Neurotrauma (Cranial and Spinal)
What the candidate must own
Structure your thinking around the ATLS sequence and the modified Glasgow Coma Scale, then move to injury classification. For traumatic brain injury: differentiate focal (contusion, extradural, subdural) from diffuse (diffuse axonal injury), know the lucid interval and the biconvex hyperdense extradural haematoma from the crescentic subdural, and understand the indications for decompressive craniectomy. Know the Monro-Kellie doctrine, cerebral perfusion pressure (MAP minus ICP), and the tiered management of raised ICP: head elevation, sedation, osmotherapy, controlled ventilation, CSF drainage, and finally decompression. For spinal trauma: know the three-column concept, the ASIA impairment scale, the role and timing of methylprednisolone, and the indications for surgical stabilisation versus conservative management.
Traps that appear in questions
- Assuming an extradural haematoma always requires surgery - small, asymptomatic, non-shifting collections can be observed.
- Confusing the ASIA grade with the injury level; a C5 injury with intact sacral sensation is not complete.
- Forgetting that a normal CT in the first hours does not exclude diffuse axonal injury.
- Overlooking associated injuries: the second hit of hypotension and hypoxia worsens outcome more than the primary injury.
Rule of thumb
In any head-injured patient, treat the patient, not the scan - the first priorities are airway, oxygenation, and blood pressure, because secondary injury is preventable. Worked example: a young patient with a lucid interval, a biconvex hyperdense temporal collection, and a blown pupil has an extradural haematoma with uncal herniation; the answer is urgent craniotomy and evacuation, with hyperventilation and osmotherapy as temporising measures only.