Cervical spinal cord compressions and Skull

fractures
Physiology
Normal Anatomy - Nervous System
The skull is a bony structure that supports the face and forms a protective cavity for
the brain. It is comprised of many bones, formed by intramembranous ossification,
which are joined together by sutures (fibrous joints). These joints fuse together in
adulthood, thus permitting brain growth during adolescence.
The bones of the skull can be divided into two groups: those of the cranium (which
can be subdivided the skullcap known as the calvarium, and the cranial base) and
those of the face.
The cranium (also known as the neurocranium) is formed by the superior aspect of
the skull. It encloses and protects the brain, meninges and cerebral vasculature.
Anatomically, the cranium can be subdivided into a roof (known as the calvarium),
and a base:
Calvarium: Comprised of the frontal, occipital and two parietal bones.
Cranial base: Comprised of six bones the frontal, sphenoid, ethmoid,
occipital, parietal and temporal bones. These bones are important as they
provide an articulation point for the 1st cervical vertebra (atlas), as well as
the facial bones and the mandible (jaw bone). [15]

Sutures of the skull

Sutures are a type of fibrous joint that are unique to the skull. They are immovable,
and fuse completely around the age of 20.
Sutures are of clinical importance, as they can be points of potential weakness in
both childhood and adulthood. The main sutures in adulthood are:

Coronal suture which fuses the frontal bone with the two parietal bones.
Sagittal suture which fuses both parietal bones to each other.
Lambdoid suture which fuses the occipital bone to the two parietal bones.
In neonates, the incompletely fused suture joints give rise to membranous gaps
between the bones, known as fontanelles. The two major fontanelles are the frontal
fontanelle (located at the junction of the coronal and sagittal sutures) and the
occipital fontanelle (located at the junction of the sagittal and lambdoid sutures).
[15]

Cervical Spine:
The cervical spine is comprised of seven vertebrae: C1, C2, C3, C4, C5, C6, and C7.
These vertebrae begin at the base of the skull and extend down to the thoracic spine.
The cervical vertebrae have cylindrical bones that lie in front of the spinal cord and
stack up one on top of the other to make one continuous column of bones in the
neck.

The nervous system consists of the brain, spinal cord, sensory organs, and all of the
nerves that connect these organs with the rest of the body. Together, these organs
are responsible for the control of the body and communication among its parts. The
brain and spinal cord form the control center known as the central nervous system
(CNS), where information is evaluated and decisions made. The sensory nerves and
sense organs of the peripheral nervous system (PNS) monitor conditions inside and
outside of the body and send this information to the CNS. Efferent nerves in the PNS
carry signals from the control center to the muscles, glands, and organs to regulate
their functions. [18]

Normal Physiology - Nervous System

The nervous system has 3 main functions: sensory, integration, and motor.
Sensory. The sensory function of the nervous system involves collecting
information from sensory receptors that monitor the bodys internal and
external conditions. These signals are then passed on to the central nervous
system (CNS) for further processing by afferent neurons (and nerves).
Integration. The process of integration is the processing of the many sensory
signals that are passed into the CNS at any given time. These signals are
evaluated, compared, used for decision making, discarded or committed to
memory as deemed appropriate. Integration takes place in the gray matter of
the brain and spinal cord and is performed by interneurons. Many
interneurons work together to form complex networks that provide this
processing power.
Motor. Once the networks of interneurons in the CNS evaluate sensory
information and decide on an action, they stimulate efferent neurons. Efferent
neurons (also called motor neurons) carry signals from the gray matter of the
CNS through the nerves of the peripheral nervous system to effector cells.
The effector may be smooth, cardiac, or skeletal muscle tissue or glandular
tissue. The effector then releases a hormone or moves a part of the body to
respond to the stimulus. [19]
Divisions of the Nervous System

Central Nervous System

The brain and spinal cord together form the central nervous system, or CNS. The
CNS acts as the control center of the body by providing its processing, memory, and
regulation systems. The CNS takes in all of the conscious and subconscious sensory
information from the bodys sensory receptors to stay aware of the bodys internal
and external conditions. Using this sensory information, it makes decisions about
both conscious and subconscious actions to take to maintain the bodys homeostasis
and ensure its survival.
Peripheral Nervous System
The peripheral nervous system (PNS) includes all of the parts of the nervous system
outside of the brain and spinal cord. These parts include all of the cranial and spinal
nerves, ganglia, and sensory receptors.

