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

Head and Neck Head and Neck PathologiesPathologies

Orthopedic Assessment III Orthopedic Assessment III – Head, Spine, and Trunk – Head, Spine, and Trunk

with Labwith Lab

PET 5609CPET 5609C

Head and Neck PathologiesHead and Neck Pathologies

Sports related Sports related concussions – 300,000 concussions – 300,000 mild traumatic brain mild traumatic brain injuries/yrinjuries/yr 3-8% of all high school and 3-8% of all high school and

collegiate football players collegiate football players sustain concussions each sustain concussions each yearyear

NCAA Injury Surveillance NCAA Injury Surveillance System had reported System had reported concussions constitute concussions constitute 12.2 and 4.8% of all 12.2 and 4.8% of all injuries occurring in injuries occurring in collegiate hockey and collegiate hockey and soccersoccer


Concussions – Mild traumatic Brain Concussions – Mild traumatic Brain InjuriesInjuries Immediate (but transient) posttraumatic Immediate (but transient) posttraumatic

impairment of brain functionimpairment of brain function Immediate effect – brain cell lossImmediate effect – brain cell loss

Secondary damage (↑ risk of brain cell Secondary damage (↑ risk of brain cell death)death)

Diagnosis:Diagnosis: Duration of symptoms (i.e. loss of Duration of symptoms (i.e. loss of

consciousness)consciousness) Neuropsychological findingsNeuropsychological findings


Concussion: Concussion: Cognitive FeaturesCognitive Features State of unawareness State of unawareness

(i.e. team opponent)(i.e. team opponent) Mental confusionMental confusion Difficulty Difficulty

concentratingconcentrating Loss of ConsciousnessLoss of Consciousness AmnesiaAmnesia

AnterogradeAnterograde RetrogradeRetrograde


Concussion: Concussion: Subjective Subjective SymptomsSymptoms HeadacheHeadache DizzinessDizziness NauseaNausea Loss of BalanceLoss of Balance Feeling “dinged”Feeling “dinged” Seeing Seeing

stars/flashing lightsstars/flashing lights Hearing problemsHearing problems IrritabilityIrritability Double VisionDouble Vision


Concussion: Concussion: Objective SignsObjective Signs Loss of or impaired Loss of or impaired

conscious stateconscious state Poor Poor

coordination/balancecoordination/balance Gait unsteadinessGait unsteadiness Poor concentrationPoor concentration VomitingVomiting Vacant stare/glassy Vacant stare/glassy

eyed appearanceeyed appearance Slurred speechSlurred speech Personality changesPersonality changes

Head and Neck PathologiesHead and Neck Pathologies Response to Trauma: Biochemical Response to Trauma: Biochemical

Changes with ConcussionChanges with Concussion Excitatory Neurotransmitters are Excitatory Neurotransmitters are

ReleasedReleased Influx of extracellular potassiumInflux of extracellular potassium

Altered ionic balanceAltered ionic balance Brain enters state of Brain enters state of

Hypermetabolism Hypermetabolism (Hyperglycolysis)(Hyperglycolysis)

Can last up to 7-10 daysCan last up to 7-10 days During this state, Brain needs During this state, Brain needs

extra nutrients, sensitive to extra nutrients, sensitive to inadequate blood flowinadequate blood flow

Biochemical changes:Biochemical changes: Implicated in neuronal loss and Cell Implicated in neuronal loss and Cell

DeathDeath Potential Mechanism for Lifelong Potential Mechanism for Lifelong

Depression due to Neuronal Death??Depression due to Neuronal Death??


