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Head and spine injuries

December 2013
Associate Professor Karin Brolin
Chalmers University of Technology

Acknowledgement:
Associate Professor Johan Davidsson and Professor Mats Svensson
have contributed to the presentation material.

What is essential to protect?

Life supporting functions

Brain
Cervical spine (above C3)

Quadriplegia above T1
Paraplegia below T1

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Principal parts of the nervous system

Central nervous system (CNS):

brain
spinal cord

Peripheral nervous system (PNS):

numerous, paired nerves joining CNS with
different parts of the body
ganglia - clusters of nerve cells

Fig.Nervous
45.03(TE
system
Art)
Central Peripheral
nervous nervous
system system

Spinal Sensory Motor

Brain cord pathways pathways

Somatic Autonomic
(voluntary)
Sensory pathways (involuntary)
nervous system nervous system

Motor pathways
Sympathetic Parasympathetic
division division

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Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Fig.Nervous
45.03(TE
system
Art)
Central Peripheral
nervous nervous
system system

Spinal Sensory Motor

Brain cord pathways pathways

Somatic Autonomic
(voluntary) (involuntary)
nervous system nervous system

Sympathetic Parasympathetic
division division

AIS examples by body region

AIS Head Thorax Abdomen and Spine Extremities
pelvic and bony
contents pelvis
1 Headache or Single rib Abdominal Acute strain Toe fracture
dizziness fracture wall: (no fracture or
superficial disl.)
2 Unconscious 2-3 rib Spleen kidney Minor fracture Tibia, pelvis or
< 1 hr.; linear fracture; or liver: without any patella: simple
fracture sternum laceration or cord fracture
fracture contusion involvement

3 Unconscious 4 rib Spleen or Ruptured disc Knee

1-6 hrs.; fracture; 2-3 kidney: major with nerve dislocation;
depressed rib fracture laceration root damage femur fracture
fracture with hemoth.
or pneumoth.

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AIS examples by body region

AIS Head Thorax Abdomen and Spine Extremities

pelvic and bony
contents pelvis
4 Unconscious 4 rib fracture Liver major Incomplete Amputation or
6-24 hrs.; with hemoth. laceration cord crush obove
open fracture Or pneumoth.; syndrome knee pelvis
flail chest crush (closed)
5 Unconscious> Aorta Kidney, liver quadriplegia Pelvis crush
24 hrs.; large laceration or colon (open)
hematoma (partial rupture
transection)

HEAD INJURIES

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Head anatomy
Scalp
Skull and facial bones
Brain and the nervous system

Complete head mass 4.5 kg

Brain mass around 1.65 kg

Skull and Facial bones

Several fused bones
Suture lines

Mandible
Large individual variations
Lateral view

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Skull base is irregular

Irregular surface
Ridges
Small holes
Arteries and veins
Cranial nerves
Foramen magnum
Brain stem

Compact bone
Transversely isotropic:

C11 C12 C13 0 0 0

C C11 C13 0 0 0
12
C13 C13 C33 0 0 0
C
0 0 0 C44 0 0
0 0 0 0 C44 0

0 0 0 0 0 C0
5 coefficients
C0 = (C11C12)/2

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Strength of trabecular bone

(b)
(a)
Compressive Tensile

Corpus callosum
Thalamus
Sensory processing
Movement
Lateral ventricle

Hippocampus
Memory
Learning

Pons
Motor control
Sensory analysis
Optic recess Sleep

Medulla oblongata
Hypothalamus Breathing, Heart Rate,
Temperature, Emotions, Hunger, Thirst Blood Pressure

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Head injuries
Skull Bone Fractures
Linear
Depressed
Basilar
Facial Bone Fractures
Soft tissue
Skin and scalp
Blood vessels
Sensory organs
Brain
with skull injury
with-out skull injury

What is so special about

Traumatic Brain Injury (TBI)?
Even a moderate bump can damage the brain.

The brain cannot be compressed without injury.

Damage to limbs may often be repaired while

brain damage many times causes permanent
harm.

