Traumatic Brain Injury and Spinal Trauma: From Emergency Evaluation to Rehabilitation

Emergency priorities in brain and spine trauma

Traumatic brain injury (TBI) and spinal trauma are time-sensitive because secondary injury can occur minutes to hours after the impact. “Secondary injury” means damage caused by low oxygen, low blood pressure, swelling, bleeding expansion, or ongoing spinal cord compression—problems that are often preventable with early stabilization.

1) Primary survey principles relevant to brain and spine

Initial care follows trauma priorities, but with specific goals to protect the brain and spinal cord. The key idea is simple: avoid hypoxia and hypotension, and prevent movement of an unstable spine.

Airway and breathing (oxygenation and ventilation)

• Assume cervical spine risk until cleared. Use in-line stabilization during airway maneuvers and intubation.
• Oxygenation target (conceptual): keep oxygen levels normal; even brief low oxygen can worsen brain injury.
• Ventilation target (conceptual): aim for normal carbon dioxide. Too much ventilation (low CO₂) can reduce brain blood flow; too little (high CO₂) can worsen swelling.
• When intubation is often needed: inability to protect airway, severe agitation preventing safe care, or worsening mental status.

Circulation (blood pressure and perfusion)

• Blood pressure target (conceptual): maintain adequate perfusion; low blood pressure is strongly associated with worse neurologic outcomes.
• Control bleeding elsewhere: major torso/limb hemorrhage can cause shock that starves the brain and spinal cord of blood flow.
• Head-injured patient who is hypotensive: assume another bleeding source until proven otherwise; isolated TBI rarely causes major hypotension.

Disability and rapid neurologic check

A quick neurologic snapshot guides urgency and imaging. Typical elements include level of consciousness, pupil size/reactivity, limb movement symmetry, and any clear focal deficits. Worsening exam over minutes to hours is a red flag for expanding bleeding or swelling.

Exposure and temperature

Fully expose to find injuries, then prevent hypothermia. Low temperature can worsen coagulopathy and bleeding.

Practical step-by-step: stabilization workflow (first minutes)

1. Immobilize the spine (collar + careful transfers) while assessing airway.
2. Secure airway if needed with in-line stabilization; provide supplemental oxygen.
3. Support circulation: IV access, fluids/blood products as indicated, treat shock.
4. Rapid neuro check and identify “deteriorating” patients.
5. Move to CT once stable enough; unstable patients may need immediate life-saving interventions first.

2) CT-driven decision-making in head injury

In acute head trauma, CT is the workhorse because it quickly shows blood, fractures, mass effect, and swelling. Management is often “CT pattern + neurologic status + trajectory over time.”

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Contusions and traumatic intraparenchymal hemorrhage

What it is: bruising/bleeding within brain tissue, commonly in frontal and temporal lobes due to impact against the skull base.

• CT clues: patchy hyperdense areas (blood) with surrounding hypodensity (edema). Contusions can “blossom” (enlarge) on repeat imaging.
• Typical approach: close observation, repeat CT if symptoms worsen or if high-risk features exist; surgery is considered if there is significant mass effect or neurologic decline.

Epidural hematoma (EDH)

What it is: bleeding between skull and dura, often arterial and associated with skull fracture.

• CT appearance: biconvex (lens-shaped) collection that does not cross suture lines.
• Clinical pattern: can deteriorate rapidly; sometimes a “lucid interval” occurs but is not required.
• Why it matters: EDH is a classic “time is brain” lesion—prompt evacuation can be lifesaving.

Subdural hematoma (SDH)

What it is: bleeding between dura and brain surface, often venous but can be mixed; commonly seen with more diffuse injury.

• CT appearance: crescent-shaped collection that can cross suture lines; may be acute (bright), subacute, or chronic (darker).
• Key decision factors: thickness, midline shift, basal cistern compression, and neurologic exam.

Skull fractures

• Linear fractures: may be managed conservatively but raise suspicion for underlying bleeding.
• Depressed fractures: fragments pushed inward; concern for dural tear, contamination, seizures, and focal injury.
• Basilar skull fractures: may be suggested by specific clinical signs and can be associated with CSF leak; CT helps define extent.

Swelling, mass effect, and herniation risk

CT can show effacement of sulci, compressed ventricles, and loss of basal cisterns—signs that swelling is raising pressure and threatening brainstem function. These findings, especially with a worsening exam, drive escalation to aggressive medical management and possible surgery.

