1. Spinal Injury
Sayun Sumethvanich M.D.

2. 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

3. 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

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

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

6. Suspected Spinal Injury
High energy trauma
Sudden deceleration (traffic accident, fall)
Unconscious
Multiple injuries
Neurological deficit
Spinal pain/tenderness

7. 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.

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

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

11. 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

12. 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

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

14. 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

15. 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

16. 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

17. Neurological assessment
Sensory
Dermatome
Pain & tempature
Positional sense

18. Motor power
Campbell, 12th edition

19. 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

20. 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

21. Acute spinal cord injury
Spinal shock
Functional classification
Anatomical classification

22. 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

23. 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

24. Functional classification
American Spinal Injury Association (ASIA) score

25. 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

26. 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

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

28. 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

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

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

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

32. Three column concept

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

34. 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

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

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

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

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

39. Thank you