Neuro-radiology for medical graduates

Various imaging modalities used for investigating neurological disorders are:

X-Rays ( Plain radiography)
Ultrasonography
CT scan of the brain & Spine, CT scan with contrast, CT Angiography
MRI Brain and Spine, MR Angiography, MRI with contrast, MR Spectroscopy, MR Tractography, Functional MRI of the brain, MR cisternography
Angiography, Digital substraction angiography ( DSA)
Myelography, CT myelogram
PET CT Scan
PET MRI
TCD ( Transcranial Doppler)
SPECT

Plain Radiography

X-Ray skull is useful for the diagnosis of skull bone osteomyelitis, Craniovertebral junction abnormalitise, Tumors of the cranial bones like osteomas, osteosarcoma,  metastasis to skull may be seen on skull X - ray films. Skull fractures in head injury & Growing skull fractures in children are diagnosed on skull radiography.

CT scan: CT scan is commonly used abbreviation of Computed Axial Tomography ( CAT ) scanning. This investigation machine was developed in 1970s and it was a most important development in the field of Neuroradiology after the development of X rays ( 1890s) and angiography ( 1920s and 1930s). It is a non invasive procedure and uses X-rays for the imaging. It utilizes X-Ray beam which passes through the tissue and produces a picture like x ray but in varying shades of grey.  The density of tissue changes the picture. CT scan produces axial or cross sectional ( slices) images of the body.
Computer  measures the density of the tissue through which x ray beam passes. CT scan machine uses multiple pencil beams of x ray which rotate in the gantry and pass through the body and on opposite side dosimeter measures the amount of radiation reaching it. Each cubic part of tissue is known as voxel ( in New machines about 512 voxels) . Each voxel produces a pixel. Computer measures the attenuation of the beam and assigns a Hounsfield Unit  ( HU ).
Sir Godfrey Hounsfield from England and Allan McLeod Cormack from USA shared Nobel prize in 1979 for invention of CT scan . All shades of Gray for image May be assigned a number ' HU'. Any HU value below minus 15 will appear pure black on CT film and any HU value above 155 HU will appear pure white.  Common  HU values are water zero ( 0 )
CSF in brain 10 to 16, Air minus 1000, Fat minus 60 to minus 120. Fat containing medullary bone will appear less white as compared to compact cortical bone ( HU +1000).


CT scan of the brain is the investigation of choice
For brain trauma patients, because
- it is less time consuming,
-the presence of the metal ( bullet in gun shot injury, metal in stab injury) is not a contraindication,
- an trauma patient where the history of pace maker of heart or metallic implant is not known , CT scan is possible,
-detects bony injuries, like a fracture, depressed fracture and hematoma associated with fracture
-better delineation of hematoma .
CT scan brain is also an investigation of choice
For detecting subarachnoid hemorrhage ( spontaneous subarachnoid hemorrhage) due to rupture of an intracranial aneurysm

CT angiography ( CTA ) is an investigation to detect the aneurysm of the brain. It has become an important tool for detecting the site of aneurysm bleed, location , and other characteristics of the aneurysm of the brain . It is more sensitive than MR Angiography and its sensitivity is comparable to the Digital Substarction Angiography.

CT scan of the spine: Although MRI of the spine is undoubtedly the investigation of choice for spine, CT scan of the spine is still an important investigation. CT scan of the spine is required when MRI of the spine is not possible, for example, if a patient is with metal prosthesis ( spinal instrumentation with ferromagnetic material like steel), or a metallic bullet is impinged in the spinal cord following a gun shot injury. CT spine also helps in conditions like canal stenosis, bony fractures, ossified posterior longitudinal ligaments, etc.

High resolution CT scan, 3D reconstruction, CT myelogram , Perfusion Coputed Tomography , Intraoperative CT scan are other applications of CT scan.

MRI is the most important development in the field of neuroradiology after the development of X- rays, Angiography, and CT scan.
MRI is a non invasive radiological investigation. It does not expose the patient to the risk of radiation. It uses magnetic field . It provides multiplanar images, i.e, images in sagittal, coronal and axial planes.
Functional MRI is another non invasive investigation which helps in imaging of the eloquent area of the brain.
MR Spectroscopy provides the clue about the nature of the lesion and helps in identifying infective and neoplastic lesions of the brain.
Intraoperative MRI is an advanced technique for intraoperative imaging of the lesions inside the operation theater.
How to interpret MRI brain images?
MRI images are usually black & white. There are T1 weighted, T2 weighted, FLAIR , Diffusion weighted images and if contrast is given then T1 contrast images.
To identify T1 weighted image, see the ventricles. lateral Ventricles are in the center and contain CSF. 
On CT usually only Axial images are seen but on MRI Axial, Coronal and sagittal images are seen.
On T1 weighted image, CSF will appear Black (Hypointense).
On T2 weighted image , CSF will appear White ( Hyperintense).
On FLAIR ( Flow Attenuation Inversion Recovery) the intraventricular CSF will appear Black but brain edema will appear White.
Contrast images are usually T1 contrast Images. So, CSF will appear Black and some lesions like Meningioma will become white ( Hyperintense) after contrast enhancement.