Somatic Nervous System

The somatic nervous system (SNS) is a division of the PNS that includes all of the
voluntary efferent neurons. The SNS is the only consciously controlled part of the
PNS and is responsible for stimulating skeletal muscles in the body.
Autonomic Nervous System
The autonomic nervous system (ANS) is a division of the PNS that includes all of the
involuntary efferent neurons. The ANS controls subconscious effectors such as
visceral muscle tissue, cardiac muscle tissue, and glandular tissue.
There are 2 divisions of the autonomic nervous system in the body: the sympathetic
and parasympathetic divisions.
Sympathetic. The sympathetic division forms the bodys fight or flight
response to stress, danger, excitement, exercise, emotions, and
embarrassment. The sympathetic division increases respiration and heart
rate, releases adrenaline and other stress hormones, and decreases digestion
to cope with these situations.
Parasympathetic. The parasympathetic division forms the bodys rest and
digest response when the body is relaxed, resting, or feeding. The
parasympathetic works to undo the work of the sympathetic division after a
stressful situation. Among other functions, the parasympathetic division works
to decrease respiration and heart rate, increase digestion, and permit the
elimination of wastes.
Enteric Nervous System
The enteric nervous system (ENS) is the division of the ANS that is responsible for
regulating digestion and the function of the digestive organs. The ENS receives
signals from the central nervous system through both the sympathetic and
parasympathetic divisions of the autonomic nervous system to help regulate its
functions. However, the ENS mostly works independently of the CNS and continues
to function without any outside input. For this reason, the ENS is often called the
brain of the gut or the bodys second brain. [20]

Pathophysiology
Skull Fractures
The majority of skull fractures result from blunt force or penetrating trauma, and can
produce numerous signs and symptoms. The clinical features may be obvious, such
as visible injuries and bleeding. There are also subtle signs of fracture, such as clear
fluid draining from the ears and nose (cerebrospinal fluid leak indicative of base of
skull fracture), poor balance and confusion, slurred speech and a stiff neck.
There are certain areas of the skull that are natural points of weakness:
The pterion: a H-shaped junction between temporal, parietal, frontal and
sphenoid bones. The thinnest part of the skull. A fracture here can lacerate
an underlying artery (the middle meningeal artery), resulting in a extradural
haematoma.
Anterior cranial fossa: Depression of skull formed by frontal, ethmoid and
sphenoid bones.
Middle cranial fossa: Depression formed by sphenoid, temporal and parietal
bones.
Posterior cranial fossa: Depression formed by squamous and mastoid
temporal bone, plus occipital bone. [21]

Symptoms of skull fractures

The symptoms of a fractured skull may include:
Bleeding. Bleeding may occur from the wound site or from the ears, nose, or
eye area.
Bruising. Bruising may occur behind the ears or under the eyes.
Pupils. Pupils may appear to be unequal in size or unreactive to light.
Neurological symptoms. Convulsions, drowsiness, headache, loss of
consciousness, slurred speech, restlessness, irritability, and visual
disturbances may occur.
Sick feeling. Skull fracture victims may experience nausea or vomiting.

Types of fractures
There are four major types of cranial fractures:
Depressed A fracture of the bone with depression of the bone inwards. They occur
as a result of a direct blow, causing skull indentation, with possible underlying brain
injury.
Linear The simple break in the bone, traversing its full thickness. They have
radiating (stellate) fracture lines away from the point of impact. The most common
type of cranial fracture.
Basal skull Affects the base of the skull. They characteristically present with
bruising behind the ears, known as Battles sign (mastoid ecchymosis) or bruising
around the eyes/orbits, known as Raccoon eyes.
Diastatic A fracture that occurs along a suture line, causing a widening of the
suture. They are most often seen in children. [22]

Cervical Spine Compression

Cervical spine injuries are best classified according to several mechanisms of injury.
These include flexion, flexion-rotation, extension, extension-rotation, vertical
compression, lateral flexion, and imprecisely understood mechanisms that may result
in odontoid fractures and atlanto-occipital dislocation.

Flexion Injury
Common injuries associated with a flexion mechanism include the following:
Simple wedge compression fracture without posterior disruption
Flexion teardrop fracture
Anterior subluxation
Bilateral facet dislocation
Clay shoveler fracture
Anterior atlantoaxial dislocation
Simple wedge fracture
With a pure flexion injury, a longitudinal pull is exerted on the nuchal ligament
complex that, because of its strength, usually remains intact. The anterior vertebral
body bears most of the force, sustaining simple wedge compression anteriorly
without any posterior disruption.
Radiographically the anterior border of the vertebral body has diminished height and
increased concavity along with increased density due to bony impaction (see the
image below). The prevertebral soft tissues are swollen. [17]

Flexion teardrop fracture

A flexion teardrop fracture occurs when flexion of the spine, along with vertical axial
compression, causes a fracture of the anteroinferior aspect of the vertebral body.
This fragment is displaced anteriorly and resembles a teardrop.