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Frequency of 10,000,000 per year world wide

TBI in the US
India Sweden

200,000 deaths

1 million injured 20,000

Langlois J, Rutland-Brown W, Wald M. The epidemiology and impact of traumatic

brain injury: a brief overview. J Head Trauma Rehabil. 21(5), pp 375-378, 2006

TraumaticBrainInjury
Other5%
Suicide;1%

Assault,10%

Falls,25%

Roadtraffic,60%

Other;1%

CenterforDiseaseControland NationalInstituteofMentalHealth&
Prevention,US NeuroSciences,India

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Acute Symptoms following TBI

Mild Brain Injury Moderate to Severe
Brief period of Persistent headache
unconsciousness Nausea
Headache Spasm
Confusion Dilation of the eye
Dizziness pupils
Sensory problems Slurred speech
Mood changes Weakness or numbness
Concentration problems Loss of coordination
Increased confusion

Long term symptoms from TBI

Trouble remembering, concentrating, making
decisions, and controlling impulses

Suffer from serious motor, sensory, and

emotional impairments

Not all TBI-related disabilities are readily

apparent to others. That's why TBI is the
"invisible epidemic"

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Type of injury

Traumatic Brain Injury

Diffuse Brain Injury Focal Brain Injury

Contusion Laceration

Hematoma

Concussion Diffuse Axonal Injury

Injury mechanism from dynamic loading

Direct contact Non-contact

Linear acceleration Inertia properties
Deformation Relative motion between
Stress waves skull and brain
Pressure gradients
Negative pressure
Cavitations
Shear strains
Direct fracture
Indirect fracture (burst fracture)
Rotational acceleration
Relative motion between skull
and brain
Shear in brain tissue

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Radial vs. oblique impact

Radial impact Oblique impact

Kleiven, Enhanced Safety of Vehicles 2007

Traumatic Brain Injury

Diffuse Brain Injury Focal Brain Injury

Laceration

Contusion
Concussion Coup
Contre-coup
Gliding Hematoma

Diffuse Axonal Injury

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Contusions
Bruise of the brain common at inferior
surfaces of frontal and temporal lobes

Mechanism: Brain contact with rigid

intracranial structures.

Traumatic Brain Injury

Diffuse Brain Injury Focal Brain Injury

Laceration
Concussion
Contusion

Diffuse Axonal Injury Hematoma

Epidural
Subdural
Subarachnoidal
Intracerebal

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Hematoma
- Blood forms a hematoma that compresses the brain tissue

Bridging veins Meningal artery

Subdural Epidural and
hematoma extradural
hematoma
Rotation injury
Fractures

Hematoma - Symptoms
Immediately to several weeks after a blow to the
head:
Headache The worst headache of their lives"
Vomiting
Slurred speech
Pupils of unequal size
Weakness in limbs on one side of your body
As more and more blood flows into the narrow space
between the brain and skull:
Lethargy
Unconsciousness

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Epidural and extradural hematoma Subdural hematoma

Artery ruptures between dura and skull.
The risk of dying is substantial.
More common in children and teenagers.
Mechanism: mostly temporal bone fracture
from falls and violence.
Subarachnoid hematoma
Artery ruptures.
Bleeding into the cerebrospinal fluid of the
sub-arachnoid space.
Permanent brain damage from ischemia or
from the presence of hematoma.
Mechanism: Rotational acceleration in
conjunction with aneurysm.
Veins rupture between dura and arachnoid.
Acute, Sub-acute and Chronic
Permanent brain damage may result.
More common in very young and old.
Mechanisms:
Laceration from penetrating objects and
bone fragments
Large contusions
Tearing of bridging veins due to rotational
motions
Age related due shrinkage of brain
Intracerebral hematoma
Blood in the white matter of the brain.
Combined with white matter shear injuries
Blood irritates the brain tissues, causing
swelling or hematoma
Mechanism: Laceration, sheer
deformation?

Traumatic Brain Injury

Diffuse Brain Injury Focal Brain Injury

Laceration
Concussion
Mild Classic Contusion

Diffuse Axonal Injury Hematoma

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Concussion
Anterograde and retrograde amnesia
Duration of amnesia correlates with the injury severity
Post concussion syndrome, which can include
memory problems, dizziness, and depression
Cerebral concussion is the most common head injury
seen in children
Mechanism: Rotational and linear acceleration of
head.

Traumatic Brain Injury

Diffuse Brain Injury Focal Brain Injury

Laceration
Concussion
Contusion

Diffuse Axonal Injury Hematoma

Mild Moderate Sever

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Diffuse Axonal Injury (DAI)

Lesions in white matter

Corpus callosum, penduncles and
thalamus
Unconscious and vegetative state
90% with severe DAI never regain
consciousness
Car, sport and child abuse.

Mechanism: shearing forces due to rotational

acceleration. Stretching axons that traverse junctions
between areas of different density

DAI mechanism
Axon torn at the site of stretch.
Distal part degrades.
Secondary biochemical cascades largely responsible
for the damage to axons.

Corpus callosum

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What do we know?
Prevention is the best solution!

