Transcript 6-Sports-Concussion

Concussion
and Neurologic Injury
Jamie B. Varney, M.D.
CAQ Sports Medicine
Pikeville Medical Center
Orthopedics and Sports Medicine
What is a Concussion?
Complex pathophysiological process
affecting the brain, induced by
traumatic biomechanical forces1
Cause of Concussion
May be caused by direct blow to head,
face, neck or elsewhere
Thought to be due to axonal injury caused
by acceleration forces
Not typically a structural injury
Electrolyte shifts and release of
neurotransmitters and free radicals
thought to play role
Fuel need/delivery mismatch
Risk Factors
Previous concussion (strongest
factor)
Improper technique
Male > Female
High Risk Sports
Football
Ice Hockey
Soccer
Boxing
Rugby
Field Hockey
Lacrosse
Symptoms
Headache
Loss of consciousness
Confusion/Memory Loss
Dizziness/Vertigo
Nausea/Vomiting
Phono/photo phobia
Incoordination/Slowed reaction
Emotional lability/irritability
Sleep disturbance
Symptoms
Confusion
– Vacant stare
– Slow response
– Easily distracted
– Decreased focus
– Disoriented
– Slurred speech
Symptoms
Memory Deficits
– Repeats questions
– Retrograde amnesia
– Anterograde amnesia (inability to form
new memories)
Rare Symptoms
Seizure 1% or less
Cortical blindness
Evaluation
Should be evaluated by trained personnel
as soon as suspected injury
On Field
– Loss of Consciousness
– ABC’s
– Rule out C-Spine injury
assumed if LOC
– Neurological Status
– Mental Status
Mental Status
Orientation
Memory
Cognitive skills
Memory
Short term
– Events of game (plays/score)
– Word recall
– Number sequence recall
Intermediate
– Delayed word recall
– Previous games
– World events
Long term
– Teammates/Family members
– Birthdates
– Presidents
Cognitive skills
Serial 7’s
Reverse spelling
Reverse alphabet
Concentration / complex commands
Neurological function
Cranial Nerves
Motor
Sensory
Reflexes
Cerebellar function/Coordination
– Finger/nose
– Heel/shin
– Gait/Tandem (eyes closed as well)
– Rhomberg/ Pronator drift
Additional Exam
Skull for depressions
Cervical spine tenderness
Nose for clear drainage
Ears for hemotympanum
Signs of skull fracture
Sideline Tools
 SCAT3>13 y/o
 Standardized Assessment of
Concussion (SAC)
 Maddock's Questions
 Modified BESS
–Balance Error Scoring System
 Child SCAT3 <13 y/o
SCAT 3 Demo
Neuroimaging
Typically normal
CT preferred if necessary
MRI more sensitive but may not correlate
with severity or outcome
Possible future role for functional MRI
Recommended Imaging
Neurological deficit
Suspected C-Spine injury
Suspected skull fracture
– Raccoon eye’s
– Battle’s Sign
– Rhinorhea
– Hemotympanum
Seizure
Coagulopathy / Anticoagulant use
Progressive symptoms
Consider Imaging
Canadian CT criteria
– GCS <15 two hours after injury
– Two or more episodes vomiting
– Age > 65
– Amnesia longer than 30 min prior
– Dangerous mechanism
MVA
Fall > 3ft or 5 stairs
Consider Imaging
New Orleans Criteria (GCS 15)
– Headache
– Vomiting
– Age >60
– Drug/ETOH intoxication
– Persistent anterograde amnesia
– Visible trauma above clavicle
Comparison
Two studies have shown both are
100% sensitive for detecting
neurosurgical abnormalities
One study showed higher sensitivity
for clinically significant findings with
New Orleans (99.4% vs 87.2%)
Canadian CT rules more specific
– Lowered CT rates 52.1% versus 88%
– Other study specificity 39.7% vs 3%
Bottom Line1


Imaging usually not helpful for
concussion
Helpful to rule out bleeds if
progressive symptoms or clinical
suspicion
Hospital Admission
GCS <15
Abnormal CT scan
Seizures
Bleeding diasthesis or anticoagulants
Consider if no one available to
monitor for progression of symptoms
Outpatient Monitoring
Monitor Closely 1st 24 hrs
Educate about warning signs
– Somnolence/Confusion
– Worsening headache
– Vision difficulties
– Vomiting or stiff neck
 Neurological deficits