Flexion-rotation Injury
Common injuries associated with a flexion-rotation mechanism include unilateral
facet dislocation and rotary atlantoaxial dislocation.

Unilateral facet dislocation

Unilateral facet dislocation occurs when flexion, along with rotation, forces one
inferior articular facet of an upper vertebra to pass superior and anterior to the
superior articular facet of a lower vertebra, coming to rest in the intervertebral
foramen. [17]

Extension Injury
Common injuries associated with an extension mechanism include hangman
fracture, extension teardrop fracture, fracture of the posterior arch of C1 (posterior
neural arch fracture of C1) and posterior atlantoaxial dislocation.

Hangman fracture (traumatic spondylolisthesis of C2)

The name of this injury is derived from the typical fracture that occurs after hangings.
Presently, it commonly is caused by motor vehicle collisions and entails bilateral
fractures through the pedicles of C2 due to hyperextension.
Radiographically, a fracture line should be evident extending through the pedicles of
C2 along with obvious disruption of the spinolaminar contour line.

Fracture of the posterior arch of C1 fracture (posterior neural arch fracture)

This fracture occurs when the head is hyperextended and the posterior neural arch of
C1 is compressed between the occiput and the strong, prominent spinous process of
C2, causing the weak posterior arch of C1 to fracture.[17]

Vertical (axial) Compression Injury

Common injuries associated with a vertical compression mechanism include
Jefferson fracture (burst fracture of the ring of C1), burst fracture (dispersion, axial
loading), atlas fracture, and isolated fracture of the lateral mass of C1 (pillar fracture).

Jefferson fracture (burst fracture of the ring of C1)

This fracture is caused by a compressive downward force that is transmitted evenly
through the occipital condyles to the superior articular surfaces of the lateral masses
of C1. The process displaces the masses laterally and causes fractures of the
anterior and posterior arches, along with possible disruption of the transverse
ligament. Quadruple fracture of all 4 aspects of the C1 ring occurs.
Radiographically the fracture is characterized by bilateral lateral displacement of the
articular masses of C1. The odontoid view shows unilateral or bilateral displacement
of the lateral masses of C1 with respect to the articular pillars of C2; this finding
differentiates it from a simple fracture of the posterior neural arch of C1. [17]

Burst fracture of the vertebral body

When downward compressive force is transmitted to lower levels in the cervical
spine, the body of the cervical vertebra can shatter outward, causing a burst fracture.
This fracture involves disruption of the anterior and middle columns, with a variable
degree of posterior protrusion of the latter.

Radiographically, this fracture is evidenced by a vertical fracture line in the frontal

projection and by comminution and protrusion of the vertebral body anteriorly and
posteriorly with respect to the contiguous vertebrae in the lateral view.

Epidemiology
Skull Fractures
The incidence of skull fractures among head injured adults who present to
emergency departments (ED) is unknown. The parietal bone is most frequently
fractured, followed by the temporal, occipital, and frontal bones. Linear fractures are
the most common, followed by depressed and basilar skull fractures.
Much of the data on skull fractures in adults come from studies of traumatic brain
injury (TBI). Each year, approximately 1.7 million people sustain head injuries in the
United States alone, with 1.3 million undergoing emergency evaluation.
According to one retrospective study of 207 head-injured patients, 37 percent of
those with associated intracranial pathology sustained a linear skull fracture.
According to another retrospective study of 2254 cases of head trauma from assault,
approximately one-third sustained a skull fracture. [21]
Cervical Spinal Cord compression
Cervical spine injuries cause an estimated 6000 deaths and 5000 new cases of
quadriplegia each year. Male-to-female ratio is 4:1. Most patients with a cervical
spine injury are in their prime and leading an active lifestyle prior to injury.
Approximately 80% of patients are aged 18-25 years.

