Abstract
BACKGROUNDThe occurrence of traumatic brain injury with spinal cord injury (SCI) in polytrauma patients is associated with significant morbidity. Clinicians face challenges from a decision-making and rehabilitative perspective. Management is complex and understudied. Treatment should be systematic beginning at the scene, focusing on airway resuscitation and hemodynamic stabilization, immobilization, and timely transport. Early operative interventions should be provided, followed by minimizing secondary pathophysiology. The authors present a case to delineate decision-making in the treatment of combined cranial and spinal trauma.OBSERVATIONSA 19-year-old man presented as a level I trauma patient after falling 30 feet as the result of scaffolding collapse. The patient was unresponsive and was intubated; he had an initial Glasgow Coma Scale score of 4. Computed tomography revealed multicompartmental bleeding and herniation, for which supra- and infratentorial decompressive craniectomies were performed. The patient also suffered from thoracic SCI that resulted in complete paraplegia. Multimodality monitoring was used. After stabilization and lengthy rehabilitation, the patient obtained significant functional improvement.LESSONSThe approach to initial management of concomitant head and spine trauma is to establish intracranial stability followed by intraspinal stability. Patients can make considerable recovery, particularly younger patients, who are more likely to benefit from early aggressive interventions and medical treatment.
Highlights
The occurrence of traumatic brain injury with spinal cord injury (SCI) in polytrauma patients is associated with significant morbidity
We present the clinical decision-making process for a patient who sustained complex severe traumatic brain injury (TBI) and SCI, in whom early stepwise operative decompressions and stabilization, along with multimodality monitoring, assisted with overall improvement in neurological function
Operative decompression for SCI should not be delayed once a patient can tolerate surgery from an intracranial perspective.[13]
Summary
The occurrence of traumatic brain injury with spinal cord injury (SCI) in polytrauma patients is associated with significant morbidity. The current TBI models of prognostication are not specific to this subpopulation of patients.[4] In part due to the complexity of specialized care and availability of medical resources, early management strategies of combined neuroaxis injury vary among providers and institutions. Early intubation and ventilation, spinal immobilization, and rapid patient transport to the nearest level I trauma center. The goal of early operative decompression is to prevent neurological deterioration and obtain mechanical stability. We present the clinical decision-making process for a patient who sustained complex severe TBI and SCI, in whom early stepwise operative decompressions and stabilization, along with multimodality monitoring, assisted with overall improvement in neurological function
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