Head and Neck

Pathologies
Orthopedic Assessment III – Head,
Spine, and Trunk with Lab
PET 5609C
 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
 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
 Head and Neck Pathologies
 Concussion: Cognitive
Features
 State of unawareness (i.e.
team opponent)
 Mental confusion
 Difficulty concentrating
 Loss of Consciousness
 Amnesia
 Anterograde
 Retrograde
 Head and Neck Pathologies
 Concussion: Subjective
Symptoms
 Headache
 Dizziness
 Nausea
 Loss of Balance
 Feeling “dinged”
 Seeing stars/flashing
lights
 Hearing problems
 Irritability
 Double Vision
 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
 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??
 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
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
Concussion Grading: University of North Carolina
Grade 1st Concussion 2nd Concussion 3rd Concussion

Grade 1 (mild) May return to play Return to play in 2 Terminate season;

if asymptomatic weeks if athlete is may return to play
asymptomatic the following season
during the if asymptomatic
previous week
Grade 2 Return to play Out a minimum of Terminate season;
(moderate) after being 1 month; may may return to play
asymptomatic for 1 return to play then the following season
week if asymptomatic if asymptomatic
for 1 week;
consider
termination of
season
Grade 3 (severe) Out a minimum of Terminate season; Terminate career in
1 month; may then may return to play contact sports
return to play if the following
asymptomatic for 1 season if
week asymptomatic;
Consider
terminating career
 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

 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

 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

 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

University of North Carolina Return to Play
 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
 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%)
 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
 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
Head and Neck Pathologies
 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
Head and Neck Pathologies
 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
 Head and Neck Pathologies

Depressed Skull Fracture Linear Parietal Skull Fracture

 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
 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
 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
 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)
 Head and Neck Pathologies

Dislocation: Result - Quadriplegia Fracture of C4-C5 segment

 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.
 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)
 Head and Neck Pathologies
 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
 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