Standardized Assessment of Concussion Standardized Assessment of Concussion (SAC)(SAC) Abbreviated neuropsychological testAbbreviated neuropsychological test Immediate objective dataImmediate objective data

Presence and severity of neurocognitive Presence and severity of neurocognitive impairmentimpairment

On or off field evaluationOn or off field evaluation Tests:Tests:

OrientationOrientation Immediate Memory RecallImmediate Memory Recall ConcentrationConcentration Delayed RecallDelayed Recall

Glasgow Coma ScaleGlasgow Coma Scale Severe brain injurySevere brain injury

Normal score: 15Normal score: 15 > 11: Excellent prognosis for recovery> 11: Excellent prognosis for recovery < 7: Serious brain dysfunction< 7: Serious brain dysfunction

RESPONSERESPONSE POINTPOINTSS

ACTIONACTION

Eye OpeningEye Opening

SpontaneouslySpontaneously 44 Reticular system intact; pt. may not be awareReticular system intact; pt. may not be aware

To verbal To verbal commandcommand

33 Opens eyes when told to do soOpens eyes when told to do so

To painTo pain 22 Opens eyes in response to painOpens eyes in response to pain

NoneNone 11 Does not open eyes to any stimuliDoes not open eyes to any stimuli

VerbalVerbal

Oriented, Oriented, conversesconverses

55 Relatively intact CNS; aware of self and Relatively intact CNS; aware of self and surroundingssurroundings

Disoriented, Disoriented, conversesconverses

44 Well articulated, organized, but disorientedWell articulated, organized, but disoriented

Inappropriate Inappropriate wordswords

33 Random, exclamatory wordsRandom, exclamatory words

IncomprehensibleIncomprehensible 22 No recognizable wordsNo recognizable words

No responseNo response 11 No audible soundsNo audible sounds

MotorMotor

Obeys verbal Obeys verbal commandscommands

66 Readily moves limbs when told toReadily moves limbs when told to

Localizes painful Localizes painful stimulistimuli

55 Moves limb in effort to avoid painMoves limb in effort to avoid pain

Flexion Flexion withdrawalwithdrawal

44 Pulls away from pain with a flexion motionPulls away from pain with a flexion motion

Abnormal flexionAbnormal flexion 33 Exhibits decorticate rigidityExhibits decorticate rigidity

ExtensionExtension 22 Exhibits decerebrate rigidityExhibits decerebrate rigidity

No responseNo response 11 Demonstrates dypotonicity, flaccid: Suggests Demonstrates dypotonicity, flaccid: Suggests loss of medullary function or spinal cord loss of medullary function or spinal cord injuryinjury

Concussion Grading: University of North Concussion Grading: University of North CarolinaCarolina

GradeGrade 11stst ConcussionConcussion

22ndnd ConcussionConcussion

33rdrd ConcussionConcussion

Grade 1 Grade 1 (mild)(mild)

May return to May return to play if play if asymptomaticasymptomatic

Return to play Return to play in 2 weeks if in 2 weeks if athlete is athlete is asymptomatic asymptomatic during the during the previous weekprevious week

Terminate Terminate season; may season; may return to play return to play the following the following season if season if asymptomaticasymptomatic

Grade 2 Grade 2 (moderate)(moderate)

Return to play Return to play after being after being asymptomatic asymptomatic for 1 weekfor 1 week

Out a Out a minimum of 1 minimum of 1 month; may month; may return to play return to play then if then if asymptomatic asymptomatic for 1 week; for 1 week; consider consider termination of termination of seasonseason

Terminate Terminate season; may season; may return to play return to play the following the following season if season if asymptomaticasymptomatic

Grade 3 Grade 3 (severe)(severe)

Out a Out a minimum of 1 minimum of 1 month; may month; may then return to then return to play if play if asymptomatic asymptomatic for 1 weekfor 1 week

Terminate Terminate season; may season; may return to play return to play the following the following season if season if asymptomatic; asymptomatic; Consider Consider terminating terminating careercareer

Terminate Terminate career in career in contact sportscontact sports


Return to Play Guidelines: Grade 0 Return to Play Guidelines: Grade 0 ConcussionConcussion Remove athlete from contestRemove athlete from contest Examine immediately:Examine immediately:

Abnormal cranial nerve functionAbnormal cranial nerve function CognitionCognition CoordinationCoordination Postconcussive symptoms (both at rest and with Postconcussive symptoms (both at rest and with

exertion)exertion) Return to contest:Return to contest:

