Emergency & GPBPKIHS, Dharan

Spinal Injury

Dr. Sundar KarkiMedical Officer

Outlines• Introduction• Epidemiology • Aetiology and distribution• Normal spinal anatomy• Common mechanism of injury• Prehospital management• Diagnosis of spinal injury• Management and prognosis• Common type of spinal fracture

Introduction

• Spinal injuries are devastating• Spinal injury may be defined as injury to the

spinal column (bone column)/spinal cord or both

• Improper management can have horrible and permanent result

• Appropriate use of immobilization can mean difference between a patient who fully recovers and other spent whole life paralyzed.

Epidemiology

• 40 cases per million in US• Most common cervical region(55%)• Mortality rate 40-50%• Between the ages 16-30. M:F=4:1• Most frequent age is 19• Current estimates are 250,000 - 400,000

individuals living with Spinal Cord Injury or Spinal Dysfunction.

Ateiolgy and Distribution

Normal Spinal Anatomy

▪33 separate irregular bones▪Vertebral foramen: canal formed for spinal cord

Cervical Vertebrae

▪C1-7,located in the neck

▪Small vetrebral body Extensive joint surface

▪C1: atlas C2: axis

Thoracic Vertebrae

▪Rib bearing vertebrae

▪Designed to remain stiff and straight

Lumbar vertebrae

▪Weight bearing vertebrae

▪Lamina, facets and SPsare major parts

Spinal Ligament

Spinal cord and Nerves▪31 pairs of nerves ▪motor and sensory both▪Ligaments provide support▪Cord is nerve tissue▪Extend from foramen magnum to the L1 and end in the form of conus medullaris

Common Mechanism• Compression • Flexion • Extension • Rotation • Lateral bending • Distraction • Penetration

Spinal Column Injury Bony spinal injuries may or may not be Bony spinal injuries may or may not be

associated with spinal cord injuryassociated with spinal cord injury These bony injuries include:These bony injuries include:

– Compression fractures Compression fractures – Comminuted fractures Comminuted fractures – Subluxation (partial dislocation) Subluxation (partial dislocation)

Other injuries may include:Other injuries may include:– Sprains- over-stretching or tearing of Sprains- over-stretching or tearing of

ligamentsligaments– Strains- over-stretching or tearing of Strains- over-stretching or tearing of

the musclesthe muscles

HyperflexionWhiplash injury:(C3-7)Traumatic injury to the soft tissue in the cervical regionHyperflexion, hyperextentionNo fractures or dislocationsMost common automobile injuryRecover 3-6 months

Hyperextension Atlanto-occipital dislocation: frequently results in prehospital cardiorespiratory arrest 3 times more common in children than adults Unstable

Hyper rotation Atlanto-Axial dislocation: Transverse ligament injury more common in children than

adults 1/3 of patients have deficit Unstable

Spinal Cord injury• Cutting compression or stretching of spinal cord• Causing loss of distal function sensation or

motion • Caused by: -unstable or sharp bony fragment

pushing the cord - Pressure from bone fragments or swelling Pressure from bone fragments or swelling

that interrupts the blood supply to the cord that interrupts the blood supply to the cord causing ischemiacausing ischemia

Spinal cord injury ▪Primary spinal cord injury - cutting, compression or stretching of

spinal cord

▪Secondary spinal cord injury -occurs later due to swelling, ischemia or

movement of unstable bony fragments

Spinal Cord injury severity▪Complete - less common - loss of motor and sensory function

below the level of injury

▪Incomplete - some preservation of motor and sensory

function

Spinal cord injury without radiological abnormality(SCIWORA)• referred to spinal cord injury without

radiographic or CT evidence of fracture or dislocation

• With advent of MRI, term has become ambiguous

• "Spinal cord injury without neuroimaging abnormality" more correct name

• Mostly in pediatric population (range: birth to 16 years old)

• Common in cervical and thoracic region

Spinal cord injury without radiological abnormality(SCIWORA)• Following findings on MRI have been recognized

as causing primary or secondary spinal cord injury:

-Intervertebral disk rupture -Spinal epidural hematoma -Cord contusion -Hematomyelia • Prognosis of SCIWORA is actually better than

patients with spinal cord injury and radiologic evidence of traumatic injury

Suspected Spinal Injury• High speed crash• Compression injury (diving, fall on buttock)• Significant blunt trauma• Very violent mechanism• Unconscious• Neurological deficit• Spinal pain/tenderness

