Acute on chronic subdural hematoma and thoracic vertebral injury in a multitrauma patient
This patient was found outside his nursing home residence unconscious. He was brought in by ambulance and proceeded to profusely vomit. A dilated right pupil was noted on examination. A CT Brain and C-spine was performed.
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There is a minimally displaced fracture of the T3 vertebral body with 2 column involvement (possibly an unstable injury). Image quality in the upper cervical spine is degraded by movement artifact and repeat imaging is suggested to exclude further cervical spine fractures.
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Subdural hemorrhage is a collection of blood in between the dura mater and the arachnoid mater of the brain. In young adults, subdural hemorrhage is typically caused by traumatic head injury associated with motor vehicle accidents. It is said to have an incidence of 12-29% of patients presenting with severe traumatic brain injury 3.
Patients with subdural hemorrhage can often present with neurological signs, such as a decreased conscious state or pupillary changes. Note that this patient demonstrated pupillary changes.
Treatment of subdural hematomas depends on the chronicity (acute vs chronic) as well as the degree of mass effect that is being produced. In this particular patient, we have an acute subdural hematoma which is producing significant mass effect, causing effacement of the right ventricle and ambient cisterns. He required an urgent decompressive cranioectomy.
Surgical intervention in acute subdural hematoma can be dictated by the following guidelines 3:
- SDH thickness greater than 10mm
- Midline shift greater than 5mm
- Neurological changes - GCS drop by 2 or more points; asymmetric pupils; intracranial pressure > 20mm Hg
This patient fulfilled all three of the above criteria and proceeded to urgent surgical management.
Traumatic fractures of the thoracic spine are a common traumatic occurrence.
They can be grouped into three different categories according to Magerl et. al. 1:
- Type A - vertebral body compression fractures
- Type B - anterior and posterior element injuries with distraction
- Type C - anterior and posterior element injuries with rotation
While definitive management is controversial, in general, surgical vs conservative management is dependent upon two things 2:
- Compromised biomechanical stability of spine
- Presence of a neurological deficit
That being said, evidence-based guidelines for the treatment of traumatic fractures of the thoracic and lumbar spine are lacking 2.
Case contributed by A/Prof. Pramit Phal.
- 1. Magerl F, Aebi M, Gertzbein SD et-al. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J. 1995;3 (4): 184-201. Pubmed citation
- 2. Verlaan JJ, Diekerhof CH, Buskens E et-al. Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine. 2004;29 (7): 803-14. Pubmed citation
- 3. Bullock MR, Chesnut R, Ghajar J et-al. Surgical management of acute subdural hematomas. Neurosurgery. 2006;58 (3 Suppl): S16-24. Pubmed citation