spine and spinal cord trauma. objectives anatomy/physiology evaluate a patient with spinal injury...

Spine and Spinal Cord Trauma

Objectives

• Anatomy/physiology

• Evaluate a patient with spinal injury

• Identify common spinal injuries and Xray features

• Appropriately manage the spinal-injured patient

• Determine appropriate disposition

Suspected Spinal Injury

• High speed crash

• Unconscious

• Multiple injuries

• Neurologic deficit

• Spinal pain/tenderness

Spinal injury

• 5% worsen neurologically at hospital

• Protection is a priority

• Detection is a secondary priority

• Spinal evaluation complicated by TBI

• Remove spine boards ASAP

Cord Injury Severity

• Complete = no motor function or sensory function below the injury level

• Incomplete = any preservation of function– Sacral sparing may be the only preservation of

function

Sensory Examination

• Levels vs sensation

Motor Examination

• Table outlining levels

Neurogenic Shock

• Hypotension associated with cervical/high thoracic spine injury

• Bradycardia

• Tx: fluid, atropine, pressors

Spinal Shock

• Neurologic, not hemodynamic phenomenon

• Occurs shortly after cord injury

• Flaccidity

• Loss of reflexes

Effects on other organ systems

• Inadequate ventilation

• Compromised abdominal evaluation

• Occult compartment syndrome

Classification of Injuries: Levels of injury

Clinical exam

Most caudal

Normal bilaterally

Motor/sensory function

Bony = site of vertebral damage

Classification

• Incomplete– Any sensation

– Position sense

– Voluntary movement in lower extremity

– Sacral sparing

• Complete– No motor/sensory

function

– No sacral sparing

– May have reflexes

Spinal Cord Syndromes

• Central• Anterior• Brown-sequard

• Anatomy diagram

Classifications: morphology

• Fracture or fracture dislocation

• SCIWORA

• Penetrating

Classification: morphology

• Unstable if:– Xray evidence of injury– Neurologic injury– Severe pain on spine movement or palpation

Xray Guidelines

• A• A• B• B• C• C• D• S

• Normal C spine Xray

C spine Xrays

• Cross table lateral detects 85%

• Additional 2 views excludes most fractures

• May also require:– Swimmer’s– CT– Flex/ex– MRI

Cspine Xrays

• 10% have a second fracture

• Look for second fracture!

• One fracture mandates full spine films

Xray Guidelines

• Adequacy• Alignment• Bones• Cartilage• Contours• Disc space• Soft tissue

• Thoracolumbar spine Xray

Screening for Spinal Injury

• Algorithim – Paraplegia/quadraplegia– Presumed spinal instability– Identify bony fracture-subluxation– Consult neurosurgery or orthopedics

Screening for Spinal Injury

• Alert, sober neurologically normal patient:– No neck pain or tenderness– No distracting injury– No pain with voluntary movement

• No further Xrays required

Screening for spinal injury

• Alert, sober, neurologically normal patient– Neck or spin pain or tenderness to palpation or

voluntary movement– After removal of c-collar?– If yes to any question

• Protect cspine

• Obtain necessary Xray exams

Screening for spinal injury

• Altered LOC– Complete spine films– Plain films– CT prn

Screening for Spinal Injury

• Radiographic– Normal Xray

• Clinical– Normal neurologic exam and– Absence of spinal pain/tenderness

• Caution!– Drugs, alcohol, distracting injuries

Management

• Immobilization– Entire patient

– Propper padding

– Maintain until cleared

– Avoid prolonged use of backboard

• Decubitus ulcer

Medical Management

• Ensure A/B

• Maintain BP

• Atropine prn

• Methylprednisolone

Medical Management

• Intravenous fluids– Treat hypovolemia first– Consider neurogenic shock– Insert foley

Medical Management

• Steroids– Methylpred doses

Medical Management

• Transfer– Unstable fractures– Neurologic deficit– Avoid delay– Proper immobilization– Respiratory support as needed

Questions

Summary

• Treat life-threatening injuries first (ABCD)

• Immobilization

• Appropriate Xrays

• Document examination

• Consultation

• Transfer