Clinical Presentation
Description of patients
According to Cesvi (Centro de Experimentacin y Seguridad Vial) the use of helmet
reduces 80% the risk of death. Moreover, Cenapra indicates that 76% of
motorcyclists use helmet. On the other hand, Mexico is a country where is not
necessary a test to grant motorcycle license. The minimum age to get a license is 15
years old.
The average age when occurs more motorcycle accidents in Mexico is between 15
and 30 years old and approximately the 80% are men, according to orthopedic
specialists in the Hospital General de Mxico Dr. Eduardo Liceaga. [1]
Cervical spinal cord compression
Symptoms
Symptoms of cervical spinal cord compression can develop quickly or slowly,
depending on the cause. Injuries may cause immediate symptoms.
These are common symptoms:
Pain and stiffness in the neck or back.
Burning pain that spreads to the arms or buttocks.
Numbness, cramping, or weakness in the arms or hands.
Trouble with hand coordination.
Loss of sexual ability.
Clumsy/weak/numb hands/legs, (neck/arm/shoulder/scapular pain), ataxia
Bowel/bladder,
impotence,
electric
shock
triggered
by
jolt/neck-flexion/jaw-protruding. [4]
Classic findings of neck pain accompanied by simultaneous bilateral hand numbness
and weakness should be only rarely missed. However, pain may be primarily in the
extremities or upper back and neurologic symptoms or signs may be unilateral or
asymmetric, which can focus the clinicians attention on other conditions such as
stroke, nerve root compression, or CTS.
Signs
Lhermitte: electric pain running down spine caused by neck-flexion/etc in cord
disease.

 Spurling: radicular pain worse with extension and rotation to affected side in
root compression.
Hoffmann: flicking tip of 3rd finger causes thumb and/or index finger flexion in
cord disease.
Inverted Radial Reflex: tapping brachioradialis just proximal to wrist causes
wrist flexion. [12]
Skull fractures
Symptoms
In some cases, as in an open or depressed fracture, it may be easy to see that the
skull is broken. Sometimes, though, the fracture isnt obvious.
Serious symptoms of a skull fracture include:
Bleeding from the wound caused by the trauma, near the location of the
trauma, or around the eyes, ears, and nose
Bruising around the trauma site, under the eyes, or behind the ears
Severe pain at the trauma site
Swelling at the trauma site
Redness or warmth at the trauma site
Less severe symptoms, or those that may not necessarily appear to be related to a
skull fracture, may include:
Headache
Nausea
Vomiting
Blurred vision
Restlessness
Irritability
Loss of balance
Stiff neck
Pupils not reacting to light

 Confusion
Excessive drowsiness
Fainting [5]
Signs
There are typical exam findings that are consistent with skull fractures. Typical
findings include raccoon eyes, conjunctiva hemorrhage, anosmia, Battle signs, vision
changes, CSF rhinorrhea or otorrhea, step off supraorbital edge, hearing loss, facial
paralysis, facial numbness. Frontal fractures were the most common fracture to have
clinical signs. However, each clinical finding had its own predictive value to having
skull base fractures. Battles sign is 100% associated with skull fractures, with
periorbital ecchymosis at 90% and bloody otorrhea with 70% association. [9]

Clinical Outcomes
Morbidity
In our country, the amount of motorcycles on the streets is increasing, as well as the
number of accidents related with the use of this vehicle.
During 2013, the Instituto Nacional de Estadstica y Geografa (INEGI) registered
41,798 accidents involving motorcycles. It is considered one of the most vulnerable
way of transportation, alongside bicycles and peatons. The CONAPRA also stated
that it has 18 times more probability to suffer from accidents than a regular car. [2]
Specialists from the General hospital Mexico assured that from the 100% of vehicle
accidents, 50% are to blame for the use of a motorcycle. They reiterated that these
incidents are the main cause for motor disability, and the 20-30% are left with some
kind of amputation or neurological sequels. [2]

Mortality
According to the World Health Organization, traffic accidents cause 1.2 million
annual deaths and represent the first worldwide cause of death among young people
from 15 to 29 years old. The 23% of these deaths are perpetuated by motorcyclists.
In Mexico, in just 4 years, the number of people that died from motorcycle accidents
doubled from 1,218 in 2010 to 1317 in 2014. [3]
CONAPRAs last figures from accidents stated that from 473 teenagers between 10
to 19 years old died last year, consequence of a wound caused by a motorcycle
accident. [7]

Part of the problem has to do with the fact that, even though 80% of motorcyclists
report the use of a helmet, only half of them counts with one that actually protects
them from a serious wound or death in case of an accident. There are many helmets
that dont fulfill the normativities imposed by the state. [1]

