Spinal Injury Sayun Sumethvanich M.D.

Spinal injury Stable injury: vertebral component will not be displace by normal movement Unstable injury: there is significant risk of displacement and damage neural tissue

Outline Goal of spine trauma care Pre-hospital management Clinical and neurologic assessment Acute spinal cord injury Term, type and clinical characteristic Common thoracolumbar spine fracture and dislocation

Goal of spine trauma care Protect further injury during evaluation and management Detect spine injury or absence of spine injury Protection Priority Detection Secondary

Maintain or restore spinal alignment Minimize loss of spinal mobility Obtain healed & stable spine Optimize conditions for maximal neurologic recovery Facilitate rehabilitation

Suspected Spinal Injury High energy trauma Sudden deceleration (traffic accident, fall) Unconscious Multiple injuries 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 Whole spine should be immobilized in neutral position on a firm surface. Can be done manually or with a combination of semi-rigid cervical collar, side head supports, long spine board and strapping.

Cervical spine immobilization Hard backboard, rigid cervical collar and lateral support (sand bag) Neutral position

Transportation of spinal cord-injured patients Rigid cervical collar Log-rolling Rigid transportation board

Initial immobilization of C-spine with a hard- collar is a priority Long spine boards are valuable primarily for extrication from vehicles Rapid evacuation to a level 1 trauma center

Clinical and neurologic assessment Advance Trauma Life Support (ATLS) guidelines Primary and secondary surveys Adequate airway and ventilation are the most important factors Supplemental oxygenation Early intubation is critical to limit secondary injury from hypoxia

Spine evaluation concurrent with resuscitative measure Assessment of gross neurological function Diagnosis of severy unstable injury Analysis of hemodynamic parameters : neurogenic shock

Neurogenic shock Secondary to spinal cord injuries of the cervical or high thoracic region Loss of symphathetic imput – vasodilation, decrease cardiac output and venous return Diagnosis hypotension with bradycardia warm extremities (loss of peripheral vasoconstriction) motor and sensory deficits

In the multiply-injured patient, hypotension had blood loss as the etiology rather than neurogenic causes Treatment Adequate airway and ventilation Most patients with neurogenic shock will respond to restoration of intravascular volume alone Administration of vasoconstrictors will improve peripheral vascular tone Dopamine may be utilized first

Physical examination Inspection and palpation Neurological assessment 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 Sacral sparing - PR

Neurological assessment Sensory Dermatome Pain & tempature Positional sense

Motor power Campbell, 12th edition

Grading Scale of motor power: 0-5 0: total paralysis 1: palpable or visible contraction 2: active movement; gravity eliminated 3: active movement: against gravity 4: active movement: against some resistance 5: active movement: against full resistance

Neurological assessment: Rectal Tone: the presence of rectal tone Perianal sensation Incomplete cord A voluntary contraction of the sphincter Bulbocavernosus reflex: Positive: the presence of this reflex implies the lack of supraspinal input to the sacral outflow and is suggestive of a complete spinal injury Negative: spinal shock

Acute spinal cord injury Spinal shock Functional classification Anatomical classification

Spinal shock The loss of spinal sensation, reflex with motor paralysis after injury of the spinal cord This commonly resolves in 48 hours Complete & Incomplete spinal cord injury - Bulbocavernosus reflex

Treatment Patient's neck and back is immobilized Airway is maintained so patient can breath normal Continue intravenous fluid and volume injected as necessary to maintain normal blood pressure Nasal oxygen is provided to maintain normal blood oxygenation Intravenous corticosteroid - controvercy

Functional classification American Spinal Injury Association (ASIA) score

ASIA Impairment Scale A = Complete: No motor or sensory function is preserved below the level of injury (including the anal area) B = Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments C = Incomplete: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade < 3 D = Incomplete: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more E = Normal: Motor and sensory function are normal

Anatomical classification Complete Spinal cord injury No sensation / motor below injury Poor prognosis - chance to recover < 5 % May be involuntary movement Incomplete Spinal cord injury Spare sensation / motor below injury Better prognosis than complete injury

Type of Spinal cord injury Brown-Sequard syndrome Hemicord Ipsilateral motor weakness Contralateral loss of pain & temp Good prognosis

Anterior cord syndrome Motor weakness, loss of pain & temp below injury level Poor prognosis Posterior cord syndrome Posterior column Loss of propioceptive , vibratory, but spare sensory and motor function Prognosis : Fair

Central cord syndrome Central area Old age – degenerative cervical spondylosis Hyperextension injury Motor weakness : arm,hand > leg Sensory : spare Prognosis : Fair

Common thoracolumbar spine fracture and dislocation Thoracic vertebrae Rib bearing vertebrae Designed to remain stiff and straight

Lumbar vertebrae Weight bearing vertebrae Lamina, facets and spinoligamentous complex are major parts of posterior elements

Three column concept

1. Wedge compression fractures Isolated failure of the anterior column Forward flexion Neurological deficit are rare

2. Burst fracture The anterior and middle columns fail because of a compressive load, but no loss of integrity of the posterior elements The posterior column is disrupted – unstable burst fracture Maybe neurological deficit

3. Flexion-Distraction injury The anterior column fails in compression The middle and posterior columns fail in tension Unstable 4. Chance fracture

5. Translational injury Fracture-dislocation Totally disruption and one part of the spinal canal has been displaced in the transverse plane

TLIC score ≤ 3 = nonoperative treatment score of ≥ 5 = operative treatment; score of 4 = either nonoperative or operative treatment

Nurse care plan Immediate care Assessment – vital sign, neurological function Ventilation Hemodynamic parameter Stabilization Pain control Pshycological support Rehabilitation – multidisciplinary approach Prevent complication

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