Exam is normal and athlete asymptomatic for 20 Exam is normal and athlete asymptomatic for 20 minutesminutes

If any Sx. develop within 20 minutes, return that If any Sx. develop within 20 minutes, return that day is NOT permittedday is NOT permittedUniversity of North Carolina University of North Carolina

GuidelinesGuidelines


Return to Play Guidelines: Grade 1 Return to Play Guidelines: Grade 1 ConcussionConcussion Daily follow-up evaluationsDaily follow-up evaluations May begin restricted participation when May begin restricted participation when

asymptomatic at rest and after exertion asymptomatic at rest and after exertion tests for the 2 daystests for the 2 days

Unrestricted participation allowed if Unrestricted participation allowed if asymptomatic for 1 additional day and asymptomatic for 1 additional day and neuropathological and balance testing neuropathological and balance testing normalnormal

University of North Carolina University of North Carolina GuidelinesGuidelines


Return to Play Guidelines: Grade 2 Return to Play Guidelines: Grade 2 ConcussionConcussion Remove athlete/prohibit returnRemove athlete/prohibit return Examine immediately and at 5-minute intervals Examine immediately and at 5-minute intervals

for evolving intracranial pathologyfor evolving intracranial pathology Re-examine dailyRe-examine daily May return to restricted participation when ATC May return to restricted participation when ATC

and physician are assured athlete has been and physician are assured athlete has been asymptomatic at rest and with exertion testing asymptomatic at rest and with exertion testing for 4 daysfor 4 days

Unrestricted participation if asymptomatic for Unrestricted participation if asymptomatic for additional 2 days and performing restricted additional 2 days and performing restricted activities normallyactivities normally



Return to Play Guidelines: Grade 3 Return to Play Guidelines: Grade 3 ConcussionConcussion Treat athlete on the field as if cervical spine Treat athlete on the field as if cervical spine

injury has occurredinjury has occurred Immediate re-examination at 5-minute intervals Immediate re-examination at 5-minute intervals

for signs of intracranial pathologyfor signs of intracranial pathology Return based on resolution of symptoms:Return based on resolution of symptoms:

If symptoms totally resolve within 1 week, return to If symptoms totally resolve within 1 week, return to restricted participation when athlete has been restricted participation when athlete has been asymptomatic at rest and exertion for 10 days. If asymptomatic at rest and exertion for 10 days. If asymptomatic for an additional 3 days of restricted asymptomatic for an additional 3 days of restricted activity, athlete may return to full participationactivity, athlete may return to full participation


University of North Carolina Return to University of North Carolina Return to Play ProgressionPlay Progression


Postconcussion Syndrome:Postconcussion Syndrome: Extended symptoms (cognitive Extended symptoms (cognitive

impairment)impairment) Altered neurotransmitter functionAltered neurotransmitter function Occurs more frequently in womenOccurs more frequently in women

Symptoms:Symptoms: ↓ ↓ attention spanattention span Trouble concentratingTrouble concentrating Impaired memory and irritabilityImpaired memory and irritability Exercise induced headaches, dizziness, Exercise induced headaches, dizziness,

premature fatiguepremature fatigue Balance disruption, ↓ cognitive Balance disruption, ↓ cognitive

performanceperformance


Second Impact Syndrome:Second Impact Syndrome: Athlete who has suffered a head injury Athlete who has suffered a head injury

sustains a 2sustains a 2ndnd head injury before the head injury before the signs/symptoms of the initial injury have signs/symptoms of the initial injury have subsidedsubsided

Scenario: Athlete suffering from Scenario: Athlete suffering from postconcussion symptoms (headache, visual, postconcussion symptoms (headache, visual, motor problems) returns to play motor problems) returns to play prematurely…suffers 2prematurely…suffers 2ndnd injury injury