PET and SPECT are nuclear neuroimaging and help in physiological assessment. PET ( Positron Emission Tomography) is further advanced to utilize CT or MRI imaging techniques and known as PET- CT or PET-MR. PET is used for detecting metastasis and recurrence of the tumor. PET scan commonly  utilizes Flurodeoxy glucose ( FDG) which is a radioactive tracer.

Digital substraction angiography ( DSA) is invasive investigation  which involves introducing a catheter and injecting intravenous contrast into the femoral artery. It is the gold standard investigation for defining an intracranial aneurysm, Arteriovenous malformation ( AVM) , vasospasm after Subarachnoid hemorrhage ( SAH) and other diseases of intracranial vasculature.

TCD ( Transcranial Doppler ): Noninvasive investigation to detect the vasospasm in a case of SAH.
          Although Ultrasound is not a good investigation to detect intracranial pathologies as ultrasound waves do not cross bones, there are certain places where bone is very thin like temporal squama or areas in cranium which have windows like orbit. So, the flow of blood through the intracranial arteries may be detected through these windows. In vasospasm the vessels are narrowed and flow velocity increases. This is the basis of TCD, which is a noninvasive procedure and can be performed on bedside.

Ultrasonography can be used to detect hydrocephalus and meningomyelocele in prenatal period . USG can also detect hydrocephalus in infant as anterior fontanel is not closed.

Intraoperative USG is used for real time imaging , localization, extent of resection of the tumor after craniotomy at the time of neurosurgery.

Neuronavigation is used to localize the lesion, route of the surgery, safer trajectory, etc.

Neurointervention is a very promising development in the field of Neuro-radiology. It is not only useful for the diagnosis but it also offers to treat many ailments of the brain and spine. The ost important and exciting applications of neurointerventions are: Coiling of the intracranial aneurysms, Preoperative embolization of the vascular tumors like meningioma, Embolization of the intracranial and spinal AVMs, Stenting of the vessel.

PET ( Positron Emission Tomography) scan

A non invasive nuclear medical imaging technique which detects pair of gamma rays emitted by a positron-emitting radionuclide (tracer), which is introduced into the body ( in blood circulation ) on a biologically active molecule.The concentrations of the tracer imaged will indicate tissue metabolic activity and may indicate cancer metastasis.
The molecule most commonly used is FDG ( fluorodeoxyglucose) , an analogue of glucose. which is concentrated in the tissues of interest in an hour and at that time person is placed in the imaging scanner. The radioisotope undergoes positron emission decay ( also known as beta decay), it emits a positron, an antiparticle of electron with opposite charge. It travels for a short distance and interacts with an electron which leads to annihilation and production of a pair of gamma ( photons ) which is detected by scintillator in the scanning device.
PET scans are read alongside CT or MRI scans giving both anatomic and metabolic information. Modern PET scanners are integrated with CT scanner so called PET-CT and because two scans are performed in immediate sequence during same session , with the patient not changing position, the sets of images are precisely registered.
PET scanner is costly because of the high costs of cyclotrons needed to produce the short-lived radionuclides for the PET scanning.
The PET scan is used for both research and clinical purpose. The clinical use in neurosurgical practice is to detect metastasis and to detect recurrence of the tumor after radiotherapy and chemotherapy. For example, a patient was operated for high grade glioma about one year ago and had already received chemotherapy and radiotherapy comes to the neurosurgeon for the complaints like headache or vomiting or seizure which creates the doubt of tumor recurrence. Then the physician should advise MRI brain with contrast with MR spectroscopy and compare the pre and post operative follow up scans. Sometimes, due to redionecrosis  the distinction better tumor recurrence and radionecrosis is not very clear and in this situation a PET scan can be advised.

 

Functional MRI ( fMRI)

For explaining functional fMRI in an easy and simple manner, it can be said that fMRI is similar to MRI in the sense that it involves MRI machine and produces scans similar to MRI except it highlights the "functional brain" area  . It is based on  the principle that when an area of the brain is in use, the blood flow to that region increases. So, the neuronal activity changes the blood flow ( Hemodynamic Response) and which, in turn,  changes the magnetization between oxygen -rich and oxygen-poor blood. f MRI uses the blood-oxygen level dependent ( BOLD) contrast and maps the neuronal activity by imaging the changes in hemodynamic response of a brain area when a patient performs an activity.
When a person is told to perform some activity or a stimulus is received by a patient ( Paradigm) , the neurons corresponding to that functional area of the brain become active , local blood flow to those brain regions increases , and oxygen rich ( oxygenated) blood displaces oxygen- depleted ( deoxygenated) blood around 2 seconds later. his rises to peak over 4-6 seconds , before falling back to original level. Deoxygenated Hemoglobin (dHB) is more magnetic ( paramagnetic) than oxygenated Hb , which is virtually resistant to magnetism ( diamagnetic). This difference to magnetism can lead to an improved MR signal and which can be mapped to show which neurons are active at a time.
Neurosurgeons may use fMRI for pre-surgical planning for lesions close to eloquent area of the brain, e.g., motor area. Similarly , language , memory areas can be mapped.
fMRI had also been used in research, effect of stroke,  brain injury on brain functions , effect of drugs, lie-detection, etc.

