Trauma: Blunt Trauma to the Head

Did you catch the UFC Fight Night over last weekend? Lyoto Machida knocked out his buddy Mark Munos with a vicious kick to the head! That was amazing! Glad to see Machida still on his game!

While watching this, I couldn't help but think about possible head traumas that could have resulted from this. A kick like this can generate over 1000 lbs of force, which is more than enough to cause devastating damage to someone's body and internal organs. So what can happen if you get kicked in the head with this amount of force?

One possibility is concussion (will discuss further in another post). This occurs when a force is exerted against the head and causes the brain to move or shift within the skull. Due to limited and non-expandable nature of the skull, brain is sensitive to any increase in pressure or movement. Between the brain and the skull, there is a thin layer of fluid called cerebrospinal fluid (csf) which serves as

a watery cushion for the brain and spinal cord, and there are layers of membrane (pia mater, arachnoid, and dura mater) that surrounds the brain within the skull. 

The CSF is between the pia mater and the arachnoid layer, aka the subarachnoid space. It is made from the ependymal cells of choroid plexus, walls of the ventricles, and circulating blood vessels, and flows into the lateral ventricles. It then flows through the foramen of Monroe (interventricular foramen) into the third ventricle, which then flows through the aqueduct of Sylvius (cerebral aqueduct) into the fourth ventricle. It then splits to flow through foramen of Magendie (median aperture) to surround the spinal cord, and also through foramen of Luschka (lateral aperture) to surround the brain in the subarachnoid space. It then flows into the sinuses in subdural space via arachnoid villi, which is then reabsorbed back into the circulation and starts the cycle all over again continuously. 

All of these things plus the skull help to protect the brain pretty effectively in most cases. However, big enough trauma to the head, such as hard kick to the head or big collisions in football or any other collision sports, can cause enough "shifting" of the brain to cause some damage. When it moves within its limited confines, it can "stretch" and cause axonal damages, or stretching of the nerves in the brain. This can lead to some bad consequences. Initially, the concussed person may present with headache, loss of consciousness, dizziness, confusion, amnesia, loss of coordination, blurry vision, and disorientation, but they can also present with something more serious, such as seizures, coma, or even death. Moreover, there can be long-lasting damage after many concussions, which is a big topic of research in the field of sports medicine currently (look up Chronic traumatic encephalopathy if curious).

Another injury that can occur is bleeding or hematoma, with or without skull fracture. There are two major types of hematoma that can occur with blunt trauma. One is epidural hematoma, which is collection of blood between dura and skull, most commonly caused by rupture of middle meningeal artery from blunt trauma to the head. The person may present with possible initial lucid intervals (in and out of symptoms) for few hours after the injury, which includes severe headache, decreased consciousness, and nausea, and can eventually lead to worsening of symptoms plus paralysis of one side of body, seizures, and blown pupil. This is an emergency, and needs to be surgically drained and decompressed as soon as possible. Another type is subdural hematoma, which is collection of blood between the dura and arachnoid meningeal layer, caused by rupture of bridging veins following trauma. This is more common among elderly people who fall and bump their head, but it is possible from a stronger blunt trauma like a kick to the head. The person may present with slowly progressing headache, change in mental status, weakness of one side of body, and increased deep tendon reflexes. This is not as emergent as the epidural hematoma, and thus the treatment plan depends in the situation and size of the hematoma, and can involved surgical drainage and decompression or supportive care.

There are numerous other possible injuries that can occur from blunt trauma to the head. Fortunately, it seems like Munos recovered pretty well, and he did not have any serious injuries, although I would not be surprised if he did get a small concussion. This brings up another reason why I stick to jiu jitsu: no head kicking.

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Neurology: Your Face Looks Funny (?)

I was walking through Target today, and couldn't help myself but overhear a conversation couple people were having. One lady said that her husband's face looked funny couple mornings ago, and his whole right side seemed to be droopy. Afraid that it might be a stroke, they rightfully went to the ER, but luckily he wasn't having a stroke. So that was a relief, but his face still looks "funny"...