SIS: Athlete appears stunned…within SIS: Athlete appears stunned…within seconds to minutes, displays life-seconds to minutes, displays life-threatening symptoms (semicomatose state, threatening symptoms (semicomatose state, rapidly dilating pupils, respiratory failure)rapidly dilating pupils, respiratory failure)

↑ ↑ Intracranial pressure (inability or loss of brain Intracranial pressure (inability or loss of brain blood supply regulation)blood supply regulation)

Time frame to brain stem failure is rapid! (2-5 Time frame to brain stem failure is rapid! (2-5 minutes post-impact) → High mortality rate (50%)minutes post-impact) → High mortality rate (50%)


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


Epidural Hematoma:Epidural Hematoma: Arterial bleeding between the dura mater and Arterial bleeding between the dura mater and

the skullthe skull Onset of symptoms → within hoursOnset of symptoms → within hours MOI: blow to the headMOI: blow to the head Size of hematoma Size of hematoma ↑, ↑, condition deterioratescondition deteriorates

Progression of symptoms:Progression of symptoms: Patient has signs of concussionPatient has signs of concussion Period of very lucid consciousness (may eliminate Period of very lucid consciousness (may eliminate

suspicion of serious concussion)suspicion of serious concussion) Patient becomes disoriented, confused, drowsyPatient becomes disoriented, confused, drowsy Patient complaints of headache that Patient complaints of headache that ↑ ↑ in intensity with in intensity with

timetime Signs and symptoms of cranial nerve disruptionSigns and symptoms of cranial nerve disruption Onset of comaOnset of coma Left untreated, death or permanent brain damage Left untreated, death or permanent brain damage

occursoccurs


Subdural Hematoma:Subdural Hematoma: Hematoma between the brain and Hematoma between the brain and

dura materdura mater Usually involves venous bleeding Usually involves venous bleeding

Slow accumulation of blood (low BP)Slow accumulation of blood (low BP) Symptoms may occur hours, days, or even Symptoms may occur hours, days, or even

weeks after initial traumaweeks after initial trauma Simple subdural hematoma:Simple subdural hematoma:

No direct cerebral damageNo direct cerebral damage Complex subdural hematoma:Complex subdural hematoma:

Contusions of brain’s surface with Contusions of brain’s surface with associated swellingassociated swelling


Skull Fractures:Skull Fractures: History:History:

Onset: AcuteOnset: Acute Pain characteristics: Pain over impact site, possible Pain characteristics: Pain over impact site, possible

headacheheadache MOI: Blunt trauma to headMOI: Blunt trauma to head

Inspection:Inspection: BleedingBleeding Ecchymosis under eyes and over mastoid processEcchymosis under eyes and over mastoid process Rounded contour of skull may be lostRounded contour of skull may be lost

Palpation:Palpation: CrepitusCrepitus Do not palpate over obvious deformityDo not palpate over obvious deformity

Neurological Tests:Neurological Tests: Cranial nerve assessment, sensory and motor testingCranial nerve assessment, sensory and motor testing

Comments:Comments: Rule out cervical fracture/dislocationRule out cervical fracture/dislocation No object should be inserted into site of skull lacerationNo object should be inserted into site of skull laceration A cerebral concussion may be associated with injuryA cerebral concussion may be associated with injury Immediate referralImmediate referral

Depressed Skull Fracture

Linear Parietal Skull Fracture



Cervical Spinal Cord Trauma:Cervical Spinal Cord Trauma: 1976: NCAA and NFHSA outlawed spearing in 1976: NCAA and NFHSA outlawed spearing in

footballfootball Present: Estimated that spearing still occurs in Present: Estimated that spearing still occurs in

19% of football plays19% of football plays Spinal cord function: InhibitionSpinal cord function: Inhibition

Impingement or laceration secondary to bony Impingement or laceration secondary to bony displacementdisplacement

Compression secondary to hemorrhage, edema, Compression secondary to hemorrhage, edema, and ischemia of the cordand ischemia of the cord