Medication, surgery etc second choice

oxygen supply, maintaining adequate blood flow, and
controlling blood pressure

Injury risk measures

Linear acceleration
Wayne State Tolerance Curve
Rotational acceleration
Injury threshold related to acceleration and brain mass
Reality = combination of linear and rotational

Peak force for fracture

Frontal impact: 4.0 6.2 kN
Lateral impact: 2.0 5.2 kN
Occipital impact: 12.5 kN

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Wayne State Tolerance Curve

Fracture as function of
linear acceleration and
duration
Forehead impacts only
Based on cadaver and
animal experiments

Assumption: Skull
fracture predicts brain
injury

Gurdjian E, Robert V, Thomas L. Tolerance curves of acceleration and intercranial

pressure and protective index in experimental head injury, J. Trauma 6(5), pp 600
604

Head Injury Criterion - HIC

Linear acceleration (g)

HIC36
36 ms interval
threshold 1000 for 50th male
Head Protection Criterion (HPC)
HIC15
15 ms interval
threshold 700 for 50th male

KleinbergerMet.al.Developmentofimprovedinjurycriteriafortheassessmentofadvanced
automotiverestraintsystems II,NHTSAreport,Nov.1999.

Widely used with Anthropometric Test Devices in consumer

testing and regulations

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Diffuse brain injury thresholds

0.05=reversible strain; concussion

0.20=irreversible strain; tissue disruption

Margulies S.S., Thibault L.E., A proposed tolerance criterion for diffuse axonal injury in
man, Journal of Biomechanics 2(8), 1992

Head injury criteria

Linear acceleration (g)

Generalized Acceleration Model for Brain Injury Threshold

Linear and rotational acceleration
acr = 250 g, cr = 10krad/s2
Overall threshold = 1.0

Rotational velocity & acceleration

Updated 2013:
Only rotational velocity
Added directional dependency

Rotational acceleration

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Head injury criteria

Gadd CW, National Research Council Publication No 977,
pp141144, 1961.
VersaceJ,Areviewoftheseverityindex.15th StappCarCrash
Conference,SAETechnicalPaper710881,1971.
KleinbergerMet.al.Developmentofimprovedinjurycriteria
fortheassessmentofadvancedautomotiverestraint
systems,NHTSAreport,Sept.1998.

Newman J, A generalized acceleration model for brain injury

threshold (GAMBIT), IRCOBI Conference, 1986.

Takhounts E, Hasija V, Ridella S, et al, Kinematic rotational

brain injury criterion (BRIC), 22nd Enhanced Safety of
Vehicles Conference. Paper No. 110263, 2011.
Takhounts E et.al. Development of Brain Injury Criteria (BrIC),
Stapp Car Crash Journal 57(Nov ), pp 243266, 2013

KimparaH,andIwamotoM,MildBrainInjuryPredictors
DerivedFromDummy6DOFMotions,40th International
WorkshoponHumanSubjectsforBiomechanicalResearch,
SavannahGA(USA),2012.

SPINE INJURY

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Spinal anatomy

Cervical spine (neck)

Thoracic spine
Ribs

Lumbar spine

Sacrum
Coccyx

Anatomy

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The intervertebral disc

Purposes:
Damping
Restrict relative translations between the vertebrae
Allow for some rotation
Hydrofilic gel
90% to 70% water
Collagen fibers in ground substance
Fiber direction 60

The intervertebral disc

10 times stiffer in compression than torsion,

shear or flexion.

The almost incompressible properties of the

nucleus pulposus result in tensile loading of the
collagen fibers when the disc is compressed.

Rate dependent properties

Viscoelasticity (fluid flow)

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Youngs Poissons Tensile Strain at

Modulus Ratio strength failure
(MPa) (MPa) (%)
Collagen 500 - 1000 0.3 50 - 100 10 - 20

Elastin 0.5 - 3 0.3 100 - 200

Ground 1-3 0.45

substance
Rubber 1.4 0.499
Oak 10,000 0.2 100 5
Steel 200,000 0.3 500 1

Youngs Yield Strain at Stress at

modulus strain failure failure
(%) (%) (MPa)
(MPa)
Collagen 500 10-20 45-125
Elastin 3 130
Ground
3
substance
Ligaments 20 25 > 100 20
Tendons 50-100 4 10 60

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Peripheral
nervous
system

Spinal injuries
AIS 3+ spine injuries are quite rare in motor vehicle
crashes.

AIS 1 neck injuries (whiplash) account for a

substantial portion of long term disabling injuries
Sweden 55%
India ?

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Epidemiology
Sever spinal cord injury

10.000 cases/year 20.000 cases/year

in the US in India
Motor vehicle 54% Traffic 45%
Fall 16% Fall 35%
Diving 12%
male:female 3:1
20-40 years of age

Epidemiology
Sever spinal cord injury
In modern cars
Roll-over
Unbelted all directions
Forward facing children age <2 years

Motorcyclist, mopeds and bikes

All accident types

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Anthropometry explains children's

increased risk for neck injury

Head center of gravity

more superior in young
children.