Avoid strenuous activity
Grading Concussion
Old system
• Colorado
• American Academy of Neurology (AAN)
• Cantu
• Prague Statement 2004
– Simple <10 days
– Complex >10 days/seizures/prolonged
LOC
• Zurich Statement 2012
– Forget Grades
Return to Play
1
 No same day play
• KHSAA and NCAA
Physical Rest Until Asymptomatic
Consider Cognitive Rest
Exercise Testing
Progressive Return To Play1

Step 1

No activity, rest, when symptom free without
meds go to step 2
•Step 2
• Light aerobic exercise, no resistance training
•Step 3
• Sport specific exercise
•Step 4
• Non Contact Practice and Resistance Training
• Step 5
• Full Contact Practice
•Step 6
• Full Game
Office Exertional Maneuvers
•Treadmill/Bike
•Sprints/Run in place
•Sit-ups, Push-ups
Progressive RTP
 If symptoms develop at any step
stop and rest. Do not proceed.
ATC's are invaluable resource
More conservative in children with
focus on cognitive rest and return to
learn before return to play
Second Impact Syndrome
Occurs after second injury before
first injury has healed
Diffuse cerebral swelling that can be
life threatening
Few cases with documentation that
is consistent with description
May only require minor injury
Post traumatic Epilepsy
Seizure within 1st week not epilepsy
Mild TBI associated with twofold risk
epilepsy in 5 years
Post Concussive Syndrome
Not related to severity of injury
Symptoms >3 months (DSMIV)
– Headache
– Dizziness
– Fatigue
– Irritability
– Anxiety/Depression
– Insomnia
– Loss of concentration or memory
– Cognitive impairment
Post Concussive Syndrome
Treatment
–Consider referral
–Treat symptoms
Chronic Traumatic
Encephalopathy (CTE)



Mood Disorders
Dementia
Movement Disorders
Neuropsychiatric Testing
Paper tests interpreted by
experienced neuropsychologist
Computerized Tests
Neuropsychiatric Testing
Speed of information processing
Memory
Attention
Concentration
Reaction Time
Scanning
Visual tracking
Problem solving
Neuropsychiatric Testing
Tested at baseline then post injury if
needed
More sensitive than classic testing
Concern is maybe too sensitive and
not specific enough
Prevention
Proper equipment / fitting
Proper training for coaches and
support staff
Enhancement and enforcement of
protective rules
Pre-participation evaluation of
concussion history
Other Neurological Injury



C-Spine
Brachial Plexus
Transient Cord Neuropraxia
Other Neurological Injury



C-Spine
Brachial Plexus
Transient Cord Neuropraxia
Brachial Plexus Injury
Commonly called stinger / burner
Caused by stretch or compression
Unilateral symptoms
– Weakness
– Numbness
– Stinging pain
C5-6 most common
If has bilateral symptoms think cord
injury
Brachial Plexus Injury
Single episode
– May return when no pain or neurologic
deficit
Recurrent episode
– Consider evaluation including flex/ext xrays and canal diameter
If symptoms last more than 1 week
consider MRI/EMG to rule out cord
lesion
Stinger/Burner
Prevention
Rehab to strengthen neck/shoulders
Proper hitting technique
Proper equipment (pads)
Neck rolls/cowboy collars
Transient Cord Neuropraxia
Flexion/extension injury with
underlying spinal stenosis
Post traumatic neurological findings
Bilateral symptoms of paresthesia
and or weakness
Upper > Lower extremities
Lasts minutes to days
If occurs must evaluate with imaging
for cord injury and spinal canal
diameter
Torg Ratio
Ratio of spinal
canal to vertebral
body
Ratio <0.8
suggestive of
stenosis
MRI measurement
of cord vs. canal
diameter more
reliable
Treatment
If have transient neuropraxia then
protect cervical spine until fracture
ruled out
Must evaluate canal diameter which
may imply risk of future injury
Neurosurgeon familiar with
treatment should help make any
return to play decision
References
1. McCrory,P. et al. Consensus Statement
on Concussion in Sport (Zurich
Statement 2012). Br J Sports Med
2013;47:250-258
2. Meehan, WP, O'Brien, MJ. SportsRelated Concussion in Children and
Adolescents: Clinical Manifestations
and Diagnosis. UpToDate. 9-22-14