Economic Impact
Motorcycle accidents currently represent a total of 730 deaths a year, that is to say,
the 4.39% of the total deaths per vial accidents in the country.
It is important say that in Mexico die 16,559 persons per traffic accidents every year.
With regard of motorcycles, per year are recorded in our country around of 35,000
accidents, what represent the 4.29% of the total accidents.
The motorcycle fleet has been registered an increase of 60.2% in the last five years,
representing today a total of 1,156,873 units registered.
Of this total, in 2010 only 109,074 motorcycles had an insurance, that is the 9.42%,
which means that in this sector the level of assurance in Mexico is lower than private
cars.
The average cost of material damages in motorcycles were 9,266 per accident,
because of which in 2010 the insurances paid $128,177,091 pesos when registering
9,232 accidents in this types of units. [6]
Direct Medical Cost.
Cost of treatment
o

Approximately, a surgery cost between 40 thousands to 120 thousands

pesos, depending on the severity of the patient, materials and
orthopedic appliances. [8]

o Laboratory studies can range from $ 3,500 to $ 6,000.

o Axial tomography study $ 2,846
o Magnetic Resonance Imaging $ 4,341
o Physical Medicine and Rehabilitation Session $ 2,358
o Transfer by ambulance $ 2,906
Hospitalization

o Day of hospitalization approximately $ 6,958

o Day of hospitalization in intensive care $ 34,232
Physician fees
o

They can range from $ 33,173 depending on the severity of the patient.
[11]

Indirect Costs
Loss of productivity
o

The 2 million 600 thousand road accidents that occur every year in
Mexico cost the country more than 150 billion pesos. Around 1.7% of
GDP.

Another 40% is related to material damages, costing approximately 70

billion pesos a year, are the second largest item of economic loss for
the country. That money is destined mainly to the public highway and
vehicles damaged, as well as to administrative processes in Courts and
Public Ministries.

The remaining 11%, that is, around 16 billion pesos is earmarked for
health care. 34% is absorbed by social security, but 66% is the pocket
of Mexicans who end up in debt. [13]

Summary

After consulting some sources of information, we already have a more concrete idea
of what causes an injury, both in the skull and at the level of the cervical vertebrae.
From the head we know that the skull is divided into the frontal, temporal, parietal,
occipital, sphenoid bone. We also know that we have 3 sutures in the skull that can
become fragile fractures to break, in case of an accident. We have 7 cervical
vertebrae, 3 atypical, C1, C2 and C7. The nervous system is responsible for
controlling the response of the human body to any situation, either voluntarily or
involuntarily. This in turn is divided into central nervous system and peripheral
nervous system, hence the somatic nervous system, autonomic nervous system. etc.
We learned that injuries to the skull can lead from the most pathetic and simple event
of accidents to a traumatic shock and that one of the structures with weakness and
that can cause a laceration in the artery that irrigates the brain, Is the pterio.
Regarding cervical lesions, it is important to emphasize that an injury not treated in
time, can trigger until the formation of an edema, which could rise to the spinal cord
and thus leaves the patient, unable to perform any type of Activity and even death.

There are many treatments based on therapies that use heat to "disinflate and
decompress the cervical, but also has deepened the research of drugs that are
auxiliary in the treatment of cervical lesions and even of the skull." The age of people
suffering from Motorcycle accidents, ranging from 15 to 30 years, and represent
about 730 deaths per year. Finally, the expenses incurred at the national level, for
motorcycle accidents, amount to $ 128,177,091. That is sought is to give them
greater security through a helmet that they can use to cover both head and spine.
References:
[1] Gmez, A. (2014). Mueren en accidentes de moto 2.5 al da. Recuperado de:
http://archivo.eluniversal.com.mx/nacion-mexico/2014/mueren-en-accidentes-de-mot
o-25-al-dia-1052745.html
[2] Velasco,F. (2016) Accidentes en moto, primera causa de muerte en Mxico.
Recuperado
de:
http://mexiconuevaera.com/sociedad/salud/2016/03/3/accidentes-en-moto-primera-c
ausa-de-muerte-en-mexico
[3]
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(2015).Accidentes
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https://www.insp.mx/avisos/3889-accidente-motocicleta.html

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http://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/s
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[5]
Kim,
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(2015).
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motocicleta
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[7] Toribio, L. (2016). Aumentan muertes por accidentes en moto, a pesar de usar
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[8] Magaa, R. S. (14 de Noviembre de 2013). Enfermarse en Mxico cuesta caro!
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[9]
Martnez,
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(2013).
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[10] Montes, R. (15 de junio de 2016). Manejar una motocicleta en la CDMX sin
restricciones
ni
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[11] Notimex. (26 de Febrero de 2016). IMSS publica lista de precios para no
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[13] Salud, O. M. (15 de Enero de 2013). El costo de los accidentes viales en Mxico
representa el 1.7% del PIB, las principales vctimas son los jvenes. Obtenido de
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