Traumatic Brain Injury
[…] involves negative pressure waves following an explosion and is hypothesized to result in diffuse axonal injury in the brain and spinal cord.3 Secondary injury involves evolution of primary intracerebral damage and extra-cerebral insults such as edema, excitatory neurotransmitter release, free-radical […]
Osteoporosis and Fractures after CNS Injury
[…] the imbalance of bone formation and resorption. Many individuals with central nervous system (CNS) injury, including individuals with brain injury, spinal cord injury (SCI), stroke, multiple sclerosis (MS), Parkinson’s disease (PD), cerebral palsy (CP), and brain tumors, are at risk for osteoporosis. […]
Mild to Moderate Pediatric Traumatic Brain Injury
[…] which may be an indication for carotid dissection. Evaluation for spinal tenderness, paresthesias, incontinence, extremity weakness, priapism which may indicate spinal cord injury. Deep tendon reflexes, presence of Babinski sign, clonus and Hoffman’s sign. Functional assessment There are various tools that have been validated for the assessment of mild TBI. These tools can be grouped into five main groups13 Common hospital assessment tools Neuropsychological tests (written and computerized) Postural stability testing Sideline Assessment Tools Symptoms Checklists In this review, we will cover a select number of tools used for assessment of mild to moderate TBI. Neuropsychological tests A commonly used neuropsychological test is the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), which provides a baseline assessment for patients. This computerized test provides scores for four areas: verbal memory, visual memory, reaction time, visuomotor speed. Demographic information, history data, current concussion details and somatic and cognitive symptoms are also taken into account. ImPACT is used for patients ages 10 and above. There is also an adapted version for ages 5-9 years old called the Pediatric ImPACT.14 While the ImPACT is useful and easily accessible, there are some limitations to its usefulness. Limitations include insufficient research in its usage for pre-existing cognitive issues (i.e. ADHD, learning disability, psychiatric diagnoses), its use in non-sports related concussion, and the ceiling effect that may diminish its reliability.6,15 More importantly, clinicians, especially sideline clinicians, should be aware of sandbagging by high school athletes who intentionally underperform in their baseline ImPACT assessment.16 Sideline assessment tools There are three main tools to assess concussions on the sidelines: the Sport Concussion Assessment Tool (SCAT5) for ages 13 and above, the Child SCAT5 for ages 5 to 12, and the Standardized Assessment of Concussions (SAC). The SCAT5 (2017) is the most updated version, revised from the prior SCAT3 (2013). Certain modifications include extended and clarified instructions, required clearance by a health professional before return to play, and emphasis on an initial rest period of 24-48 hours.17 The SCAT5 should not be used as a standalone tool for assessment and its utility decreases after 3-5 days post-injury.18 These measure the patient’s memory, orientation, and concentration (reference: page 300 – acute evaluation) using a checklist and the assessment of cognitive performance. Physicians can use the results of these assessments to guide their management. The Standardized Assessment of Concussions (SAC) is another screening tool available for sideline evaluation. The SAC is a brief evaluation of cognitive function and includes standard questions of orientation (place, time, date, month, year), working memory via the immediate recall of 5 words, concentration by recalling a list of digits and the months backward, and remote memory via delayed recall.19 Certain modifications have been made including increasing the recall to 10 words to prevent the ceiling effect.18 Postural stability testing The vestibular/ocular motion screening (VOMS) tool is also used to measure vestibular and ocular impairments specially to evaluate concussion after sport-related activities. The tool evaluates smooth pursuits, horizontal and vertical saccades, the near point of convergence, horizontal and vertical vestibular ocular reflexes, and visual motion sensitivity, and should be used in tandem with pre- and post-symptoms assessments to determine provocation severity (e.g., dizziness).20 Symptoms checklists The post-concussion symptoms scale (PCSS) is a 22-item self-reported questionnaire recommended by the 5th International Conference on Concussion in Sport