The activity performed or stimulus received by the patient is termed a paradigm, and each is designed to elicit a specific cortical response. The four common stimuli are: visual , motor, speech  and   memory paradigm.

Study/ testing designs in fMRI:

Block design uses repeated blocks of activity (paradigm) separated by blocks of inactivity of alternative activity.  This is by far the most frequently used study design in clinical fMRI. 

Event related design involves individual events rather than blocks, and can be randomly distributed during the study. 

Sources:
Radiopedia.org
Wikipedia.org

 

Lower Backache (Back pain), Low Back Pain, Lumbago, Lumbar Spondylosis, PIVD (Prolapse of intervertebral disc), Sciatica, Spondylo-listhesis & Lumbar canal stenosis

Lower back pain is a very common complaint in all age groups. We all have experienced back pain at some time in our life time. Sometimes, it persists and affects our routine and becomes a matter of concern. But, in fact, most of the times it is just stiffness or muscle strain due to hard work, prolong standing, sternuous excercise, play, or after lifting some heavy object. Such back pain is not due to any underlying disease. Mild or moderate level of pain gets relieved by taking analgesics (like an adult may take Diclofenac 50 mg after meal, SOS) and after taking rest. The other causes of backache are muscle sprain, muscle pull, strain, wrong posture, etc.
 Pain is a subjective sensation and the complaint of backache may vary from person to person. For example, for an athlete the lower backache after a prolong run or play may not be of a great concern but similar intensity of pain may be very debilitating for an old age person.
So, mild back pain which can be explained on the basis of obvious cause like prolong walk and play should not be investigated. Bed rest is the best medical advice for relieving backache.
However, severe persistent  backache without any obvious precipitating factor may warrant a consultation with the medical specialist. Orthopedicians, Physiotherapists, Sport medicine physicians, Neurologists and Neurosurgeons commonly encounter patients with complaints of lower backache.

One of the common causes of lower backache is lumbar spondylosis, which is a progressive degenerative disease of the spine. With aging the water content in the intervertebral disc, ligament and bone is gradually decreased and it restricts the movement of the spine. The vertebral column or spine consists of cervical, thoracic, lumbar and sacral part.

A model image of the entire spine

diagram of spine

Cervical part is located on the back of the neck and is the most mobile part. Even without our notice we move our neck and cervical spine for about 80,000 times in a day. So, the cervical spine is very prone for the degenerative changes in older age group.  Because thoracic spine ( chest ) is relatively less mobile due to rib cage it is less prone for spondylosis. Lumbar is the lower part and it bears the weight of the body. Due to excessive weight bearing this part of spine is prone for slip disc or listhesis.

What is Lumbar Spondylosis or Lumbar Degenerative disease?

Lumbar Spondylosis is medical term to describe a degenerative disease of the lower part of vertebral column.  Our vertebral column or back bone or spine consists of four areas, namely: cervical, thoracic, lumbar and sacral region. Lower part of the spine, i.e, region below the rib cage , consists of lumar and sacral region. 
There are 5 lumbar vertebrae with intervertebral discs between two adjacent vertebral bodies.So, progressive wear and tear of this region may cause different types of diseaes. Lumbar spondylosis may lead to lumbar canal stenosis, prolapse of intervertebral disc ( PIVD) and spondylolisthesis. Lumbar spondylosis is a common cause of lower backache.

                                  Image showing parts of the vertebral bodies with disc.
Spinal cord is contained inside the spinal column which is formed anteriorly by the vertebral bodies and discs and bounded posteriorly by the lamina and spinous processes. In this image spinal nerve roots are seen emerging from the spinal cord ( source: http://www.medicinenet.com) 
Our vertebral column consists of vertebrae and the intervertebral disc which are strengthened by many ligaments. The vertebral column contains vertebral canal within this bony canal a 45 centimetre long spinal cord is contained. The spinal nerves come out through the intervertebral foramina which are bordered by disc, pedicle, vertebral  body and facet joints. So, any abnormality of disc, facet joint or vertebral joint leads to narrowing of the intervertebral neural foramina which compress the spinal nerves causing pain and later neurological deficit in the form of loss of sensation and muscle weakness.

What causes Lumbar Spondylosis?

