This article reviews the successful utilization of telemedicine in managing head trauma. Telemedicine has made geography history and distance meaningless. It can be a major tool in providing expertise for the management of neurotrauma cases, in far away areas. With the digital divide reducing in India, telemedicine should be considered a method to overcome the shortage of neuro-traumatologists. Following a discussion of the relevance of telemedicine in the Indian context after outlining the author's personal experience, the world literature is reviewed

Key words: Telemedicine, Head Injuries, neurotrauma

Spinal cord injury is a devastating form of neurotrauma known to mankind since antiquity. It strikes mostly the young, and leads to lifelong disability. The pathology, besides the mechanical disruption neural tissue, involves complex biological events which are gradually unfolding and being recognized clinically and in the laboratory. Surgical stabilization is important for early rehabilitation. The role of methyeprednisolone in acute spinal cord injury is still not convincing.

Key words : methyleprednisolone, spinal cord injury

'Cerebral protection' signifies strategies used to protect neural tissue from cellular events induced by deprivation of oxygen or glucose or both to the brain. Neurons are particularly susceptible to ischemic injury because they have a higher demand for energy and limited energy stores. Depletion of intrinsic central nervous system energy stores occurs within 2 to 4 minutes of anoxia. Protecting the brain from ischemic during Neurosurgery is one of the most important concerns for neuro anesthesiologists. Pharmacological brain protection may be employed to rest the brain while a temporary regional disruption in nutrient flow is expected to occur. Appropriate monitoring (EEG, Evoked potentials, sump pressure, trans-cranial doppler) is needed to optimize therapy.

Cerebral protection may be initiated prior to the occurrence of brain ischemia. Certain prophylactic measures can interfere with the cascade of events triggered by the injury. Such a salutary effect may be achieved by reducing demand for energy (using barbiturates or hypothermia) or blocking mediators of ischemic injury. In designing the anesthetic plan for patients at high risk of cerebral ischaemia (e.g. Carotid endarterectomy, open heart procedures), it is useful to consider the relative degree of protection provided by various agents. Treating patients with neuroprotective agents after cardiac arrest or a focal ischemic insult may be consideration in improving overall neurological outcome. Focal ischemia encompasses stroke subarachnoid haemorrhage (SAH) and trauma. With few exceptions, animal studies have shown that therapeutic efficacy is lost if treatment is delayed more than one hour after impact. Sooner the neuroprotective drug is given, better is the outcome.

Key words : brain protection, calcium channel blockers, hypothermia, propofol

Coagulopathy following pediatric head injury is not well known; in spite of its common occurrence following the injury and the fact that it may have a major prognostic role in the predicting the outcome of these children. The authors discuss the incidence, pathophysiology and management of coagulopathy in children with head injuries in light of the available literature and its usefulness in predicting outcome following head injury.

Key words : Pediatric head injury, coagulopathy, outcome

Posterior fossa extradual haematoma is a rare entity as compared to supratentorial EDH, but are the most common traumatic space occupying lesion in the posterior fossa. A retrospective study of 61 patients from 1991-2001 was carried out to study the clinical spectrum and demographic characteristics of posterior fossa extradural hematomas and assess factors influencing outcome. Clinical features and radiological parameters were analyzed and correlation with outcome was evaluated. GCS score was the most important factor dictating outcome, and children fared better than adults.

Key words : Posterior fossa extradural hematoma, Glasgow Coma Scale (GCS)

Optic nerve injury following closed head injury is uncommon and reported in 1-5% cases. Interestingly, incidences as high as 44% was reported by Crompton, among them 20% had bilateral pathologies, surprisingly only few large series has been published in the World literature. Most of the published series are retrospective analysis of smaller number of cases. We at AIIMS have prospectively analyzed a large number of patients with optic nerve injury over the last 2 decades and rationalized the protocol, based on our experience including indications for optic nerve decompression. This publication is based on the experience of 800 patients of optic nerve injury, treated between 1983-2002.

Key words : Optic nerve injury, Head injury, Rationale of optic nerve decompression, outcome

MRI has emerged as the most important imaging modality in the evaluation of spinal cord injury. Its importance in the diagnosis and prognostication has been well established. We retrospectively studied the MRI appearance of 29 patients with cervical spinal cord injury without radiologically demonstrable fracture or dislocation of the cervical spinal. All patients were adults, who presented with varying grades of cervical myelopathy following trauma; eight of these were elderly with stenotic spinal canals due to cervical spondylosis. Neurological function and MRI appearances were correlated. The presence and rostrocaudal extent of intraaxial haematoma, extrinsic stenotic compression of spinal cord were each significantly associated with poor neurological function at presentation and in long-term follow-up examinations. Although the best single predictor of long-term improvement in neurological function was the neurological grade at the time of presentation, the presence and extent of intraaxial spinal cord haematoma and the presence of spinal cord compression provided significant additional information. MRI provides accurate diagnostic and prognostic information regarding neurological function and aids in treatment planning in cervical spinal cord injury without accompanying skeletal injury.

Key words : cervical spinal, magnetic resonance imaging, quadriplegia, spinal injury

A retrospective analysis of sixty patients with cervical spinal cord injury operated during Jan 2001 to Dec 2003 was carried out. Fifty four (90%) were male and six were female patients. Amongst them 45 (75%) were in the age group 21 to 40 years. Thirty six (60%) sustained injury by vehicular accident and 24 due to fall, wrestling, boxing, obstacle crossing, terrorist activities, cattle and camel hits. All patients presented with evidence of post-traumatic cervical spinal cord injury and evaluated with Frankel's neurological grade at admission. Six patients presented with grade 'A', 02 grade 'B', 36 grade 'C', 16 grade 'D' neurological deficit as per Frankel's classification. Plain radiography, Computerised tomography (CT) Scan and Magnetic Resonance Imaging (MRI) of cervical spine revealed disc prolapse in 30, anterior thecal compression due to burst/compression fracture in 24 and dislocation in 06 patients. Cord contusion and haematoma in 08 and cord transection in 04 patients were detected in MRI. Anterior Cervical Microdiscectomy (ACD) and fusion in 10; discectomy, fusion and titanium plating in 20; corpectomy and bone grafting in 05; corpectomy and cage placement in 03; corpectomy, bone grafting and titanium plating in 16, post fusion was carried out in 06 cases. Postoperative radiography showed good alignment, stability of spine and implants in position. Outcome was evaluated again with Frankel's scale. There were 26 patients with grade 'E', 25 grade 'D', 01 grade 'C', 06 patients did not show any recovery and 02 patients died. Recovery was rewarding in patients with initial incomplete spinal cord injury.

Key words : Cervical Spine Injury, Functional recovery, Stabilization

Abstract: A rare case of superior migration of mandibular condyle into middle cranial fossa is reported.

Key words : superior migration, mandibular condyle, middle cranial fossa