as a means to monitor clinical recovery. It asks patients to rate the severity of various symptoms they may be experiencing with higher scores indicating more severe levels of dysfunction.18 The Graded Symptom Checklist (GSC) is another self-report measure for concussion symptoms where symptom severity is rated up to 72 hours after the inciting event.21 A combination of the computerized assessments with the PCSS or GSC have demonstrated confidence in distinguishing pediatric patients with and without mTBI.22 Laboratory studies Currently, mild to moderate TBI is a clinical diagnosis. There are no standard laboratory studies or markers that have been adopted in the diagnosis of mild-moderate TBI in pediatric patients. However, research is underway to identify markers that may be useful in the future for diagnosis and prognosis. S100B, neuron-specific enolase (NSE), glial fibrillary acidic protein (GFAP), and ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1) are among the most commonly measured brain-specific biomarkers. Though studies have demonstrated overall increased levels of these biomarkers in pediatric patients suffering TBI with links to worse outcomes, there is still insufficient evidence regarding its significance and accuracy in the setting of mild and moderate TBI.22,23 Imaging Noncontrast computed tomography (CT) of the head is typically the imaging modality of choice in a child with a GCS 5 minutes, poorer scores on ImPACT testing.6 Dizziness at 2 weeks post-injury is the single most predictive symptom for post-concussive syndrome.25 Social role and social support system There may be changes in a child’s emotional, behavioral and social interactions after a TBI. The recovery process may be challenging for patients and family alike, which calls for additional support from an interdisciplinary team. Social workers, psychologists and educators may be necessary for coping and adjustment. Community support groups may be valuable as well. Professional issues If abuse is suspected, patients should be further evaluated by the medical team for signs of non-accidental trauma. Please see the Knowledge NOW submission on Child Abuse for further details regarding evaluation and reporting requirements. Rehabilitation Management And Treatments Initial recovery phase management Recommend 2-3 days of rest with stepwise symptoms-limited activity. Introduce cognitive activity followed by physical activity as tolerated by following gradual return to play (RTP) and return to learn (RTL) protocols. Progression through the stages of the RTP and RTL protocols will be based on symptoms exhibited, so close monitoring by clinicians, family, and school professionals is important. Abortive headache medication (i.e. NSAID) may also be used If sleep disturbances occur, melatonin may also be used Monitor for mood changes Return to learn protocol Phase 1: “Brain rest” – No school/complete cognitive rest 24-48 hours Definition: High levels of symptoms; physical symptoms that are most prominent and may interfere with even basic tasks. Interventions: Avoid bright lights, avoid activities that worsen symptoms like screen time, reading, video games, loud music Sleep as much as needed, drink fluids and eat healthy foods Learning: No school. No homework or take-home tests. Can ask for copies of notes from students or teachers Phase 2: “Restful home activity” Patient starts to improve but may still have some symptoms; may only be able to do cognitive activities for short periods of time Intervention: Easy tasks at home like drawing or cooking. Soft music and audiobooks. Regular bedtime schedule to allow 8-10 hours of sleep and naps. Limiting screen time to less than 30 minutes a day Learning: No school. No homework or take-home tests. Can ask for copies of notes from students or teachers Phase 3: Return to school – partial day Once patients can complete 60-90 minutes of light mental activity from phase 2 and have fewer symptoms, consider returning to school partially. Interventions: 8-10 hours of sleep per night, avoid naps. Continue eating healthy foods and drinking fluids; limit screen time to less than 1 hour a day. Limited social time with friends Learning: Limited homework. Multiple choice or verbal assignments preferred over writing. Offer tutoring if needed. Take breaks in a quiet room as needed. Stop work when symptoms worsen. Phase 4: Return to school – full day Once patient can complete phase 3 without symptoms Intervention: Continue with 8-10 hours of sleep per night, drinking plenty of fluids and eating healthy foods Learning: