Head and Neck Trauma

1. Head and Neck Trauma George C. Phillips, MD, FAAP, CAQSM Clinical Assistant Professor of Pediatrics September 20, 2007

3. Case History • 16-year-old male football player • Helmet-to-helmet collision during practice six days prior to initial visit in our center • Confused and disoriented at the time of injury • Bilateral upper extremity numbness and tingling that lasted 20 minutes

4. Case History • Evaluated on the day of injury at a local emergency department • Head CT showed right frontal soft tissue swelling, with normal brain parenchyma • Diagnosed with concussion and removed from participation until follow-up at the University of Iowa Sports Medicine Center

5. Case History • At our initial visit, he reported retrograde and post-traumatic amnesia • He denied headache, dizziness, blurry vision, confusion, tinnitus, or cognitive/school performance issues • He went running the previous day without symptoms

6. Case History • Patient reports a previously unrecognized injury occurring one week prior to the index injury • Helmet-to-helmet contact • Bilateral upper extremity numbness/tingling • Brief loss of vision in left eye • Symptoms resolved within 24 hours

7. Case History • No prior head trauma • Multiple hand fractures • No surgeries • Exercise-induced asthma, well-controlled

8. Physical Examination • HEENT, Neck, Pulmonary, Cardiovascular, Abdominal, and Skin exams were unremarkable • No C-spine tenderness • Negative Spurling’s maneuver • No visual or ocular disturbances • Negative Battle sign

9. Physical Examination • Impaired delayed recall (3/5 words) • Mild concentration difficulties (6 digits, reverse order of months) • Balance impairment (single leg stand with eyes closed) • Fully oriented, immediate memory intact • Intact light touch and 2-point discrimination

10. Differential Diagnosis • Complex concussion • Spinal cord contusion • Cervical spine injury with cord compression • Arnold-Chiari malformation • Cerebrovascular accident • Vascular injury/anomaly to brain stem / spinal cord

11. Concussion • “Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.” • “Summary and Agreement Statement of the 2nd International Symposium on Concussion in Sport, Prague 2004” – Clin J Sport Med 2005

12. Concussion • Mechanics: direct blow to head/face/neck or indirect force transmission (body blow) • Timecourse: rapid onset, short-lived impairment, spontaneous resolution • Pathophysiology: function > structure • Symptoms: graded syndromes, may or may not include LOC, sequential resolution

13. Headache Nausea Vomiting Balance problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to noise Irritability Sadness Nervousness Feeling more emotional Numbness or tingling Feeling slowed down Feeling mentally “foggy” Difficulty concentrating Difficulty remembering Visual problems Postconcussion Symptom Scale J Head Trauma Rehabil 1999;9:193-8

14. Clinical Signs of Concussion • Consciousness (LOC) – not required • Memory – post-traumatic/retrograde amnesia • Cognition • Neurological (physical) • Personality (emotional)

15. Question #1 • Should a concussed athlete return to play on the day of the injury?

17. Concussion and RTP • Athletes will not report concussion • CJSM 2005 McCrea et al • Only 47 % of HS athletes reported concussion • Of those not reporting concussion: • 66% thought the injury was not serious enough • 41% did not want to be held out of the game • 36% were not sure what a concussion was • 15.3% of athletes had a concussion in 1 season • 29.9% of athletes had a history of concussion

18. Concussion and RTP • AJSM 2000 Guskiewicz et al • 30% of athletes RTP same day • For the other 70%, average RTP was 4 days • JAMA 2003 McCrea et al • Major deficits in balance, cognition, symptoms • Balance 3-5 days; cognition 5-7 days; symptoms 7 days • 10% of athletes had symptoms > 1 week

19. Concussion and RTP • JAMA 2003 Guskiewicz et al • 75% of same-season repeat concussion occurred <7 days from the first; 92% < 10 days • A seven-day waiting period would likely result in resolution of symptoms and normalized cognitive function • A seven-day waiting period may prevent a majority of repeat concussions

20. Question #2 • How many concussions are too many concussions?

22. Multiple Concussions • 2003 Neurosurgery Collins et al • History of ≥3 concussions = 9.3x more likely to experience 3 of 4 “onfield markers” • LOC, RG amnesia, AG amnesia, or confusion • 6.7x more likely to experience LOC • 2003 JAMA Guskiewicz et al • ≥3 concussions = 3x more likely to have another concussion • ≥3 concussions: 30% had symptoms > 1 week

23. Multiple Concussions • 2004 Brain Injury Iverson et al • ≥3 concussions = more preseason symptoms • ≥3 concussions = 7.7x more likely to have memory problems 2 days after injury • 2005 Neurosurgery Moser et al • ≥2 concussions = same neuropsych scores while symptoms free as 1 week post-concussion for first-time concussions • 2006 BJSM Iverson et al • 1-2 concussions versus 0 = no difference on ImPACT

24. Tests and Results • Head CT from the day of the index injury • Mild soft tissue swelling in right frontal area • Normal parenchyma • No hemorrhage, ischemia, or hydrocephalus

25. Tests and Results • AP and lateral flexion/ extension views of the C-spine • No instability, pre-vertebral soft tissue swelling, fracture or dislocation • Mild levoconvex curve of upper thoracic spine

26. Tests and Results

27. Tests and Results • MRI of the C-spine • Normal alignment • Normal signal of brainstem, cerebellum, and spinal cord • Cerebellar tonsils extend 5 mm below the inlet to the foramen magnum

28. Tests and Results

29. Final Working Diagnosis • Chiari I Malformation • Concussion

30. Treatment and Outcomes • The athlete was disqualified from contact and collision sports • Fortunately, he also had a significant interest in golf • Neurosurgical referral was discussed • The patient has not returned to our center for any additional visits

31. Pearls • Differences in Chiari malformations • Chiari I: cerebellar tonsils • Chiari II: cerebellar vermis (Arnold-Chiari) • Chiari III: portion of cerebellum within an occipital encephalocele • At least 30% of persons with Chiari I with tonsils down 5-10 mm are asymptomatic • 12 mm down almost always symptoms

32. Pearls • Chiari I and II malformations are associated with syringomelia • Chiari I is not associated with myelo-meningocele or other neural tube defects • Chiari I can be accompanied by skull abnormalities • Neurologic symptoms could include central cord syndrome

34. Can we manage SCI? • Methylprednisolone for 24-48 hours • Evidence is weak at best • Respiratory complications, sepsis, GI bleeds • Hypothermia • Unclear mechanism • Decreases cerebral metabolism and ICP • Hypotension, bradycardia, and infection are risks of treatment

35. Can we manage SCI? • Future agents for study: • Estrogen • Progesterone • Minocycline • Erythropoietin • Magnesium

36. Can we manage SCI?

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