Trauma to spinal cord above C4: Trauma to spinal cord above C4: ↑ ↑ probability of probability of death secondary to dysfunction of brain stem or death secondary to dysfunction of brain stem or phrenic nervephrenic nerve


Cervical Fracture or Dislocation:Cervical Fracture or Dislocation: Dislocation: Dislocation:

↑ ↑ threat to spinal cordthreat to spinal cord Lower cervical vertebrae (C4-C6)Lower cervical vertebrae (C4-C6)

MOI: Neck forced into flexion and rotation MOI: Neck forced into flexion and rotation

History:History: Onset: AcuteOnset: Acute Chief complaints:Chief complaints:

Pain in cervical spinePain in cervical spine Numbness, weakness, parasthesia radiating into Numbness, weakness, parasthesia radiating into

extremitiesextremities Cervical muscle spasmCervical muscle spasm Chest painChest pain Loss of bladder or bowel controlLoss of bladder or bowel control


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


Cervical Fracture or Dislocation:Cervical Fracture or Dislocation: Functional Tests:Functional Tests:

ROM testing should not be performed if ROM testing should not be performed if numbness, weakness, or parasthesia radiating numbness, weakness, or parasthesia radiating into extremities or bowel/bladder signs presentinto extremities or bowel/bladder signs present

Neurological Tests:Neurological Tests: Upper and lower quarter screenUpper and lower quarter screen

Special Tests:Special Tests: Not applicable if fracture/dislocation suspectedNot applicable if fracture/dislocation suspected

Comments:Comments: Immediate transportation (EMS activation)Immediate transportation (EMS activation)

Fracture of C4-C5 segment

Dislocation: Result - Quadriplegia


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.



Transient Quadriplegia:Transient Quadriplegia: Body-wide state of decreased or absent Body-wide state of decreased or absent

sensory and motor functionsensory and motor function MOI: Blow to head (cervical spine forced into MOI: Blow to head (cervical spine forced into

hyperextension, hyperflexion or axial load force)hyperextension, hyperflexion or axial load force) Result: Neuropraxia of cervical spinal cordResult: Neuropraxia of cervical spinal cord Predispositions:Predispositions:

Spinal stenosis (C3-C4 )Spinal stenosis (C3-C4 ) Congenital fusion of cervical canal or other Congenital fusion of cervical canal or other

abnormalitiesabnormalities Cervical instabilityCervical instability Pavlov ratio 0.80 or less (ratio between diameter Pavlov ratio 0.80 or less (ratio between diameter

of spinal canal and diameter of vertebral body)of spinal canal and diameter of vertebral body)


Transient Transient Quadriplegia:Quadriplegia: Predisposing Predisposing

Conditions: (continued)Conditions: (continued) Spear Tackler’s Spine:Spear Tackler’s Spine:

Pavlov ratio of <0.8Pavlov ratio of <0.8 Straight or kyphotic Straight or kyphotic

alignment of the neck on alignment of the neck on a neutral lateral a neutral lateral radiographradiograph

Posttraumatic Posttraumatic radiographic abnormalityradiographic abnormality

Documentation of the Documentation of the patient's use of the spear-patient's use of the spear-tackling techniquetackling technique

Spear tackler's spine = Spear tackler's spine = contraindication for contraindication for return to playreturn to play


Transient Transient Quadriplegia:Quadriplegia: Signs and Symptoms:Signs and Symptoms:

Initially, resemble those Initially, resemble those of catastrophic cervical of catastrophic cervical injuryinjury

Sensory dysfunction, Sensory dysfunction, burning, pain, burning, pain, numbness, parasthesia numbness, parasthesia in upper and lower in upper and lower extremitiesextremities

Motor dysfunction Motor dysfunction (weakness to paralysis)(weakness to paralysis)

Symptoms clear: 15 Symptoms clear: 15 minutes to 2 daysminutes to 2 days

Diagnosis:Diagnosis: X-rays, CT, MRI, X-rays, CT, MRI,

electromyelogramselectromyelograms

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

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