It is due to increased stress over the lumbar vertebrae which causes protrusion of the intervertebral disc, calcification of the ligaments and  osteoplytes formation . Osteophytes are the abnormal bony projections. Stress over the vertebrae is mostly due to increased body weight, sedentary lifestyle,  wrong posture or due to old age. 
Due to many risk factors, the disc may age prematurely and dries up ( disc dessication ), leading to narrowing of the disc space. This in turn decreases the flexibility of the spine and osteophyte formation in the vertebral bodies. 
Nerve compression causes nerve edema, alteration in nutritional transport along the nerve, and local inflammation, therefore bed rest and anti-inflammatory medications may relieve the symptoms of the patient.

Image showing a normal part of spine and part of osteoarthritic spine

What are the common symptoms of Lumbar Spondylosis?
Lumbar canal stenosis is commonly a disease of the old age and commonly occurs due to hypertrophy of the ligamentum flavum. Patient complains of pain in lower back ( Claudication ) after walking for a long distance ( Claudication distance). Gradually , over a time , this distance decreases and person starts complaining of lower backache even after walking for 100 meters. Pain gets relieved on taking rest or in sitting position. There is no pain on bending. I this way pain due to Lumbar canal stenosis differs from the pain caused by PIVD. Pain due to disc prolapse usually increases on bending.
This problem is very commonly seen in old age persons. Initially they are able to walk for a long distance with very mild pain at the end of the walk. But, gradually with advancing age the intensity of pain increases and they start feeling pain even after walking for 200 meters or so. The moment they take rest and sit idle for a moment pain subsides. So, sitting is not painful. Some people find no difficulty in cycling but prolong walking induces lower backache.

Prolapse of intervertebral disc ( PIVD)
Prolapse or buldge or protrusion of the intervertebral disc causes compression of the spinal nerve which causes lower backache. PIVD causes pain in the legs and sometimes bladder & bowel symptoms. Pain in the lower back is usually caused by muscle strain. It may also include sciatica (pain that radiates from the back to the buttock and down into the leg). Onset of pain may be immediate or occur some hours after an activity.

Pain and stiffness may be ongoing, or only occur when you are in certain positions. The pain may get worse by coughing, sneezing, bending, or twisting. Even sitting may induce pain. Such type of lower backache only lying on bed in certain posture may relief pain.

                       Image showing prolapse of the intervertebral disc posteriorly causing compression of the spinal nerve

Spondylolisthesis is another type of degeneration . The one vertebral body is slipped over the another vertebral body. It also leads to pain in lower back. 
Spondylolisthesis is very common in lumbosacral region of the spine. L4 vertebra is displaced over the L5 vertebra ( L4/L5 spondylolisthesis) or L5 is displaced over the S1 verterbra ( L5/S1 spondylolisthesis). In old aged females  osteoporosis is very common and the ligaments are also weakened , so the degenerative spondylolisthesis is very common in lumbosacral region.

How to recognize Lumbar Spondylosis?

One should not ignore the severe lower backache and particularly if pain is radiating to lower limb or associated with numbness or weakness of the lower limb. Investigations like X-ray of the lumbosacral spine and  MRI scan of the lower back can diagnose this problem.

Sometimes, X-ray of the spine in standing posture with bending forward & backword is required to diagnose spondylolisthesis.
MRI of the lumbosacral spine is the preferred investigation for diagnosis of cause of lower backache. It will show the alignment of the lumbar vertebrae and intervertebral disc, dural sac, lumbar canal diameter and nerve roots. So, even a minimal disc bulge is visible on MRI. MRI may exclude other causes of the lower backache line nerve sheath tumors, any other disease of this region like Potts spine ( tuberculosis), Multiple Myeloma, etc.
So, Plain X-ray and MRI of the spine are indispensable for the diagnosis of any disease of the spine. Sometimes, CT scan of the spine may be required.

What are the treatment options?
Almost everyone experiences pain after exercise or after a prolong walk or on exertion. So, all cases of mild lower backache need not to be investigated.

Treatment will depend on the cause of the pain. Usually a strict bed rest, lumbosacral  belt and analgesics  ( mild pain drugs such as aspirin, ibuprofen, or acetaminophen) for a short period of time can relieve the symptoms.

Many treatment options are available. Physiotherapy measures like short wave diathermy, ultrasound therapy , traction and exercise therapy may help in chronic cases of lumbar spondylosis.

Sometimes stronger pain relieving drugs, muscle relaxants, and drugs to reduce inflammation may be needed.

Urgent neurosurgical  intervention  is required if there is high degree of degeneration of veretebrae, or if a disk is protruded,or associated canal stenosis or weakness or decreased sensation in the lower limbs or difficulty in urination. Neurosurgical Microscopic discoictomy, endoscopic discoidectomy are common surgical interventions.

In some cases, like severe spondylolisthesis, spinal surgical fixation with implants is required.

Can lumbar spondylosis be prevented?

