Concurrent cranial and cervical spine injuries by associated injury mechanisms in traumatic brain injury patients

SA Journal of Radiology ISSN: (Online) 2078-6778, (Print) 1027-202X Page 1 of 5 Original Research Concurrent cranial and cervical spine injuries by associated injury mechanisms in traumatic brain injury patients Authors: Pilasande Hlwatika1 Timothy C. Hardcastle2,3 Affiliations: 1 Department of Radiology, Inkosi Albert Luthuli Hospital, University of KwaZulu-Natal, Durban, South Africa Trauma Service and Trauma ICU, Inkosi Albert Luthuli Central Hospital, Durban, South Africa 2 Department of Surgical Sciences, University of KwaZulu-Natal, Durban, South Africa 3 Corresponding author: Pilasande Hlwatika, Dates: Received: 14 Oct. 2021 Accepted: 16 Jan. 2022 Published: 24 Mar. 2022 How to cite this article: Hlwatika P, Hardcastle TC. Concurrent cranial and cervical spine injuries by associated injury mechanisms in traumatic brain injury patients. S Afr J Rad. 2022;26(1), a2321. https://doi.org/10.4102/sajr. v26i1.2321 Copyright: © 2022. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License. Read online: Scan this QR code with your smart phone or mobile device to read online. Background: The incidence of concurrent traumatic brain injury (TBI) and cervical spine injury (c-spine) is relatively high, with a variety of risk factors. Objectives: The purpose of this study was to determine the incidence and related factors associated with combined cranial and c-spine injury in TBI patients by assessing their demographics and clinical profiles. Method: A retrospective study of patients attending the Trauma Centre at the Inkosi Albert Luthuli Hospital as post head trauma emergencies and their CT brain and c-spine imaging performed between January 2018 and December 2018. Results: A total of 236 patients met the criteria for the study; 30 (12.7%) patients presented with concurrent c-spine injury. Most TBI patients were males (75%) and accounted for 70% of the c-spine injured patients. The most common mechanism of injury with a relationship to c-spine injury was motor vehicle collisions (MVCs) and/or pedestrian vehicle collisions (70%). The risk factors associated with c-spine injury in TBI patients were cerebral contusions (40%), traumatic subarachnoid haematomas (36%) and skull fractures (33.3%). The statistically significant intracranial injury type more likely to have an associated c-spine injury was diffuse axonal injury (p = 0.04). Conclusion: The results suggest that concurrent TBI and c-spine injury should be considered in patients presenting with a contusion, traumatic subarachnoid haematoma and skull fracture. The high incidence of c-spinal injury and more than 1% incidence of spinal cord injury suggests that c-spine scanning should be employed as a routine for post MVC patients with cranial injury. Keywords: concurrent cranial injury; cervical spine injury; post-traumatic coma; radiation; computed tomography scan. Introduction Trauma is one of the major causes of morbidity and mortality in children and young adults in South Africa (SA). According to a study by Norman et al., the injury-related mortality rate in SA is reported to be six times higher and road traffic injuries two times higher, compared with the global rate.1 Traumatic brain injuries (TBIs) are among the most common injuries that lead to hospitalisation, surgical interventions, permanent disabilities and, in severe cases, death.2 According to the United States of America’s Centre for Disease Control and Prevention, most TBIs are due to motor vehicle collisions (MVCs), sports and firearm-related injuries and other assaults.2,3 A study in Pietermaritzburg, KwaZulu-Natal (KZN), in 2014, reported that the most common cause associated with TBI was interpersonal violence (39.4%), with a male-to-female ratio of 4.7:1.4,5 Kong and Clarke analysed 5 years (2008–2011 and 2012–2014) of morbidity and mortality conferences (MMCs) performed in the Pietermaritzburg Metropolitan Trauma Service (PMTS) and reported that the highest percentage of patients were isolated TBI post-blunt trauma at 56.5%, with multiregional injuries in 21.3% thereof and isolated neck injuries at 1.5%.6 Milby et al. reported that there was a high prevalence of cervical spinal injury (c-spine) in TBI patients post-blunt trauma with 3.7% overall.7 A study by Fujii et al. estimated that the incidence of concurrent TBI and c-spine injury was between 1.7% and 8.0% in all trauma cases.8 Another study by Tian et al. found that patients who had TBI as a result of MVCs and a low Glasgow Coma http://www.sajr.org.za Open Access Page 2 of 5 Scale (GCS) score of less than or equal to 8 were associated with an increased risk of c-spine injury. The clinical evaluation of the TBI level using the GCS is scored as follows: mild (GCS: 13–15), moderate (GCS: 9–12) and severe (GCS: 3–8).9 According to Malale et al., the chance of an abnormal imaging finding increases with a decreasing GCS score.10 The other risk factors for concurrent c-spine injury and TBI included an older age group in MVCs, skull or facial fractures and chest, pelvic, upper limb or other spinal injuries.8 The incidence of concurrent head and c-spine injuries was documented as high as 9.3% by Thesleff et al. in an article published in 2017, with the retrospective data collected for cases between August 2010 and 2012.11 Failure to diagnose c-spine injury in a TBI patient can result in irreversible and devastating neurological damage. Therefore, the diagnosis of a c-spine injury in all patients presenting with TBI is an essential aspect of the trauma evaluation process.7 Using the general guideline, all patients presenting with a TBI and with an altered level of consciousness are treated as having a concurrent c-spine injury. Many c-spine injuries may be diagnosed utilising conventional cervical radiography. Although plain radiographs are relatively inexpensive and readily available in rural hospitals in SA, they are, however, associated with up to 15% missed injury rate compared with CT,12 which is currently considered as the gold standard for diagnosing a c-spine injury, with a better sensitivity of 98% compared with that of plain radiography at 54%.13 The high incidence of c-spine injury in patients with TBI led to CT evaluation of TBI and c-spine injuries in a government healthcare facility in Pietermaritzburg13 based on retrospective data collected from all the trauma patients from January 2016 to June 2016. Interestingly, the results showed that a combined diagnosis of TBI and c-spine injuries was relatively uncommon affecting 4.76% of the overall study population and was found mostly in patients involved in MVCs and pedestrian vehicle collisions (PVCs). The aim of this study was to determine the incidence of and the associated risk factors for c-spine injuries in patients undergoing head scans for TBI, by describing the demographic and clinical profile of the patients, determining the predictive mechanism of injury, level of injury, severi (...truncated)