Facet joints are more

horizontal.

Burdi, A. R., Huelke, D. F., Snyder, R. G., Lowrey, G. H. (1969/07)."Infants and children in
the adult world of automobile safety design: Pediatric and anatomical considerations for
design of child restraints." Journal of Biomechanics 2(3): 267-280

In automotive crashes
If unbelted head contact the windscreen in frontal
crashes
Axial compression
Shear loading
Bending
Minor soft tissue neck injuries due to inertia
Axial tension
Shear loading
Bending

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Sever neck load - examples

Pedestrian accident
Bad design

Out of position airbag injuries

Sever neck loading

Pure compressive loading
Jefferson fracture of the atlas (C1) is unstable.
Burst fracture of vertebral bodies (C2-C7)
Increasing load can give facet dislocation
Flexion-compression loading
Dislocations (often at Occiput-C1)
Tension-extension loading
Hangmans fracture of C2
Lateral bending and compression loading
Fractures on the compressed side

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Whiplash Associated Disorders (WAD)

- soft tissue injury
Injury mechanism ?

Prevention Treatment

Diagnosis

Tension-extension loading, caused by inertia loading of the head.

http://www.mvd.chalmers.se/~mys

Injury mechanisms
Facet joints ? Still not know research ongoing
Pain (>40%)
Pain sensitization.
Muscle ?
Good prognosis
CNS ?
Dorsal nerve root ganglion injury due to pressure
wave
Ligament ?
Disc ?

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Experimental studies
Human subjects
Animal models

Pull-
force
Pull-rod
x-acc. Backrest
Head-

z-acc.
Operating-
Rod table

Straps X

Angular
displacement Coordinate-
transducers system
Z

Linear displacement transducer

Professor Mats Svensson at Chalmers.

http://www.mvd.chalmers.se/~mys

RID 3D

Crash Dummies
BioRID II

http://www.mvd.chalmers.se/~mys

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Female rear dummy

Neck injury criteria

AIS3+
Nij =Fz/Fint+My/Mint

AIS1
NIC =0.2 arel + vrel2
Nkm = Fx/Fint+My/Mint

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Nij dummy values

proposed by NHTSA

KleinbergerMet.al.Developmentofimprovedinjurycriteriafortheassessmentofadvancedautomotive
restraintsystems II,NHTSAreport,Nov.1999.

NIC = Neck Injury Criterion

NIC = 0.2 arel + vrel2

arel = aT1 - ahead ahead, Vhead
vrel = vT1 - vhead

50% risk: NIC=25 m2/s2

NIC=15 m2/s2

aT1, VT1

Hypothesis: Pressure aberrations inside the spinal canal.

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Nkm Neck protection criterion

load case Intercept value

Extension moment 47.5 Nm
Flexion moment 88.1 Nm
Shear 845 N
Euro-NCAP uses different threshold values depending on the crash pulse, the
critical Nkm ranges from 0.12 - 0.69 (van Ratingen et al. 2009)

Hypothesis: Linear combination of shear and y-moment is

responsible for relevant neck loading

Neck injury criteria

AIS3+
Nij
KleinbergerMet.al.Developmentofimprovedinjurycriteriaforthe
=Fz/Fint+My/Mint assessmentofadvancedautomotiverestraintsystems,NHTSA
report,Sept.1998.

AIS1
NIC
BostrmO,SvenssonM,AldmanB,HanssonH,HlandY,LvsundP,
=0.2 arel + vrel2 SeemanT,SunesonA,SljA,rtengrenT(1996):Anewneck
injurycriterioncandidatebasedoninjuryfindingsinthecervical
spinalgangliaafterexperimentalneckextensiontrauma,Proc.
IRCOBIConf.,pp.123136

Nkm
SchmittKU,MuserM,NiedererP(2001):Anewneckinjurycriterion
= Fx/Fint+My/Mint candidateforrearendcollisionstakingintoaccountshearforces
andbendingmoments,Proc.ESVConf.
SchmittKU,MuserM,WalzF,NiedererP(2002):Nkm aproposal
foraneckprotectioncriterionforlowspeedrearendimpacts,
TrafficInjuryPrevention,Vol.3(2),pp.117126

KullgrenA,ErikssonL,KrafftM,BostrmO(2003):Validationofneck
injurycriteriausingreconstructedrealliferearendcrasheswith
recordedcrashpulses,Proc.18thESVConf

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Protective strategies

WHIPS (Volvo) 1998.

Self-aligning head restraint (SAAB) 1998.

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