Practical step-by-step: how CT findings translate to actions

1. Identify a surgical mass lesion (EDH/SDH/large contusion) and correlate with exam.
2. Check for mass effect (midline shift, cistern compression) and signs of impending herniation.
3. Look for fracture patterns that change risk (depressed, basilar) and may require specific precautions.
4. Decide disposition: ICU vs monitored bed vs discharge with instructions (for mild injuries with reassuring CT and exam).
5. Plan repeat imaging if high risk for progression (anticoagulation, worsening symptoms, large contusions, significant SDH/EDH managed nonoperatively).

3) When surgery is considered in TBI

Surgery is considered when there is a treatable structural problem causing pressure on the brain or when swelling threatens survival despite maximal medical therapy. The goal is to remove mass effect, restore perfusion, and prevent herniation.

Evacuation of hematomas (EDH/SDH) and contusions

• Indications (conceptual): neurologic deterioration, significant mass effect on CT, large hematoma volume, or refractory elevated pressure.
• Common procedures: craniotomy to remove clot and control bleeding; sometimes a bone flap is left off if swelling is expected.
• Practical considerations: correct coagulopathy/anticoagulation when possible; coordinate with trauma team for other life-threatening injuries.

Decompressive craniectomy (concept)

What it is: removing a large portion of skull to give the swollen brain room to expand outward rather than compress vital structures.

• When considered: severe swelling with refractory intracranial hypertension or diffuse injury with impending herniation despite optimized medical management.
• Trade-offs: can be lifesaving but may increase survival with significant disability in some cases; decision-making often involves prognosis discussions with family.

CSF diversion (concept)

What it is: temporary drainage of cerebrospinal fluid to reduce pressure and allow monitoring/management.

• When considered: acute hydrocephalus after trauma, intraventricular blood, or to help manage elevated pressure in severe TBI.
• How it helps: relieves ventricular pressure and can guide therapy by tracking pressure trends.

Practical step-by-step: how “surgery vs no surgery” is approached

1. Confirm the lesion on CT and assess whether it is surgically accessible and likely to improve mass effect.
2. Assess the trajectory: stable vs deteriorating exam; need for escalating support.
3. Optimize physiology: oxygenation, blood pressure, temperature, glucose; reverse coagulopathy if possible.
4. Choose the operation type: evacuation alone vs evacuation + decompression; consider CSF diversion if hydrocephalus/pressure issues are prominent.
5. Plan postoperative pathway: ICU monitoring, repeat CT, seizure prophylaxis when indicated, and early rehab planning.

4) Spine trauma: patterns, instability, cord injury signs, immobilization

Spinal trauma management focuses on preventing a second hit to the spinal cord. The spine can be injured at the bone, ligament, disc, or cord level; instability means the spine can move abnormally and threaten the cord or nerve roots.

Fracture patterns and the idea of instability

Rather than memorizing every classification, beginners should recognize what makes an injury unstable:

• Disruption of multiple supporting structures (bone + ligaments/disc).
• Malalignment (translation, angulation) on imaging.
• Fracture-dislocation or perched/locked facets in the cervical spine.
• Burst fractures with retropulsed fragments narrowing the canal.

Stable injuries may be treated with bracing and activity modification; unstable injuries often need surgical stabilization.

Spinal cord injury (SCI) signs to recognize

• Motor deficits: weakness or paralysis below the injury level.
• Sensory changes: numbness, tingling, loss of pain/temperature, or a clear sensory “level.”
• Autonomic issues: low blood pressure with bradycardia (neurogenic shock), temperature dysregulation, urinary retention.
• Spinal shock vs incomplete injury: early after injury, reflexes may be absent; later spasticity and hyperreflexia can develop.

Immobilization and safe handling

• Prehospital/ED: collar and careful transfers; avoid twisting. Use a coordinated “log-roll” only when necessary and with enough helpers to maintain alignment.
• When to be extra cautious: altered mental status, intoxication, distracting injuries, midline neck/back pain, or neurologic symptoms.
• Reassessment: repeat neuro checks after any move, procedure, or change in symptoms.

Practical step-by-step: initial spine trauma actions

1. Immobilize immediately and maintain alignment during all care.
2. Screen for neurologic deficits (strength, sensation, rectal tone when indicated, bladder function).
3. Identify red flags: progressive weakness, respiratory compromise (high cervical injury), neurogenic shock.
4. Coordinate imaging once stable; CT defines bony injury, while MRI is often used when cord/ligament injury is suspected or deficits are unexplained by CT.
5. Decide stabilization plan: brace vs surgery, based on stability and neurologic status.