Primary prevention of lumbar spondylosis is possible by regular exercise, physiotherapy, correct posture and weight reduction. Once diagnosed with lumbar spondylosis a patient  should avoid lifting heavy weight & bending forward. 

Posture correction, use of correct lifting techniques, avoidance of sudden twisting movement of back, use of cushion at lower back to maintain lumbar lordotic curve is mandatory to prevent progressive degeneration of lumbar spine.

    Image suggests correct standing posture standing posture  without a hunch or lordosis

Surgery prevents further deterioration is severe cases. Discoidectomy and Spinal fixation may treat severe cases of spondylolisthesis and prevent further neurological deficit. Severe cases of disc extrusion should be operated to avoid foot drop and cauda equine syndrome.

Lifting of the heavy object in stooping posture is common cause of acute disc prolapse. In first image a person is lifting object in stooping posture which makes him prone to the acute neurological deficit due to PIVD. In second part the person is trying to lift the object not in stooping posture and it may be relatively safe.

Working over computer table for a long period in incorrect posture leads to early onset of spondylosis

What are the Rehabilitation options for patients with lumbar spondylosis?  

Neurological rehabilitation is a therapeutic program designed to improve function. Various rehabilitative measure like Isometric back exercises , core stability exercises and mobilization of lower limb joints and stretching of tight muscles are done to maintain normal anatomical integrity of the spine. Different  interventions like Ultrasonic therapy, Transcutaneous Electrical Nerve Stimulation ( TENS) , Short Wave Diathermy ,Traction and Interferential Therapy are available for rehabilitation of the lumbar spondylosis patients.

In case of severe neurological deficit rehabilitative therapy is available to promote compensatory strategies to attain maximum possible functional independence. These measures are mainly motor retraining,  Neurodevelopmental therapy ( NDT) , ADL training , Assistive and adaptive techniques and ergonomic rehabilitation.

Other causes of lower backache like Sponylolisthesis
SPINAL TRAUMA
OSTEOPOROSIS
NERVE SHEATH TUMORS , infections of the vertebrae like spinal tuberculosis,
OSTEOARTHRITIS OF HIP JOINT
            Should also be investigated.
X-ray of the lumbosacral spine ( anteroposterior and lateral view May provide an initial clue to the diagnosis.
For diagnosis of L1 vertebra collapse fracture, x- ray film of dorsolumbar spine is advised. This is very common fracture in people who fall from height.
MRI is the investigation of choice. It shows intervertebral disc, ligaments, vertebral bodies, integrity of the spinal cord.

Labelled diagram of MRI side ( sagittal view) showing different parts of lumbosacral region of spine

Sources
Naturopathy & yogic management of Lumbar spondylosis . Booklet of Central council for research in yoga and naturopathy ( An autonomous organisation under Ministry of AYUSH , Govt of India)

Online resources

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Head Injury

HEAD INJURY

What is head injury?

Injury to the head involves the scalp, skull, or brain. Head injuries may be external or internal. Head injury is a major public health problem mostly affecting economically productive population.

What are the causes of head injuries?

Head injury commonly occurs due to road traffic accidents, fall from height and assaults.Head injuries can cause physical problems, cognitive (thinking) dysfunction, or emotional changes. Head injuries can be mild , moderate or severe. Severe head injury  can be life-threatening and mostly associated with permanent brain damage. Young children, teens, and the elderly are more often affected.

Common symptoms of head injury?

Head injury symptoms may occur right away, or hours or days later. Common symptoms  include one or more of the following effects: swelling and bleeding at the site of the injury , fracture of the skull, loss of consciousness, abnormal breathing, clear or bloody fluid discharge or leak from the nose, mouth, or ear, drowsiness, confusion, irritability, or loss of memory black color around the eyes, vomiting, changes in vision or speech, dizziness, headache or stiff neck,  and seizure. Sometimes, head injury may lead to behavior changes and psychiatric symptoms, especially in older patients.

How to diagnose head injury?

Medical examination include checking the person's ABCs (airway, breathing, and circulation), testing the person's alertness ( Glasgow coma scale), thorough clinical examination including any laceration, ear , nose or throat bleed, associated extracranial injury or weakness of the limbs.

Investigations:

Such as X-ray of the skull and cervical spine remove coma, remove full stop.  CT, or MRI are often done to check for brain damage. To rule out extracranial injury  some other investigations are required, like  chest x ray and x ray of the pelvis or lumbosacral spine, USG abdomen, CT scan of the abdomen. All the severe head injury patients should be screened for  cervical spine injury by x-ray cervical spine.

What are the treatment options for head injury?

Medical care starts with checking the person's ABCs (airway, breathing, and circulation). Any visible head injuries will be treated. A person with a mild head injury can be sent home after initial medical care. Someone must stay with the person and watch for serious symptoms over the next 24 hours. Instructions may include waking the patient every 2 to 3 hours to check for alertness. Get medical help if you cannot awaken or arouse the person.

