously 4 Reticular system intact pt. may not be aware
To verbal command 3 Opens eyes when told to do so
To pain 2 Opens eyes in response to pain
None 1 Does not open eyes to any stimuli
Verbal
Oriented, converses 5 Relatively intact CNS aware of self and surroundings
Disoriented, converses 4 Well articulated, organized, but disoriented
Inappropriate words 3 Random, exclamatory words
Incomprehensible 2 No recognizable words
No response 1 No audible sounds
Motor
Obeys verbal commands 6 Readily moves limbs when told to
Localizes painful stimuli 5 Moves limb in effort to avoid pain
Flexion withdrawal 4 Pulls away from pain with a flexion motion
Abnormal flexion 3 Exhibits decorticate rigidity
Extension 2 Exhibits decerebrate rigidity
No response 1 Demonstrates dypotonicity, flaccid Suggests loss of medullary function or spinal cord injury
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Concussion Grading University of North Carolina
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Grade 1st Concussion 2nd Concussion 3rd Concussion
Grade 1 (mild) May return to play if asymptomatic Return to play in 2 weeks if athlete is asymptomatic during the previous week Terminate season may return to play the following season if asymptomatic
Grade 2 (moderate) Return to play after being asymptomatic for 1 week Out a minimum of 1 month may return to play then if asymptomatic for 1 week consider termination of season Terminate season may return to play the following season if asymptomatic
Grade 3 (severe) Out a minimum of 1 month may then return to play if asymptomatic for 1 week Terminate season may return to play the following season if asymptomatic Consider terminating career Terminate career in contact sports
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Head and Neck Pathologies

• Return to Play Guidelines Grade 0 Concussion
• Remove athlete from contest
• Examine immediately
• Abnormal cranial nerve function
• Cognition
• Coordination
• Postconcussive symptoms (both at rest and with
  exertion)
• Return to contest
• Exam is normal and athlete asymptomatic for 20
  minutes
• If any Sx. develop within 20 minutes, return that
  day is NOT permitted

University of North Carolina Guidelines
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Head and Neck Pathologies

• Return to Play Guidelines Grade 1 Concussion
• Daily follow-up evaluations
• May begin restricted participation when
  asymptomatic at rest and after exertion tests for
  the 2 days
• Unrestricted participation allowed if
  asymptomatic for 1 additional day and
  neuropathological and balance testing normal

University of North Carolina Guidelines
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Head and Neck Pathologies

• Return to Play Guidelines Grade 2 Concussion
• Remove athlete/prohibit return
• Examine immediately and at 5-minute intervals for
  evolving intracranial pathology
• Re-examine daily
• May return to restricted participation when ATC
  and physician are assured athlete has been
  asymptomatic at rest and with exertion testing
  for 4 days
• Unrestricted participation if asymptomatic for
  additional 2 days and performing restricted
  activities normally

University of North Carolina Guidelines
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Head and Neck Pathologies

• Return to Play Guidelines Grade 3 Concussion
• Treat athlete on the field as if cervical spine
  injury has occurred
• Immediate re-examination at 5-minute intervals
  for signs of intracranial pathology
• Return based on resolution of symptoms
• If symptoms totally resolve within 1 week, return
  to restricted participation when athlete has been
  asymptomatic at rest and exertion for 10 days.
  If asymptomatic for an additional 3 days of
  restricted activity, athlete may return to full
  participation

University of North Carolina Guidelines
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University of North Carolina Return to Play
Progression
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Head and Neck Pathologies

• Postconcussion Syndrome
• Extended symptoms (cognitive impairment)
• Altered neurotransmitter function
• Occurs more frequently in women
• Symptoms
• ? attention span
• Trouble concentrating
• Impaired memory and irritability
• Exercise induced headaches, dizziness, premature
  fatigue
• Balance disruption, ? cognitive performance

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Head and Neck Pathologies

• Second Impact Syndrome
• Athlete who has suffered a head injury sustains a
  2nd head injury before the signs/symptoms of the
  initial injury have subsided
• Scenario Athlete suffering from postconcussion
  symptoms (headache, visual, motor problems)
  returns to play prematurelysuffers 2nd injury
• SIS Athlete appears stunnedwithin seconds to
  minutes, displays life-threatening symptoms
  (semicomatose state, rapidly dilating pupils,
  respiratory failure)
• ? Intracranial pressure (inability or loss of
  brain blood supply regulation)
• Time frame to brain stem failure is rapid! (2-5
  minutes post-impact) ? High mortality rate (50)

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Head and Neck Pathologies

• Cumulative Injury Research has shown an ? risk
  of concussion incidence following initial injury
• Risk of suffering a 2nd concussion is
  approximately 4 times that of the chance of
  initial injury in high school football players
• Recent study Collegiate players with previous
  history (3 or more) were 3 times as likely to
  suffer a concussion in comparison to those with
  no prior history

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Head and Neck Pathologies

• Epidural Hematoma
• Arterial bleeding between the dura mater and the
  skull
• Onset of symptoms ? within hours
• MOI blow to the head
• Size of hematoma ?, condition deteriorates
• Progression of symptoms
• Patient has signs of concussion
• Period of very lucid consciousness (may eliminate
  suspicion of serious concussion)
• Patient becomes disoriented, confused, drowsy
• Patient complaints of headache that ? in
  intensity with time
• Signs and symptoms of cranial nerve disruption
• Onset of coma
• Left untreated, death or permanent brain damage
  occurs

