Spinal Injury asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd

7/29/2019 Spinal Injury asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdas

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.

.

Spinal Injury&

Spinal Cord

Injury

Spinal Injury&

Spinal Cord

Injury

For General Practice


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OutlineOutline

Goal of spine trauma care Pre-hospital management

Clinical and neurologic assessment

Acute spinal cord injury Term, type and clinical characteristic

Common cervical spine fracture and

dislocation


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Goal of spine trauma careGoal of spine trauma care

Protect further injury during evaluation andmanagement

Identify spine injury or document absence ofspine injury

Optimize conditions for maximal neurologic

recovery


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Goal of spine trauma careGoal of spine trauma care

Maintain or restore spinal alignment

Minimize loss of spinal mobility

Obtain healed & stable spine

Facilitate rehabilitation


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Suspected Spinal InjurySuspected Spinal Injury

High speed crash Unconscious

Multiple injuries

Neurological deficit Spinal pain/tenderness


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Pre-hospital managementPre-hospital management

Protect spine at all times during themanagement of patients with multiple injuries

Up to 15% of spinal injuries have a second(possibly non adjacent) fracture elsewhere inthe spine

Ideally, whole spine should be immobilized inneutral position on a firm surface


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PROTECTION PRIORITY Detection Secondary

Log-rolling


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Pre-hospital managementPre-hospital management

Cervical spine immobilization

Transportation of spinal cord-injured

patients


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Cervical spine immobilizationCervical spine immobilization

Safe assumptions Head injury and unconscious

Multiple trauma

Fall

Severely injured worker

Unstable spinal column

Hard backboard, rigid cervical collar and lateralsupport (sand bag)

Neutral position


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Philadelphia hard collarPhiladelphia hard collar


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patients


patients

Emergency Medical Systems (EMS) Paramedical staff

Primary trauma center

Spinal injury center


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Clinical assessmentClinical assessment

Advance Trauma Life Support (ATLS)guidelines

Primary and secondary surveys

Adequate airway and ventilation are themost important factors

Supplemental oxygenation

Early intubation is critical to limit secondary

injury from hypoxia


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Physical examinationPhysical examination

Information Mechanism

energy, energy

Direction of Impact

Associated Injuries


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Is the patient awake or

unexaminable?

Is the patient awake or

unexaminable?

Whats the difference ? Awake

ask/answer question

pain/tenderness

motor/sensory exam

Not awake

you can ask (but they wont answer)

cant assess tenderness

no motor/sensory exam

OW!

------


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Unexaminable

No exam


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Physical examinationPhysical examination

Inspection and palpation Occiput to Coccyx Soft tissue swelling and bruising Point of spinal tenderness

Gap or Step-off Spasm of associated muscles

Neurological assessment

Motor, sensation and reflexes PR

Do not forget the cranial nerve (C0-C1 injury)


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Neurogenic ShockNeurogenic Shock

Temporary loss of autonomic function of the

cord at the level of injury results from cervical or high thoracic injury

Presentation

Flaccid paralysis distal to injury site Loss of autonomic function

hypotension

vasodilatation

loss of bladder and bowel control

loss of thermoregulation

warm, pink, dry below injury site

bradycardia


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Neurogenic Hypovolemic

Etiology Loss of sympatheticoutflow

Loss of blood volume

Bloodpressure Hypotension Hypotension

Heart rate Bradycardia Tachycardia

Skintemperature

Warm Cold

Urine

output

Normal Low

Comparison of neurogenic and hypovolemic shock


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Definitions of termsDefinitions of terms

Neurologic level Most caudal segment with normal sensory and

motor function both sides

Skeletal level

Radiographic level of greatest vertebral damage

Complete injury

Absence of sensory and motor function in the

lowest sacral segment Incomplete injury

Partial preservation of sensory and/or motor

function below the neurologic level


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Neurologic assessmentNeurologic assessment

Spinal shock Bulbocavernosus reflex

Complete VS incomplete cord injury

spinal shock Sacral sparing

Voluntary anal sphincter control

Toe flexor Perianal sensation

Anal wink reflex


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Neurologic assessmentNeurologic assessment