Pre-hospital management• Protect spine at all times during the

management of patients with multiple injuries

• Up to 5% of spinal injuries have a second (possibly non adjacent) fracture elsewhere in the spine

▪ Ideally, whole spine should be immobilized in neutral position on a firm surface

Pre-hospital management

• Cervical spine immobilization

• Transportation of spinal cord-injured patients

Cervical spine immobilization• “Safe assumptions”

– Head injury and unconscious– Multiple trauma– Fall – Severely injured worker– Unstable spinal column

• Hard backboard, rigid cervical collar and lateral support (sand bag)

• Neutral position

Philadelphia hard collar

Transportation of spinal cord-injured patients

• Emergency Medical Systems (EMS)• Paramedical staff• Primary trauma center• Spinal injury center

• PROTECTION PRIORITY• Detection Secondary

• Rigid cervical collar• “Log rolling”• Rigid transportation board remove• Rigid transfer slide

Immobilization at hospital

Diagnosis of Spinal injury: clinical evaluation• Inspection and palpation: occiput to coccyx - tenderness - gap or step - edema and bruising - spasm of associated muscle

Diagnosis of Spinal injury: clinical evaluation• Neurological Examination - sensation - motor function - reflexes - rectal examination

Neurological: Sensory

Neurological: Motor

Neurological Examination: Rectal

• Tone: the presence of rectal tone in itself does not indicate incomplete injury

• Sensation• Voilition: a voluntary contraction of

sphincter or the presence of rectal sensation supports the presence of a communication between the lower spinal cord and supraspinal centers

Neurological examination: Rectal

• Bulbocavernosus reflex -refers to anal sphincter contraction in response to

squeezing the glans penis or tugging on the Foley;

-reflex involves S-1, S-2, and S-3 nerve roots and is spinal cord- mediated reflex arc

-absence of this reflex documents continuation of spinal shock or spinal injury at the level of the reflex arc itself.

Is the patient awake or “unexaminable”?

• What’s the difference ?– Awake

• ask/answer question• pain/tenderness• motor/sensory exam

– Not awake• you can ask (but they won’t answer)• can’t assess tenderness• no motor/sensory exam

OW!

------

Neurologic assessment and grading

• 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

American Spinal Injury association grade

Incomplete Cord Injury: Anterior cord syndrome

• Loss of motor, pain and temperature

• Preserved propioception and deep touch

Incomplete cord injury: Brown-Sequard syndrome

• Loss of ipsilateral motor and propioception

• Loss of contralateral pain and temperature

Incomplete cord injury: Central cord syndrome

• Weakness : – upper > lower

• Variable sensory loss

• Sacral sparing

Radiographic 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 Med 2000; 343:94-99

Canadian C-Spine rules– Prospective study whereby patients were evaluated for 20

standardized 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

NEXUS• NEXUS Criteria:

1. Absence of tenderness in the posterior midline2. Absence of a neurological deficit3. Normal level of alertness (GCS score = 15)4. No evidence of intoxication (drugs or alcohol)5. No distracting injury/pain

NEXUS• Patient who fulfilled all 5 of the criteria

were considered low risk for C-spine injury

No need C-spine X-ray

• For patients who sort of any of the 5 criteria

radiographic imaging was indicated ( AP, lateral and open mouth views)

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 safeassessment 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

National Emergency XRadiography Utilization Study

(NEXUS)

Both have:• Excellent negative predictive value for

excluding patients identified as low risk

The Canadian C-spine rule

&

Clearance of Cervical Spine Injury inConscious, Symptomatic Patients

1. Radiological evaluation of the cervical spine is indicated 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

Cervical Spine Imaging Options

– Plain films• AP, lateral and open mouth view

– Optional: Oblique and Swimmer’s

– CT• Better for occult fractures

– MRI• Very good for spinal cord, soft tissue and ligamentous

injuries

– Flexion-Extension Plain Films• to determine stability

Radiolographic evaluation

X-ray Guidelines (cervical) AABBCDS

• Adequacy, Alignment• Bone abnormality, Base of skull• Cartilage• Disc space• Soft tissue

Adequacy

• Must visualize entire C-spine • A film that does not show the

upper border of T1 is inadequate

• Caudal traction on the arms may help

• If can not, get swimmer’s view or CT

Swimmer’s view

Alignment• 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 issignificant anywhere

Lateral Cervical Spine X-Ray

• Anterior subluxation of one vertebra on another indicates facet dislocation– < 50% of the width of a

vertebral body unilateral facet dislocation

– > 50% bilateral facet dislocation

Bones

Disc

• Disc Spaces– Should be

uniform • Assess spaces

between the spinous processes

Soft tissue• Nasopharyngeal space

(C1)– 10 mm (adult)

• Retropharyngeal space (C2-C4)– 5-7 mm

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

AP C-spine Films

• Spinous processes should line up

• Disc space should be uniform

• Vertebral body height should be uniform. Check for oblique fractures.