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Head and Neck Pathologies
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Head and Neck Pathologies

• Subdural Hematoma
• Hematoma between the brain and dura mater
• Usually involves venous bleeding
• Slow accumulation of blood (low BP)
• Symptoms may occur hours, days, or even weeks
  after initial trauma
• Simple subdural hematoma
• No direct cerebral damage
• Complex subdural hematoma
• Contusions of brains surface with associated
  swelling

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Head and Neck Pathologies
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Head and Neck Pathologies

• Skull Fractures
• History
• Onset Acute
• Pain characteristics Pain over impact site,
  possible headache
• MOI Blunt trauma to head
• Inspection
• Bleeding
• Ecchymosis under eyes and over mastoid process
• Rounded contour of skull may be lost
• Palpation
• Crepitus
• Do not palpate over obvious deformity
• Neurological Tests
• Cranial nerve assessment, sensory and motor
  testing
• Comments
• Rule out cervical fracture/dislocation
• No object should be inserted into site of skull
  laceration
• A cerebral concussion may be associated with
  injury
• Immediate referral

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Head and Neck Pathologies
Depressed Skull Fracture
Linear Parietal Skull Fracture
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Head and Neck Pathologies

• Cervical Spinal Cord Trauma
• 1976 NCAA and NFHSA outlawed spearing in
  football
• Present Estimated that spearing still occurs in
  19 of football plays
• Spinal cord function Inhibition
• Impingement or laceration secondary to bony
  displacement
• Compression secondary to hemorrhage, edema, and
  ischemia of the cord
• Trauma to spinal cord above C4 ? probability of
  death secondary to dysfunction of brain stem or
  phrenic nerve

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Head and Neck Pathologies

• Cervical Fracture or Dislocation
• Dislocation
• ? threat to spinal cord
• Lower cervical vertebrae (C4-C6)
• MOI Neck forced into flexion and rotation
• History
• Onset Acute
• Chief complaints
• Pain in cervical spine
• Numbness, weakness, parasthesia radiating into
  extremities
• Cervical muscle spasm
• Chest pain
• Loss of bladder or bowel control

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Head and Neck Pathologies

• Cervical Fracture or Dislocation
• History
• MOI
• Most fractures axial load
• Most dislocations hyperflexion or
  hyperextension and rotation
• Predisposing Conditions
• ? risk of cervical fracture if normal lordoctic
  curve of cervical spine is ?
• Inspection
• Malalignment of cervical spine
• Head may be abnormally tilted and rotated
• Unilateral dislocation ? head tilts towards site
  of dislocation muscles on opposite side are in
  spasm muscles on side of dislocation are flaccid
• Swelling

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Head and Neck Pathologies

• Cervical Fracture or Dislocation
• Functional Tests
• ROM testing should not be performed if numbness,
  weakness, or parasthesia radiating into
  extremities or bowel/bladder signs present
• Neurological Tests
• Upper and lower quarter screen
• Special Tests
• Not applicable if fracture/dislocation suspected
• Comments
• Immediate transportation (EMS activation)

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Head and Neck Pathologies
Fracture of C4-C5 segment
Dislocation Result - Quadriplegia
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Head and Neck Pathologies
Spinal repair involving four types of spinal
reconstruction.  Several of the vertebral disks
have been replaced with bone graft material.  A
plate and screws have been  used to lock the
vertebral bodies of C5, C6 and C7 tightly against
the graft. From a posterior approach, lateral
mass  screws at C4, C5 and C6 prevent rotation
and lateral bending.  A thin titanium cable  and
cable clamp has also been used to lash a strut of
bone onto the spinous processes of C4 to C7 to
resist flexion forward.
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Head and Neck Pathologies

• Transient Quadriplegia
• Body-wide state of decreased or absent sensory
  and motor function
• MOI Blow to head (cervical spine forced into
  hyperextension, hyperflexion or axial load force)
• Result Neuropraxia of cervical spinal cord
• Predispositions
• Spinal stenosis (C3-C4 )
• Congenital fusion of cervical canal or other
  abnormalities
• Cervical instability
• Pavlov ratio 0.80 or less (ratio between diameter
  of spinal canal and diameter of vertebral body)

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Head and Neck Pathologies

• Transient Quadriplegia
• Predisposing Conditions (continued)
• Spear Tacklers Spine
• Pavlov ratio of lt0.8
• Straight or kyphotic alignment of the neck on a
  neutral lateral radiograph
• Posttraumatic radiographic abnormality
• Documentation of the patient's use of the
  spear-tackling technique
• Spear tackler's spine contraindication for
  return to play

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Head and Neck Pathologies

• Transient Quadriplegia
• Signs and Symptoms
• Initially, resemble those of catastrophic
  cervical injury
• Sensory dysfunction, burning, pain, numbness,
  parasthesia in upper and lower extremities
• Motor dysfunction (weakness to paralysis)
• Symptoms clear 15 minutes to 2 days
• Diagnosis
• X-rays, CT, MRI, electromyelograms