American Spinal Injury Association grade Grade A E

American Spinal Injury Association score Motor score (total = 100 points)

Key muscles : 10 muscles

Sensory score (total = 112 points)

Key sensory points : 28 dermatomes


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Incomplete cord injuryIncomplete cord injury

Anterior cord syndrome Brown-Sequard syndrome

Central cord syndrome


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Anterior cord syndromeAnterior cord syndrome

Loss of motor, pain

and temperature

Preserved

propioception and

deep touch


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Brown-Sequard syndromeBrown-Sequard syndrome

Loss of ipsilateral

motor and

propioception

Loss of contralateral

pain and

temperature


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Central cord syndromeCentral cord syndrome

Weakness :

upper > lower

Variable sensory

loss

Sacral sparing


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Radiographic imagingRadiographic imaging

Who needs an x- ray of the spine ?

NEXUS -The National Emergency X- Radiograph

Utilization Study

Prospective study to validate a rule for the decision to obtain

cervical spine x- ray in trauma patients

Hoffman, N Engl J Med2000; 343:94-99

Canadian C-Spine rules

Prospective study whereby patients were evaluated for 20standardized clinical findings as a basis for formulating a

decision as to the need for subsequent cervical spine

radiography

Stiell I. JAMA. 2001; 286:1841-1846


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NEXUSNEXUS

NEXUS Criteria:

1. Absence of tenderness in the posterior midline

2. Absence of a neurological deficit

3. Normal level of alertness (GCS score = 15)4. No evidence of intoxication (drugs or alcohol)

5. No distracting injury/pain


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NEXUSNEXUS

Patient who fulfilled all 5 of the criteria wereconsidered low risk for C-spine injury

No need C-spine X-ray

For patients who had any of the 5 criteria

radiographic imaging was indicated

( AP, lateral and open mouth views)


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The Canadian C-spine Rule for alert and stable trauma patients where cervical

spine injury is a concern.

The Canadian C-spine Rule for alert and stable trauma patients where cervical

spine injury is a concern.

Any high-risk factor that mandates radiography?

Age>65yrs or Dangerous mechanism or

Paresthesia in extremities

Any low-risk factor that allows safe

assessment of range of motion? Simple rear-end MVC, or

Sitting position in ER, or

Ambulatory at any time, or

Delayed onset of neck pain, or

Absence of midline C-spine tenderness

Able to actively rotate neck?

45 degrees left and right

No Radiography

Radiography

NO

YES

ABLE

YES

NO

UNABLE


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National Emergency X

Radiography Utilization Study

(NEXUS)

National Emergency X

Radiography Utilization Study

(NEXUS)

Both have:

Excellent negative predictive value forexcluding patients identified as low risk

The Canadian C-spine rule

&


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Clearance of Cervical Spine Injury in

Conscious, Symptomatic Patients

Clearance of Cervical Spine Injury in

Conscious, Symptomatic Patients

1. Radiological evaluation of the cervical spine isindicated for all patients who do not meet the

criteria for clinical clearance as described

above

2. Imaging studies should be technically adequate

and interpreted by experienced clinicians


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Cervical Spine Imaging OptionsCervical Spine Imaging Options

Plain films AP, lateral and open mouth view

Optional: Oblique and Swimmers

CT Better for occult fractures

MRI Very good for spinal cord, soft tissue and

ligamentous injuries

Flexion-Extension Plain Films to determine stability


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Radiolographic evaluationRadiolographic evaluation

X-ray Guidelines (cervical)

AABBCDS

Adequacy, Alignment Bone abnormality, Base of skull

Cartilage

Disc space Soft tissue


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AdequacyAdequacy

Must visualize entire C-spine

A film that does not show theupper border of T1 is

inadequate Caudal traction on the arms

may help

If can not, get swimmers viewor CT


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Swimmers viewSwimmers view


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AlignmentAlignment

The anterior vertebral line,

posterior vertebral line, and

spinolaminar line should

have a smooth curve with

no steps or discontinuities

Malalignment of the

posterior vertebral bodies is

more significant than that

anteriorly, which may be

due to rotation

A step-off of >3.5mm is

significant anywhere


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Lateral Cervical Spine X-RayLateral Cervical Spine X-Ray