There are many things that you should consider when someone's face seems droopy. This occurs often due to some sort of "damage" to cranial nerve 7, or also known as the facial nerve. The damage can happen anywhere along the peripheral section of the nerve (away from the brain, closer to the facial muscles) or can happen in the central section (in the brainstem, right between the pons and medulla). Depending on the section of the nerve that is affected, it is called either "peripheral facial palsy" or "central facial palsy." It is sometimes difficult differentiate between the two without further testing, but clinically the peripheral facial palsy generally presents with drooping of the whole side of the face (including forehead, eye lid, and mouth) and the central facial palsy generally presents with drooping of just the lower half of the face (just the corner of the mouth). This is because the upper part of the face is also innervated by the other side branches of the facial nerve (cranial nerves run in pairs), thus the nerves from the contralateral side compensates for the loss of innervation from the ipsilateral side. As presented by the lady's husband in the story above, he had complete one side facial droopiness, which most likely means he had a peripheral facial palsy. But what caused this to happen?

There are many things that can cause facial nerve palsy. Just to name some, here is a list of differential diagnoses (possible causes) from Medscape:

• Acoustic neuroma and other cerebellopontine angle lesions
• Acute or chronic otitis media
• Amyloidosis
• Aneurysm of vertebral artery, basilar artery, or carotid arteries
• Autoimmune syndromes
• Botulism
• Carcinomatosis
• Carotid disease and stroke - Including embolic phenomenon
• Cholesteatoma of the middle ear
• Congenital malformation
• Facial nerve schwannoma
• Geniculate ganglion infection
• Glomus tumors
• Guillain-Barré syndrome
• Herpes zoster
• Human immunodeficiency virus (HIV) infection
• Leukemia/lymphoma
• Leukemic meningitis
• Malignant otitis externa
• Melkersson-Rosenthal syndrome
• Meningitis
• Mycoplasma pneumonia
• Nasopharyngeal carcinoma
• Osteomyelitis of the skull base
• Otitis media
• Parotid gland disease or tumor
• Pontine lesions
• Sarcoma
• Skull base tumor
• Teratoma
• Tuberculosis
• Viral syndromes
• Wegener granulomatosis
• Wegener vasculitis
• Alcoholic neuropathy
• Anesthesia nerve blocks
• Basal skull fractures
• Barotrauma
• Benign intracranial hypertension
• Birth trauma
• Carbon monoxide exposure
• Diphtheria
• Facial injuries
• Facial trauma (blunt, penetrating, iatrogenic)
• Forceps delivery
• Iatrogenic - As in otologic, neurotologic, skull base, or parotid surgery
• Infectious mononucleosis
• Kawasaki disease
• Leprosy
• Metastatic disease
• Mumps
• Polyneuritis
• Temporal bone fracture
• Tetanus
• Thalidomide exposure
• Toxic

Yes, that was a long list. But that is exactly the point. There are NUMEROUS causes of facial palsy. Are they all common? Of course not. Doctors just love to make a long list when they're not sure what to do. Of these, the most common ones to consider are herpes simplex or zoster virus, stroke, Guillain-Barre Syndrome, acoustic neuroma, and trauma (various kinds). You should also consider Lyme Disease if you live somewhere in the Northeast region of U.S. Moreover, to make things more confusing, they can occur on BOTH sides of the face at the same time! These are very rare, and some possible causes are sarcoidosis, Lyme Disease, Guillain-Barre Syndrome, meningitis, and neurofibromatosis type 2.

For our main character of the story above, luckily it sounded like he had one of the more benign causes of unilateral peripheral facial palsy, or also known as Bell's Palsy. This is usually idiopathic (unknown reason, because we are idiots... just kidding), or it can be due to underlying herpes simplex virus type 1, which about 65 - 90% of people around the world have (often presenting as cold sores), or some other virus that had been living dormant in the facial nerve. Most of these cases go away on their own, and there are no critical sequelae afterwards. Obviously I do not know the whole story behind the above mentioned gentleman's history and I most likely will not know what happens to him later on. If you encounter a similar situation, you should always be aware of the "red flags" and try to figure out if it is an emergency or not. Sometimes that is hard to do, so in that case you should go to the hospital. But, some red flags to look for are: concurrent extremity/limb numbness or paralysis, fever, severe headache, neck stiffness and pain, and history of recent trauma to the head or neck (Carotid artery dissection can lead to a stroke and cause droopiness of upper of the face! We will revisit this topic when we talk about STROKE in the future, and how that may relate to Jiu Jitsu!). If you notice any of those red flags or are just unsure, then make sure to go to the ER. If not, or if you've had it for a while without anything else happening, you can just make an appointment as an outpatient with your primary care doctor. But I always say, when it doubt, just go to the hospital.