In other head injuries, the treatment will depend on the severity. Hospital care may be needed for a period of time, and then rehabilitation care may be required.

Severe head injury may be fatal if not treated on urgent basis. Full stop timely intervention like immobilization of  neck, maintaining   airways, maintaining circulation and stopping the hemorrhage etc. may be life saving. Radiological investigation like CT scan and then neurosurgical care like evacuation of intracranial hematoma prevent the complication of head injuries. Neurosurgical intervention like cerebral decongestants and evacuation of hematoma prevent the brain shifts & reduce tertiary brain injuries. Long term follow up is needed for severely head injury patients.

Can head injury be prevented?

In Head injury cases prevention is better than cure & so public awareness programme and enforcement of legal actions can greatly reduce the incidence of severe head injury. Head injury  can be prevented by use of seat belts or wearing helmets during driving.. Use of helmets and seat belts while driving provide safety and significantly decreases mortality and morbidity. Don't drink or use mind-altering drugs and drive. Wear protective headgear when head injury is a risk. Place young children in approved safety car seats.

Mandatory speed limit for the vehicular traffic prevents injuries of the pedestrians and the drivers. Driving  after drinking alcohol is one of the causes of rash driving and injuries. Children should not be allowed to drive.Strict legal action against the drunk drivers, violator of traffic rules and mandatory provision for helmets and seat belts significantly reduces the incidence of head injury.

Majority of the severe head injury patients die because of lack of prompt medical care.Pre hospital care by the trained paramedical personnel concept golden hour and rapid transfer of patient to the trauma centre help to decrease the mortality during the early period of  severe head injury.

What are the Rehabilitation options for patients with  head injury?  

Neurosurgical rehabilitation is  required to prevent long term  complication.

Multidisciplinary rehabilitation of head injured patient involves speech therapy,behavioral therapy, chest and limb physiotherapy and occupational therapy.

Sensory stimulation program  and use of various graded sensory inputs to facilitate selective motor input.

Bed sore management and proper positioning is use to prevent recurrence of bed sores.

Prevention of contracture and deformities.

Education of caregivers like regular change of position and handling of the patient.

Source: IHBAS, Online Resources

Public Awareness about Neurological Birth Defects

CONGENITAL ANOMALIES OF BRAIN & SPINE ( BIRTH DEFECTS)

What is congenital anomaly?
Congenital anomalies are also known as developmental defects and are usually seen at the time of birth. So, it may also be called as birth defects. Connial anamalies may affect any part of the body of a child, like heart, brain, spine, gut, limbs, etc.

Hydrocephalus, encephalocele,  and spina bifida are common congenital neurosurgical problems. Hydrocephalus is due to increased collection of CSF in the brain. Encephaloceles are associated with abnormal herniation of brain tissue in the sac. Meningocoele or meningomyloceole are associated with defects in the vertebral column and present as swelling in the lower part of back with without weakness of the lower limbs. Sometimes congenital anomalies are part of syndrome and can be associated with abnormalities of other organs ar systems of body.

What causes congenital anomaly?

Maternal age is an important factor & when maternal age advances beyond 35 years the incidence of congenital anomaly increases significantly. Maternal fetal infection, alcohol consumption, cocaine abuse and consumption of certain teratogenic drugs as well as exposure to radiation during pregnancy may cause congenital anomaly. Some congenital anomalies are genetically inherited and have increased incidence in certain families.

What are the common symptoms of congenital anomalies?

Hydrocephalus  causes progressive enlargement of the head in a small child, and vomiting, seizure, headache, diminished vision in older children. Spine bifida can present as a swelling over the vertebral column.

   Meningomyelocele causes weakness of the limbs and difficulty in urination.

How to diagnose congenital anomaly?

¨      Antenatal diagnosis can be made by screening the mothers with high risk.

¨      X-ray ,CT scan and MRI help in diagnosis of congenital  neurosurgical  anomalies.

¨      Examination of the new born at birth, Congenital Hydrocephalis can be detected by antenatal ultrasound.

Can congenital anomalies be prevented?

All pregnant females should receive folic acid  during pregnancy & receive antenatal care.

If the first child is born with congenital CNS malformation, the incidence of such anomaly increases in subsequent pregnancies. In such females, the   preconception counseling should be done & folic acid should be started before planned pregnancy. Folic acid supplements decrease the incidence of neural tube defects.

Proper antenatal care, prevention of perinatal infections, ultrasound of pregnant mother can help in  early diagnosis and hence prevention of congenital anomaly.

Secondary prevention of congenital malformation is possible with the help of antenatal ultrasonography.

The further deterioration can be stopped by detection and treatment of hydrocephalus, chairi malformation, spina bifida, tethered cord syndrome, encephalocoele.

What are the treatment options for patients with congenital anomalies?