Gradual progression to attending classes full days. Phase 5: Full recovery Full recovery is typically defined as being able to complete all assignments/tests without symptoms. Patients may initiate return to play protocol once they achieve full recovery for return to learn protocol.26 Return to play Patients should not return to play on the same day of injury. It is recommended to complete RTL before proceeding with Return to Play (RTP). Phase 1: Patient completed their RTL protocol. Walking short distances is acceptable. Phase 2: Light aerobic activity – 5-10 minutes on an exercise bike, walking or light jogging. No weightlifting. Phase 3: Moderate aerobic activity – moderate jogging, brief running, moderate intensity weight lifting (less time and/or weight from their typical routine) Phase 4: Heavy, non-contact activity – sprinting/running, regular weightlifting routine, non-contact sport-specific drills Phase 5: Practice, full contact. Phase 6: return to competition An athlete should only move onto the next phase if they are asymptomatic at their current phase. If symptoms return at any phase, the athlete should stop and may resume at the same phase only after asymptomatic > 24 hours. Long-term impacts While many patients recover, some may suffer long-term consequences from their mild to moderate TBI. They […]
Tethered Cord Syndrome
[…] symptoms that include pain, incontinence, musculoskeletal deformities, motor weakness, and sensory abnormalities resulting from abnormal stretch placed on the distal spinal cord by congenital or acquired factors.1 Etiology Primary TCS is associated with abnormal primary or secondary neurulation during spinal […]
Sexual Dysfunction in Acquired Brain Injury (ABI)
[…] and stimuli) and output (engagement of proper motor responses). Autonomic and somatic nerves participate in an elaborate network involving numerous spinal and supraspinal sites in the central nervous system. Some studies suggest that lesions in the right cerebral hemisphere cause […]
Spinal Procedures
[…] based on risk of serious bleeding18 Spinal-Procedures-–-Table-1Download Table 2. Management of anticoagulants and antiplatelet medications prior to following interventional spine procedures18 Spinal-Procedures-–-Table-2Download Neurologic complications of epidural injections Can occur with nerve root injury or spinal cord injury Transforaminal epidural steroid injection May have rare catastrophic complications when performed in the cervical spine region Complications are associated with embolic events because of inadvertent intra-arterial injection. There is a greater association with particulate steroids than non-particulate steroids. Complications include brain infarction, spinal cord infarction, cortical blindness, high spinal anesthesia, and seizures.1,17 Interlaminar epidural steroid injection Complications include dural puncture with cord trauma and post-dural puncture headache Post-dural puncture headache (PDPH) Risk is reduced with the use of a smaller gauge needle. Symptoms include nausea, vomiting, hearing loss, tinnitus, vertigo, dizziness, paresthesia of the scalp, and limb pain. The incidence of PDPH is higher in older population (>51 years) compared to younger population (
Pressure Injury Management in CNS Disorders
[…] incidence increases significantly with advancing patient age.5 The absence of protective sensation increases risk of pressure injury, such as from spinal cord injury (SCI) or other neurologic conditions. From SCI model systems data, the prevalence of pressure injury increases in time post-injury, […]
Hematological, Metabolic and Endocrine Complications of CNS Injury
[…] elsewhere separately as a specific topic. Etiology Hematological, metabolic, and endocrine complications can result from traumatic brain injury (TBI) and spinal cord injury (SCI), as well as non-traumatic disorders involving the brain or spinal cord such as stroke and CNS cancer. Endocrine […]
Sexuality and Reproduction after SCI
[…] sexual and reproductive function.The effect of a SCI on sexual function and health depends on the level and severity of spinal cord injury, as well as personal attributes such as partnership status, pre-morbid sexual experiences and attitudes, and openness to sexual experimentation. […]
Vascular Myelopathy
Disease/ Disorder Definition Vascular myelopathy (VM) refers to spinal cord injury (SCI) secondary to ischemia or hemorrhagic compression of the spinal cord. Etiology Etiologies of VM are most often secondary to tissue infarction caused by spinal cord ischemia (secondary to lack of […]