Brain and Spinal Cord Injury Diagnosis

  • Diagnosis

    Traumatic brain injury is sudden physical damage to the brain. The damage can result from a closed head injury, such as that caused by impact of the head with an object like the windshield or the dashboard of a car. The damage can also result from a penetrating brain injury, such as that caused by a bullet piercing the skull. Approximately 200,000 people die each year in the US from brain injuries, with an additional 500,000 hospitalized for treatment. About 10% of surviving individuals have continuing disabilities that may impair their ability to live independently.

    Traumatic spinal cord injury is damage to the spinal cord that results in loss of mobility or feeling. In most cases, the spinal cord remains intact, but the damage results in loss of nerve function. The spinal cord is a dense bundle of nerves that lies in a narrow canal in the center of the vertebrae. The spinal cord carries all of the major nerve pathways that connect the brain to the rest of the body. Injuries to the neck or back may damage the spinal cord, causing loss of function of the nerves below the injury. In the US, approximately 8,000 new cases of spinal cord injury occur each year, and an estimated 450,000 people in the country live with the condition.

    Automobile accidents are the most common cause of brain and spinal cord injuries. Other common causes of brain and spinal cord injuries include acts of violence and sports injuries. In infants, toddlers, and elderly people, brain injury is often caused by falls in or around the home. Very young children who are violently shaken can experience severe and potentially permanent brain damage.

    Spinal column fracture or dislocation resulting in spinal cord compression (such as that caused by diving into shallow water) can cause injury to the spinal cord. Severe spinal cord injury usually occurs after dislocation or compression of the spinal cord. Severing the spinal cord results in immediate paralysis and loss of sensation below the break. Less severe damage to the spinal cord generally results in less severe loss of function.

    The extent of secondary damage such as inflammation or hemorrhage following brain or spinal injury often determines the permanence of the initial damage. One of the body’s responses to injury is inflammation. Inflammation occurs when certain cells of the immune system move towards the area of injury and release potent chemicals. Among other effects, these chemicals cause fluid to build up in the injured area. Because both the brain and spinal cord are confined in tight spaces, inflammation or internal bleeding can cause pressure on the nerves. If the pressure does not subside, the nerves will start to die in a few hours. Rapid treatment to reduce the pressure caused by inflammation or internal bleeding may prevent permanent damage to the brain or spinal cord.

    The symptoms of brain injury depend on the areas of the brain that are damaged Table 01. A brain injury can be localized to a single area (focal damage), or can spread out over a wide area of the brain (diffuse damage). Localized damage usually occurs at the place where an object strikes the head or penetrates the brain. When this type of damage occurs, the function performed by that part of the brain may be temporarily or permanently lost.

    The brain moving within or colliding with the skull usually causes diffuse damage. Because the speech and language areas of the brain sit in pockets of the skull that allow the most movement, they are the most common areas to be injured. As a result, difficulty communicating is a common symptom of closed head injuries. Other symptoms of brain injury may include difficulty swallowing, loss of coordination or balance, blurry or double vision, loss of consciousness, impaired memory, confusion or drowsiness, slurred speech, vomiting, changes in ability to smell, or fluid or blood leaking from the nose or ears. In the most severe cases, heartbeat and breathing may stop, and the injured person may enter a coma or die.

    Table 1.  Symptoms of Brain Injury

    Minor injury (80%) More severe injury (10%) Injury requiring emergency medical care (10%)
    Mild headacheCuts or bruises on scalp Difficulty communicatingTemporary confusion or memory lossLoss of coordination or balanceBlurry or double visionChanges in smell Severe head or facial bleedingLoss of consciousness, even if only temporaryConfusion or memory loss lasting more than a few minutesBlack and blue marks below the eyes or behind the earsBlood or clear fluid leaking from the ears or nose (not as a result of a direct blow to the nose)Heartbeat or breathing stops

    The type and severity of spinal cord injury will determine the kinds of symptoms that emerge Table 02. Typical symptoms of whiplash injuries include headache, neck or back pain, swelling in the affected area, and bruising on the neck or back. Compression injuries, dislocation injuries, or severe whiplash may result in weakness, tingling, or numbness in the arms or legs. Other symptoms may include loss of bladder or bowel control and difficulty breathing. In the most severe cases, spinal cord injury results in total paralysis and loss of sensation below the site of damage.

    Table 2.  Symptoms of Spinal Injury

    Headache; pain in the neck or back
    Swelling in the affected area
    Bruises on head, neck, shoulders, or back
    Weakness, tingling, or numbness in the arms or legs
    Loss of bowel or bladder control
    Difficulty breathing

    The extent of damage depends upon the location of the damage to the brain or spinal cord Table 03 Figure 01. Nerves run from the brain through the spinal cord to specific areas of the body. Some nerves travel a relatively short distance through the spinal cord; others, like those that control leg movement, travel long distances through the cord. When the spinal cord is injured, nerve function is affected, causing weakness, paralysis, and loss of sensation below the injury. Consequently, the lower the injury is in the spinal cord, the more localized the symptoms. For example, an injury to the lower spine may affect only leg movement and sensation, whereas an injury to the neck may cause paralysis of the arms, legs, and chest muscles.

    Table 3.  Symptoms of Spinal Injury by Location

    Neck (cervical region) Chest (thoracic region) Lower back (lumbar region) Tailbone (sacral region)
    Loss of sensation and paralysis in the arms, legs, and chest Loss of sensation and paralysis in the legs and chest Loss of sensation and paralysis in the legs Loss of sensation in sacral region and paralysis in the feet
    Loss of bladder and bowel controla ? ? ?

    a Loss of bladder and bowel control can occur with severe injury anywhere in the spinal cord.