Open mouth view

• Adequacy: all of the : all of the dens and lateral dens and lateral borders of C1 & C2borders of C1 & C2

• Alignment: lateral : lateral masses of C1 and C2masses of C1 and C2

• Bone: Inspect dens for lucent fracture lines

CT Scan

• Thin cut CT scan should be used to evaluate abnormal, suspicious or poorly visualized areas on plain film

• The combination of plain film and directed CT scan provides a false negative rate of less than 0.1%

MRI• Ideally all patients

with abnormal neurological examination should be evaluated with MRI scan

Management of SCI• Primary Goal

– Prevent secondary injury

• Immobilization of the spine begins in the initial assessment– Treat the spine as a long bone

• Secure joint above and below– Caution with “partial” spine splinting

Management of SCI• Spinal motion restriction: immobilization devices• ABCs

– Increase FiO2

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

• Acute respiratory failure• GCS <9• Increased RR with hypoxia• PCO2 > 50 • VC < 10 mL/kg

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

Management of SCI• Clinical assessment and neurological

examination • Spinal Imaging and send laboratory

investigation• GI intervention: put nasogastric tube to

prevent aspiration• Pain Management - Opiates and NSAIDs

Management of SCI

• 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– Bolus followed by a 45-min pause – Then infusion 5.4mg/kg IV for 23 hours

Neurogenic 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

Spinal and Neurogenic shock

Hemodynamic state in neurogenic shock • Unopposed parasympathetic outflow can lead to

dysrythmias and hypotension(most common within 14 hours)

• Loss of sympathetic innervation to the heart (T1 through T4 cord levels) leaves the parasympathetic cardiac innervation via the vagus nerve unopposed, resulting in bradycardia, or an absence of reflex tachycardia.

• Most common dysrythmia is bradycardia

Hemodynamic instability: intervention

• First line volume resusciation ( 1-2 liter)

• Second line: vasopressor (dopamine/norepinephrine) to

counter loss of sympathetic tone and provide chronotropic support to the heart

Hemodynamics and cord perfusion

• Avoid hypotension• Maintain MAP 85-90mmHg for first 7

days if possible

Bradycardia: intervention

• Prevention -avoid vagal stimulation - hyperventilate and hyperoxygenate before

suctioning - premedicate patient with known

hypersensitivity to vagal stimuli ▪Symptomatic bradycardia atropine 0.5- 1.0 mg IV

Indication for Surgery• Decompression of neural elements( spinal

cord and nerves)• Stabilization of bony element( spine)• Deformity correction• Thoracolumbar spine fracture/dislocation

Prognosis of recovery• Patient with complete cervical spine injuries that

remain within the first 24 hours of admission are unlikely to regain significant ambulatory function

• Cervical injuries have a higher potential for recovery than do thoracic or thoracolumbar injuries

• Younger patient fare much better than older• Intermedullary hemorrhage signifies a worse

neurological outcome

Jefferson Fracture

• Burst fracture of C1 ring

• cervical spine is subjected to an axial load, as would occur from a direct blow to the top of the head

• Unstable fracture

• Need CT scan

Hangman’s Fracture

• Hyperextension injury

• Bilateral fractures of C2 pedicles

(white arrow) • Anterior dislocation of

C2 vertebral body (red arrow)

• Unstable

Odontoid 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 body of

axis– Best prognosis

Odontoid Fracture Type II

Odontoid Fracture Type III

Burst Fracture

• Fracture of C3-C7 from axial loading

• Spinal cord injury is common from posterior displacement of fragments into the spinal canal

• Unstable

Clay Shoveler’s Fracture

• Avulsion off the end of one of the lower cervical spinous processes

• C7>C6>T1

• Stable fracture

Flexion Teardrop Fracture

• Flexion injury causing a fracture of the anteroinferior portion of the vertebral body

• Unstable because usually associated with posterior ligamentous injury

Bilateral Facet Dislocation

• Flexion injury• Subluxation of dislocated

vertebra of greater than ½ the AP diameter of the vertebral body below it

• High incidence of spinal cord injury

• Extremely unstable