When detected well in time, hydrocephalus and spina bifida can be treated by neurosurgery. Various treatment options are endoscopic third ventriculostomy, ventriculoperitoneal shunting, excision and repair of meningocele or myelo meningocele, etc.

What are the Rehabilitation options?
Many children with congenital anomalies lead a normal life. Many cases of meningocele are excised and repaired without any neurological sequelae. Many cases of congenital anomalies do not require any corrective surgeries.
So, each child with any type if congenital anomaly should be thoroughly evaluated and a tailor made approach should be offered to each case.  

Neuro rehabilitation prevents the morbidity of the patients with congenital anomalies. Some children with congenital anomaly develop neurological deficit and require interventions like progressive graded activities to build strength and endurance.For some patients home modification for ADL independence and training in use of assistive and adaptive techniques may be helpful.

Cervical spondylosis & Neck pain

CERVICAL SPONDYLOSIS

What is cervical spondylosis?

Cervical spondylosis is a degenerative process and incidence of cervical spondylosis increases with aging.  With aging, there is wear and tear on the vertebrae (bones of the spine) and the disks between these vertebrae. Bony growths called osteophytes  (or spurs) and prolapsed  disc  cause compression over the nerves , blood vessels and the spinal cord.

What causes cervical spondylosis?

It is due to increased stress over the cervical  vertebrae which causes protrusion of the intervetebral disc , calcification of the ligaments and  osteoplytes formation . Osteophytes are the abnormal bony projection.

Stress over the vertebrae is mostly increased by prolong  work in sitting posture , lifting weight  over the head , wrong posture or due to old age.

What are the common symptoms of cervical spondylosis?

Cervical spondylosis  causes neck pain and stiffness that  may extend to the shoulder upper arms, hands  and  back of head.. Other common symptoms are : Numbness ( loss of feeling) , tingling or weakness  in the arms, hands, and fingers. Neck pain may worsen and there may be associated  headache and dizziness. Pressure over the spinal cord causes muscle weakness or muscle spasms and stiffness and weakness of the lowe limbs.

How to recognize Cervical  Spondylosis?

Any person who feels neck pain or stiffness of the neck muscles or sensory deficit or weakenss of the limbs should consult a doctor.

X-ray of the cervical spine  and MRI of the cervical spine are required to diagnose cervical spondylosis. Sometimes other investigations like Nerve conduction studies are required.

What are the treatment options?

Simple analgesics, anti spasticity drugs , physiotherapy, restriction of neck movements with cervical collar, can provide relief in early stages of cervical spondylosis..

Neurotrophic vitamins, help in the neural compression.

Sometimes surgery is required if patient does not improve with  conservative   management .

 Neurosurgical operations are required to treat disc prolapse, canal stenosis,  osteophytes  &     myelopathy and other  manifestation of cervical spondylosis.

Operative intervention prevents the  further neurological deterioration in a  patient of cervical spondylosis

Can  cervical spondylosis be prevented?

·           Improve your posture.

·           Use a firm chair and sit with  straight back.

·           Sleep without a pillow. Instead, use a cervical pillow, wear a soft fabric collar, or put a small rolled towel under the neck

·           You can prevent some neck injuries, which might help prevent the risk. Wear protective headgear for contact sports. Use seat belts in vehicles and keep headrests at proper height.

·           Excessive movements and neck  injuries to be avoided.

·           One should avoid lifting a very heavy object over his/her head.

·           The jerky massage  or chiropractic practice may  damage the cervical spine.

·           Regular exercise of the neck prevents the occurrence of cervical spondylosis.

·           Contact sports, like wrestling, football etc, increase the risk of neck injury so people with spondylosis should avoid contact sport.

·           Regular intake of neurotrophic vitamins ( vitamin B6, B12,Vitamin E) and wearing a cervical collar can prevent further deterioration of a patient.

·           Neurosurgical intervention cervical spine discoidectomy and fixation decreases the risk of developing myelopathy(card dmamage) is severe cases of cervical spondylosis.

What are the Rehabilitation options for patients with lumbar spondylosis?  

The physiotherapy measures include isometric exercise, tanscutanaeous  nerve stimulation, ultrasonic diathermy help in rehabilitation.

External immobilization like cervical collar is must for early mobilization of the cervical spondylotic patient.

Prosthesis Like spinal instrumentation, artificial disc prosthesis help in early rehabilitation of patient.

Ergonomic modification and  training in use of assistive and adaptive techniques to increase independence in ADL  prevent recurrence of  symptoms.

Training in simulated work and progressive repetitive tasks help to decrease spinal stress and build strength for specific activities.

Functional capacity evaluation is done to determine the strength ares and limitations.

Home modification is advised for safe performance of ADL activities.

Sources: IHBAS Delhi Team, Online Resources

Brain Tumors

BRAIN TUMORS

What is brain tumor? 