Anterior subluxation of onevertebra on another indicatesfacet dislocation

< 50% of the width of a vertebralbody unilateral facetdislocation

> 50% bilateral facet

dislocation


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BonesBones


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DiscDisc

Disc Spaces

Should be uniform

Assess spacesbetween the

spinous processes


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Soft tissueSoft tissue

Nasopharyngeal space(C1) 10 mm (adult)

Retropharyngeal space(C2-C4) 5-7 mm

Retrotracheal space(C5-C7) 14 mm (children) 22 mm (adults)


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AP C-spine FilmsAP C-spine Films

Spinous processes

should line up

Disc space should beuniform

Vertebral body height

should be uniform.Check for oblique

fractures.


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Open mouth viewOpen mouth view

Adequacy: all of: all of

the dens andthe dens and

lateral borders oflateral borders ofC1 & C2C1 & C2

Alignment: lateral: lateral

masses of C1 andmasses of C1 and

C2C2

Bone: Inspect dens

for lucent fracture

lines


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CT ScanCT Scan

Thin cut CT scan shouldbe used to evaluateabnormal, suspicious orpoorly visualized areas

on plain film

The combination of plainfilm and directed CT scan

provides a false negativerate of less than 0.1%


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MRIMRI

Ideally all patients withabnormal neurological

examination should beevaluated with MRI

scan


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Management of SCIManagement of SCI

Primary Goal Prevent secondary injury

Immobilization of the spine begins in the initialassessment

Treat the spine as a long bone

Secure joint above and below

Caution with partial spine splinting


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Spinal motion restriction: immobilization devices ABCs

Increase FiO2

Assist ventilations as needed with c-spine control Indications for intubation :

Acute respiratory failure

GCS 50

VC < 10 mL/kg

IV Access & fluids titrated to BP ~ 90-100 mmHg


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Look for other injuries: Life over Limb

Transport to appropriate SCI center once

stabilized

Consider high dose methylprednisolone Controversial as recent evidence questions benefit

Must be started < 8 hours of injury

Do not use for penetrating trauma

30 mg/kg bolus over 15 minute

After bolus: infusion 5.4mg/kg IV for 23 hours


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Principle of treatmentPrinciple of treatment

Spinal alignment deformity/subluxation/dislocationreduction

Spinal column stability unstable stabilization

Neurological status

neurological deficit decompression


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Jefferson FractureJefferson Fracture

Burst fracture of C1 ring

Unstable fracture

Increased lateral ADI onlateral film if rupturedtransverse ligament anddisplacement of C1 lateralmasses on open mouth view

Need CT scan


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Burst FractureBurst Fracture

Fracture of C3-C7 fromaxial loading

Spinal cord injury iscommon from posteriordisplacement of fragmentsinto the spinal canal

Unstable


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Clay Shovelers FractureClay Shovelers Fracture

Flexion fracture of

spinous process

C7>C6>T1

Stable fracture


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Flexion Teardrop FractureFlexion Teardrop Fracture

Flexion injury causing afracture of theanteroinferior portion ofthe vertebral body

Unstablebecauseusually associated withposterior ligamentous

injury


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Bilateral Facet DislocationBilateral Facet Dislocation

Flexion injury

Subluxation of dislocated

vertebra of greater than

the AP diameter of thevertebral body below it

High incidence of spinal

cord injury

Extremely unstable


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Hangmans FractureHangmans Fracture

Extension injury

Bilateral fractures of

C2 pedicles

(white arrow)

Anterior dislocation of

C2 vertebral body

(red arrow)

Unstable


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Odontoid FracturesOdontoid Fractures

Complex mechanism of injury

Generally unstable

Type 1 fracture through the tip

Rare

Type 2 fracture through the base

Most common

Type 3 fracture through the base and bodyof axis

Best prognosis


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Odontoid Fracture Type IIOdontoid Fracture Type II


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Odontoid Fracture Type IIIOdontoid Fracture Type III


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THANK YOU

FOR YOUR ATTENTION

THANK YOU

FOR YOUR ATTENTION

Documents

Spinal Injury asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd asdasdasd