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Head Injury with Concurrent Cervical Spine Injury

Julius Kiboi,1 Ahmednasir Omar,1 Mohamed Ali Omar 2

1 School of Medicine University of Nairobi

2 Mbagathi District Hospital, Nairobi, Kenya

Correspondence to: Dr. Julius Kiboi, PO Box 51612–00200, Nairobi; email: j_kiboi@yahoo.com

Abstract

Dual diagnoses of moderate or severe head injuries occurring concurrently with cervical spine injuries are postulated to have very poor outcomes. These outcomes are unknown in resource-limited settings. Methods: Patient files with dual diagnoses between 2012 and 2016 at the Kenyatta National Hospital (KNH) were reviewed retrospectively. Clinical and outcome parameters were identified for each case and SPSS version 20 was used for correlation and regression tests. Results: Eleven patient files were identified; patients’ median age was 34 years. C2 was the modal cervical spine injury level. The most common clinical presentation (63%) was loss of consciousness; 45% of patients had a Glasgow Outcome score ≤1. Using Pearson correlation study, age was significantly positively correlated with outcome: r = 0.751, n = 11, p = 0.008. A significant regression equation was found (F (1, 9) = 11.624, p <0.001) with an adjusted R2 of 0.515 to predict outcome on the Glasgow Outcome Scale based on age. Conclusion: For patients with dual diagnoses in a resource-limited setting, survival rate is 45%; and older patients have poorer outcomes. Neurosurgeons practising in areas with limited resources should keep this in mind with the hope of attaining better outcomes.

Key words: Head injury, Dual diagnosis, Cervical spine injury

Ann Afr Surg. 2019; 16(1):11–15

DOI: http://dx.doi.org/10.4314/aas.v16i1.3

Conflicts of Interest: None

Funding: None

© 2019 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction

Traumatic brain injury (TBI) is the leading cause of death in all age groups and is postulated to be in the range of 20–30% (1). Estimates show TBI affects over 10 million people annually, leading to either hospitalization or mortality (2). The burden is worse in low and middle income countries (LMIC) because of the preponderance of risk factors associated with TBI and of health systems inadequately prepared to address the outcomes.

Sub-Saharan Africa demonstrates a higher TBI-related incidence rate of 170/100,000 owing to road traffic injuries relative to the global rate of 106/100,000 (2). The rate of road traffic accidents in Kenya is 68 per 100,000 population, and traumatic brain injuries account for 50% of this figure (3). Other factors that increase the rate of road traffic injuries in this setting include flouting of traffic rules by road users, inadequate protective gear such as helmets or lack of their use by road users, and delayed response times by emergency medical personnel because of shortages or failures within the system. Over the last 50 years, the average annual incidence of concomitant TBI and spinal cord injuries has increased (4). Studies show that in trauma patients with known head injury, simultaneous cervical spine injury occurs in 4–8% of

the cases (5, 6). Cervical spine injuries occurring concurrently with moderate and severe head injuries typically worsen the patient’s condition and have worse outcomes in resource-poor settings in LMIC. The most frequently involved area in the cervical spine is between the occiput and the C3 region (7). Patients with upper cervical injury are at a greater risk of suffering from skull base fractures and severe intracranial hematomas than those with mid to lower cervical injury (8). Approximately one-third of patients with cervical spine and/or cord injuries have moderate or severe head injuries (6, 8). Injuries to the cervical spine are critical and may result in poor outcomes because of the anatomical proximity to the centers for control of respiration and cardiovascular activity and the reticular activating system. Cervical injuries may also compound the effects of head injuries through loss of diaphragmatic innervation with subsequent inadequate respiratory effort or spinal cord injury, resulting in neurogenic shock from loss of sympathetic outflow (5). Thus, survival of patients is hampered.

Currently, there is limited local data on presentation and outcome of patients who have dual injuries in our local setting. This retrospective study focuses on elucidating the

demographic characteristics of patients with dual diagnoses of moderate or severe head injury occurring concurrently with cervical spine injury,