I hope this was an interesting/helpful topic. Feel free to ask me any questions!  

=)  <------ no droopiness!

Sources: 

http://emedicine.medscape.com/article/1146903-differential

http://www.mayoclinic.com/health/bells-palsy/DS00168/DSECTION=causes 

Welcome!

Hello!

Welcome to the Jiu Jitsu Doc blog! My name is Brian, and I enjoy many things life has to offer, such as movies, sports, food, snowboarding, good times with friends and family, etc, etc. Nonetheless, I do have two main passions in my life: medicine and Brazilian jiu jitsu! As you probably already guessed from the title of this page, this blog will be all about medicine and jiu jitsu!

I am currently a fourth year medical student (almost done!), and I am a blue belt in jiu jitsu. Some of you may be thinking right now, "How the heck does a medical student have time to practice jiu jitsu AND write a blog?" Yes, I ask myself that also from time to time, and it was definitely not easy. I started training in San Diego under the great Saulo and Xande Ribeiro while I was in college, then I skipped a whole year during my first year in medical school, and then I resumed training under Tom Knox of Elite Team Visalia during the latter half of my second year. Even after resuming, I was able to train only 2-3 times a week, and that was definitely difficult. But somehow I managed to do one competition last year and finally earned myself a blue belt early this year. It was tough, but I'm glad I went through it, as it helped me keep myself fit and I got to meet many good people. Plus, now that I am a fourth year student, I do have a bit more time to do some silly things, like training and blogging.

So now back to the main topic: Why a jiu jitsu/medicine blog? The more I learn about medicine and jiu jitsu, I can't help but see the parallel similarities between the two disciplines. First of all, they are both TOUGH. There is SO MUCH to learn, and even when you get your medical license or a black belt, the real learning has only begun! Yet, the challenge, discipline, and the subsequent achievements are the exact attributes that attract many people to medicine and jiu jitsu.  In either field, you must put in hard work and much sacrifice to achieve success. Secondly, they are both humbling. Many people with some sort of athletic background like football or wrestling walk into a jiu jitsu school for the first time and quickly learn that it is not a joke. Similarly, most students starting medical school were once top of their classes during college, and once they start their first semester of medical school they quickly realize that they are no longer the superstar students anymore! In fact, they learn that college was actually simple in comparison! It's a tough fact to accept, but in either field, you are quickly humbled. Third, you just cannot force things. The more you try to force that one guy off of top mount, the more tired you'll become and more likely he/she will catch you with an arm bar. Moreover, the more you try to force memorize every little detail and cram like a crazy person the night before an exam, the worse you will perform on your exams. You must find your balance and flow, and figure out what works for you. Fourth, they are both expensive (lol).

I want to share on this blog some of my experience in both medicine and jiu jitsu. I would also like to share medical topics involving jiu jitsu, such as joint anatomy, body physiology, and injury treatment/prevention in jiu jitsu. I am planning on going into the field of Physical Medicine and Rehab (aka Physiatry; here's a link with explanation if you are wondering what it is: http://www.aapmr.org/patients/aboutpmr/pages/physiatrist.aspx) next year and focusing on sports medicine. Every time I come across something interesting in medicine, jiu jitsu, or both I will post it here and share with you all! This is my first blog site ever, so I promise it will get better as it goes on. Please feel free to share comments, feedbacks, or just a hello!

(From left) Charlie Johnson, Me, Tom Knox, Bruce Tafoya

Elite Team Group Pic!

My classmates and I