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 B 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