Brain tumor is the abnormal cell growth in the brain. The growth may be benign (non-cancerous) or malignant (cancerous). Brain tumors can affect any age group.

What causes brain tumor?

Exact cause is unknown for most brain tumors. There are genetic factors and environmental factors involved. Some tumors begin in the brain and are called primary. Other brain tumors are called secondary. Brain is a frequent site of metastasis for other tumors, most commonly cancers of the breast, lungs & kidney.Risk of brain tumor increases if there is history of  radiation exposure or immune system disorder.  Rarely, certain types of tumors run in families.

Cancers never discriminate, it is equally common in all social economic groups, male and females and in adults and children.

Although sometimes brain tumors are more common in  smokers, tobacco chewers, or alcoholic but it is also very common in persons who do not have  any addiction.

 Common symptoms of brain tumor?

The symptoms can be caused by pressure, as the tumor gets larger, or can be caused by the location, size, and type of tumor. Brain tumor may present as seizure, vomiting, headache, mood change, difficulty in speech,  difficulty in walking, diminished vision or  weakness of the limbs.  Other common symptoms are: memory loss, confusion, loss of concentration, personality and  behaviour changes, lack of balance and dizziness, loss of sense of smell and hearing.

How to recognize brain tumors?

Any person should not ignore the symptoms of brain tumor like headache,              vomiting, visual deficits, seizures, hearing loss or paralysis of a part of body. Brain tumor is a deadly  disease but early detection may be life saving. Thorough clinical examination,  fundus examination, CT scan or MRI brain can diagnose brain tumor. Brain tumors can be benign or malignant which can be confirmed by biopsy.

What are the treatment options?

The outcome depends on several factors. These include type of tumor, its size, location, spread of tumor, other cancer in the body, age and health of the patient, and the patient's response to treatment. Medications are used  to reduce swelling of the brain tissue, to control seizures, to relieve headache and decrease intracranial tension.

Because there are over 100 different types of brain tumors, treatment needs to be specific for each person.

Neurosurgical decompression or excision is required for majority of brain tumors  which may be safely excised and patients may have normal life after surgery. For complete treatment radiotherapy and chemotherapy is also required in some tumors. Treatment can include surgery, radiation, chemotherapy (anticancer drugs), and immunotherapy.  Surgery is often needed. It may involve removal of all or part of the tumor and nearby tissue. Radiation may be used for certain stages of the tumor. It is normally not used for children under age 3.  After neurosurgical intervention, long term rehabilitation is required for brain tumor patients to prevent morbidity. Now a days, some non surgical treatment options like Gamma Knife, cyber knife, stereotactic, radiotherapy are also available for some type and small sized tumors.

Can brain tumors be prevented?

Awareness about the radiation exposure, ill effects of smoking ,and tobacco and alcohol may greatly reduce the occurrence of brain tumors. Screening of patients for primary concerns elsewhere in body reduces the risk of metastasis to brain.

Education of the people about the symptoms of brain tumor helps in early detection.

Newer diagnostic modalities like CT scan, MRI of the brain, help prompt neurosurgical intervention in effective treatment of the brain tumor and prevent the further spread or recurrence of the brain tumor.

What are the Rehabilitation options for patients with brain tumors?  

Some patients may develop sensory or motor deficit following excision of the brain tumor. Multidisciplinary  approach involving  neurooncologist,  physiotherapist, oocupational  therapist  may be required for the rehabilitation of brain tumor patients who were operated and received chemotherapy and  radiotherapy.

Care givers are educated  for prevention of contracture, deformities, or bed sore in paralysed  patients with spasticity.

Training in ADL activities is done  to improve independence .

Vocational training , home modification ,cognitive and perceptual training  is also helpful in rehabilitating brain tumor patients.

Prognosis

Due to technological advancements and better understanding of brain tumors, there had been a significant improvement in the clinical outcome of brain tumors. The majority of the brain tumors are now diagnosed at a very early stage. CT scan or MRI of the brain is a very common diagnostic tool and help to diagnose any lesion inside the brain.

All the brain tumors need not be operated. Non invasive single dose radiation therapy like Gamma knife or Cyberknife is a noninvasive way of treating small lesions of the brain.

Stereotactic biopsy helps in minimal invasive way of diagnosing brain tumor.

Stereotactic Radiotherapy ( SRT) is used to treat malignant lesions of the brain. Even multiple metastasis of systemic cancers of the body to the brain can be treated with surgery and SRT.

Meningioma which constitute about 15% of all the primary brain tumors can be excised completely without any recurrence.

So, if somebody is diagnosed as a case of brain tumor should not lose hope. Unlike other tumors of the body, the brain tumors are not labeled as cancer and non cancer. Rather, there are differerent grades of the tumor ( WHO Grade 1 to IV). Grade 1 tumors are usually benign and do not require chemotherapy or radiotherapy.

Source: IHBAS, Delhi Team, Online resources