5) Surgical stabilization and decompression concepts in spine trauma

Spine surgery after trauma generally has two goals: decompression (remove pressure from cord/nerve roots) and stabilization (restore alignment and prevent harmful motion).

Decompression (concept)

• What is being decompressed: the spinal cord, cauda equina, or nerve roots.
• How compression happens: bone fragments (burst fracture), disc herniation after trauma, epidural hematoma, or dislocation.
• Why timing matters: ongoing compression can worsen neurologic injury; early decompression is often considered when there is a clear compressive lesion with deficits.

Stabilization (concept)

• Methods: screws/rods/plates, sometimes combined with fusion, to hold the spine in a safe alignment while healing occurs.
• Approach selection: anterior, posterior, or combined approaches depend on where the instability and compression are located.
• Nonoperative stabilization: rigid collars or thoracolumbar braces may be used for stable patterns or when surgery risk outweighs benefit.

Practical step-by-step: how surgeons decide on spine surgery

1. Define the injury pattern (alignment, canal compromise, ligament integrity).
2. Match symptoms to anatomy (is there a deficit? is there a compressive lesion?).
3. Determine stability (will normal movement risk further injury?).
4. Choose goals: decompression, stabilization, or both.
5. Plan perioperative care: DVT prevention, skin protection, bladder/bowel plan, respiratory support if high cervical injury.

6) Recovery trajectory: ICU to rehabilitation

Recovery after TBI or SCI is a continuum. Early phases focus on survival and preventing complications; later phases focus on regaining function and adapting to lasting deficits.

ICU and acute hospital phase

• Neurologic monitoring: frequent exams and repeat imaging when changes occur.
• Physiologic optimization: maintain adequate oxygenation and perfusion; manage fever and glucose; treat seizures when they occur or provide prophylaxis when indicated.
• Early mobility and prevention: positioning, pressure injury prevention, pulmonary hygiene, and early physical/occupational therapy consults.

Transition to inpatient rehabilitation

Rehab starts earlier than many people expect—often while still hospitalized. The intensity increases once medically stable.

Roles of therapy disciplines (practical examples)

• Physical therapy (PT): gait training, balance, strength, transfers. Example: practicing safe bed-to-chair transfers with a spinal brace and learning fall-prevention strategies.
• Occupational therapy (OT): activities of daily living (ADLs) like dressing, bathing, cooking adaptations, fine motor retraining. Example: one-handed dressing techniques after hemiparesis.
• Speech-language pathology (SLP): swallowing safety and cognitive-communication therapy. Example: structured exercises for attention and memory, and strategies to reduce aspiration risk.
• Neuropsychology: cognitive assessment, coping strategies, return-to-work/school planning.

Common complications to anticipate and manage

Seizures

• Early post-traumatic seizures: may occur in the first days; risk is higher with cortical contusions, intracranial hematomas, and depressed skull fractures.
• Practical management concept: recognize events promptly, protect airway, treat medically, and adjust activity restrictions (e.g., driving) per local rules.

Spasticity and tone changes (especially after SCI or severe TBI)

• What families notice: stiffness, involuntary spasms, difficulty with hygiene or transfers.
• Rehab approach: stretching, splinting, positioning, and medications when needed; goals include comfort and function, not just “relaxing” muscles.

Mood, behavior, and sleep changes

• Common issues: depression, anxiety, irritability, impulsivity, emotional lability, insomnia.
• Practical strategies: consistent routines, minimizing overstimulation, therapy for coping skills, and medication when appropriate.

Headache, dizziness, and cognitive fatigue

• Pattern: symptoms can worsen with screens, noise, multitasking, or poor sleep.
• Practical pacing: graded return to activity with scheduled rest breaks; symptom diary to identify triggers.

Autonomic and bladder/bowel issues (more common in SCI)

• Bladder: retention or incontinence may require timed voiding, catheter strategies, and urology follow-up.
• Bowel: structured bowel programs reduce constipation and accidents.
• Blood pressure regulation: some patients experience orthostatic hypotension or episodes of autonomic dysreflexia depending on injury level.

Family support considerations

Family and caregivers often become part of the care team. Setting expectations and teaching practical skills reduces complications and burnout.

• Education topics: safe transfers, brace/collar care, seizure first aid, medication schedules, skin checks, and recognizing red flags (worsening headache, confusion, new weakness, fever, wound drainage).
• Communication tips: use short instructions, one task at a time, and calm environments for patients with attention or irritability issues.
• Planning: home safety evaluation (stairs, bathroom setup), equipment needs (walker, wheelchair, shower chair), and follow-up schedule coordination.