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Traumatic brain injury (TBI) and traumatic spinal cord injury (TSI) represent pathologies that result from a diverse spectrum of primary insults to the central nervous system (CNS). Nearly 2 million cases of neurotrauma, including both TBI and TSI, occur annually in the United States making it an important public health issue.1–3 In addition to the long-term physical disabilities and the psychosocial impairments seen in neurotrauma survivors, the economic burden of TBI and TSI is significant. The cost of TBI in the United States is estimated to be somewhere between $40 and $200 billion.3–6 For TSI, it is estimated that the lifetime total cost directly attributable to spinal cord injury in a 25-year-old patient may exceed $3 million.2
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Advancements in our understanding of the pathophysiology of CNS injury post-trauma have led to improvements in the critical care of patients with TBI and TSI. Indeed, the development of standardized guidelines for aggressive medical and surgical management of these patients has been credited for helping to improve outcomes.7,8 For severely brain- and/or spinal cord–injured patients, it is crucial that a multidisciplinary approach be taken from the outset. The foremost principle guiding the management of TBI and TSI patients is to minimize the secondary neural injury that inevitably follows a primary CNS insult. Appropriate and timely emergency stabilization, critical care management, and surgical interventions are essential for delaying the progression of secondary CNS injury. Toward this end, the clinician treating TBI and TSI patients must be able to assess, monitor, and treat the multitude of physiologic derangements that result from and also facilitate CNS injury. In this chapter, we review the epidemiology, pathophysiology, and critical care management of TBI and TSI patients. As neurosurgical intervention—whether at the bedside or in the operating room—is generally necessary for TBI and TSI patients, the surgical indications for pathology encountered in the emergency and critical care setting will also be reviewed.
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Traumatic Brain Injury
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The Centers for Disease Control and Prevention (CDC) estimates that 1.7 million people sustain TBI annually.1 Of this total, approximately 52,000 die, 275,000 are hospitalized, and 1.365 million are treated and released from an emergency department. However, the actual number of TBI cases is uncertain as many patients either receive care in the field or do not seek medical attention at all. The causes of TBI in all age groups combined are: falls in 35.2%, motor vehicle accident in 17.3%, being struck in 16.5%, assault in 10%, and other or unknown causes in 21%. Among all age groups, males have higher incidences of TBI and on average present with TBI about 1.4 times more frequently than females. The CDC identified three age groups—children aged 0–4 years, adolescents aged 15–19 years, and adults aged 65 years and older—as most likely to sustain TBI. Children aged 0–4 years had the highest rate of TBI-related emergency department visits (1,256 per 100,000 population) while ...