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Head and Neck Pathologies

Head and Neck Pathologies. Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C. Sports related concussions – 300,000 mild traumatic brain injuries/yr 3-8% of all high school and collegiate football players sustain concussions each year

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Head and Neck Pathologies

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  1. Head and Neck Pathologies Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

  2. 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 Head and Neck Pathologies

  3. 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

  4. Concussion: Cognitive Features State of unawareness (i.e. team opponent) Mental confusion Difficulty concentrating Loss of Consciousness Amnesia Anterograde Retrograde Head and Neck Pathologies

  5. Concussion: Subjective Symptoms Headache Dizziness Nausea Loss of Balance Feeling “dinged” Seeing stars/flashing lights Hearing problems Irritability Double Vision Head and Neck Pathologies

  6. 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 Head and Neck Pathologies

  7. 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?? Head and Neck Pathologies

  8. 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 • > 11: Excellent prognosis for recovery • < 7: Serious brain dysfunction

  9. Concussion Grading: University of North Carolina

  10. 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

  11. 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

  12. 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

  13. 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

  14. University of North Carolina Return to Play Progression

  15. 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

  16. 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 prematurely…suffers 2nd injury • SIS: Athlete appears stunned…within 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%)

  17. 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

  18. 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

  19. Head and Neck Pathologies

  20. 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 brain’s surface with associated swelling

  21. Head and Neck Pathologies

  22. 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

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

  24. 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

  25. 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

  26. 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

  27. 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)

  28. Head and Neck Pathologies Dislocation: Result - Quadriplegia Fracture of C4-C5 segment

  29. 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.

  30. 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)

  31. Transient Quadriplegia: Predisposing Conditions: (continued) Spear Tackler’s Spine: Pavlov ratio of <0.8 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 Head and Neck Pathologies

  32. 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 Head and Neck Pathologies

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