    Symptoms of brain injury usually develop soon after the trauma. In some cases, however, an injured person will have no symptoms at first, only to develop serious symptoms hours or days later. In minor cases, a person with a head injury may have a mild headache, a lump on the head, and a bruise or a cut on the scalp. The absence of major physical symptoms, however, does not rule out a serious brain injury. Especially in cases where an injury causes fluid to build up within the brain, symptoms may not appear until much later. For this reason, a person who has experienced a brain injury should be watched closely for any sign of delayed symptoms.

    Click to enlarge: The spinal cord

    Figure 01. The spinal cord

    Although anyone can experience brain or spine injuries, most injuries occur in young men between the ages of 15 and 24, presumably because many young men engage in active, high–risk lifestyles.

    Young children and adults over 75 years of age are more susceptible to brain injuries because of their increased risk of falling.

    Failure to use protective gear such as seat belts while riding in automobiles or helmets while riding a bike increases your risk of sustaining serious head or spinal cord injury should an accident occur.

    Because brain and spinal cord injuries are often life–threatening medical emergencies, the doctor must make a rapid initial diagnosis. The doctor or emergency medical technician (EMT) will normally first ask questions about how the injury occurred. If the injured person is unconscious or unable to respond, the doctor or EMT will ask witnesses for details about what happened. If a brain injury has occurred, the doctor will be particularly interested in the timing and duration of any loss of consciousness. For example, a person who was alert immediately after the injury but lost consciousness later may be experiencing bleeding or other fluid build–up within the brain.

    After obtaining the initial history, the doctor will assess the patient’s neurological function. The doctor will examine the patient’s pupils for response to light, ask questions to determine whether the patient is confused or disoriented, and will test the patient’s motor responses. A high level of neurological function indicates a minor injury. Patients with impaired neurological function are normally given additional diagnostic tests, and are admitted to the hospital for observation.

    A physical examination can identify the likely location of a spinal cord injury. During the initial diagnosis, the physician will test for the patient’s ability to feel or move the arms, legs, and other areas of the body to determine the most likely area of injury.

    When brain or spinal cord injury is suspected, the physician will order computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, or x–rays of the affected area. A CT or MRI scan can identify swelling, bleeding, blood clots, or compression in the brain or spinal cord. X–rays can identify fractures of the skull or spine.

    Because excessive pressure can quickly cause permanent nerve damage, the physician will normally insert a gauge inside the skull of someone with a severe injury. Reducing pressure within the brain or spinal cord may prevent the secondary damage to nerves that can result in permanent disability. A pressure–monitoring gauge can identify and track inflammation and bleeding within the brain, and is a critical part of intensive care.

    Many brain and spinal cord injuries can be prevented by using proper protective gear. Consistent use of seat beats in automobiles can reduce the risk of injuries during accidents. Proper use of car seats can reduce the risk of injury to infants and toddlers. Wearing a helmet while biking, motorcycling, or skating can significantly reduce the risk of head injuries associated with these activities. The risk of injury during contact sports (e.g., football) or other sports with fast–moving projectiles (e.g., hockey or baseball) can be reduced with the use of appropriate helmets and padding.

    Injuries that occur in the home can often be prevented. Most brain and spinal injuries that occur in the home result from falls, especially on stairs, in bathrooms, and off ladders or stepstools. Infants, toddlers, and the elderly are especially at risk for falls inside the home. Protective barriers, railings, and handholds can help prevent falls and subsequent injury. Proper use of ladders and stepstools can minimize the risk as well.

    Accidents and injuries associated with alcohol use can often be prevented. Alcohol use is a contributing factor in many brain and spinal cord injuries. Driving while under the influence is a major cause of automobile accidents. Excessive alcohol consumption is also often a factor in accidents around the home. Avoiding alcohol before driving or performing other activities that require good judgment or coordination can reduce the risk of accidents that lead to many brain and spine injuries.

    Do not dive into shallow water.

  • Prevention and Screening

    Many brain and spinal cord injuries can be prevented by using proper protective gear. Consistent use of seat beats in automobiles can reduce the risk of injuries during accidents. Proper use of car seats can reduce the risk of injury to infants and toddlers. Wearing a helmet while biking, motorcycling, or skating can significantly reduce the risk of head injuries associated with these activities. The risk of injury during contact sports (e.g., football) or other sports with fast–moving projectiles (e.g., hockey or baseball) can be reduced with the use of appropriate helmets and padding.

    Injuries that occur in the home can often be prevented. Most brain and spinal injuries that occur in the home result from falls, especially on stairs, in bathrooms, and off ladders or stepstools. Infants, toddlers, and the elderly are especially at risk for falls inside the home. Protective barriers, railings, and handholds can help prevent falls and subsequent injury. Proper use of ladders and stepstools can minimize the risk as well.

    Accidents and injuries associated with alcohol use can often be prevented. Alcohol use is a contributing factor in many brain and spinal cord injuries. Driving while under the influence is a major cause of automobile accidents. Excessive alcohol consumption is also often a factor in accidents around the home. Avoiding alcohol before driving or performing other activities that require good judgment or coordination can reduce the risk of accidents that lead to many brain and spine injuries.

    Do not dive into shallow water.

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