1. Spinal Trauma

2. Types  Cervical 40%  Thoracic 10%  Lumbar 3%  Dorso lumbar 35%  Combination of areas 14%

3. Anatomy  Spinal cord ends below lower border of L1  Cauda equina is below L1  Mechanical injury - early ischaemia, cord edema - cord necrosis  Neurological recovery unpredictable in cauda equina ie. peripheral nerves

6. Cauda equine compression

7. Cervical spine anatomy  Anterior column - Anterior longitudinal ligament+ Anterior annular ligament and anterior half of VB.  Middle column – Posterior long. Lig. + Posterior annular ligament +Posterior half of VB.  Posterior Column – Lig flavum + superior & Interspinous lig + intertransverse capsular lig + neural arch + pedicle & spinous process.

11. Significance  Unstable if middle column + either Anterior or Posterior column is damaged  Rupture of interspinous ligament is : - associated with avulsion of spinous process - Unstable spine - Further flexion increases neurological injury

12. Level of Spinal injury  Neurological level is at the most lowest segment with normal motor & sensory function  Difficult to determine : - as most muscle efferents receive fibres from more than one level - Closed cord lesions may extend over several cms. - Dermatomes have imprecise boundaries.

13. Cord level  C2 – C7 = add +1 for cord level  T1 – T6 = add +2  T7 – T9 = add +3  T10 = L1, L2 level  T11 = L3, L4 level  L1 = sacro coccygeal segments

17. Degrees of injury  Complete - flaccid paralysis + total loss of sensory & motor functions  Incomplete - mixed loss - Anterior sc syndrome - Posterior sc syndrome - Central cord syndrome - Brown sequard’s syndrome - Cauda equina syndrome

19. Anterior spinal cord syndrome  Flexion rotational force to spine  Due to compression fracture of vertebral body or anterior dislocation  Anterior spinal artery compression  Loss of power, reduced pain and temperature below the lesion.

22. Posterior cord syndrome  Hyperextension injuries  Posterior vertebral body fracture  Loss of proprioception and vibration sense  Severe ataxia

23. Central cord syndrome  Older age with cervical spondylosis  Hyperextension with minor trauma  Cord is compressed by osteophytes from vertebral body against thick ligamentum flavum.  Damages the central cervical tract  UMN lesion to legs (spastic)  LMN to arms (flaccid paralysis)

24. Brown sequards syndrome  Hemisection of the cord  Stab injury and lateral mass fractures  Uninjured side has good power but absent pinprick and temperature.  Spinothalamic tracts cross to opposite side of the cord three segments below.

25. Types of bony injury  Flexion  Extension  Flexion with rotation  Compression

26. Pathophysiology  Primary Neurological damage  Direct trauma, haematoma & SCIWORA ( Spinal Cord Injury w/o Radiologic Abnormality ) < 8yrs old In 4hrs - Infarction of white matter occurs In 8hrs - Infarction of grey matter and irreversible paralysis  Secondary damage Hypoxia Hypoperfusion Neurogenic shock Spinal shock

27. Hypoxia  Lesions above C 5 – damage to diaphragm leads to 20% reduction in vital capacity Rx Phrenic n. pacing  Lesions at D 4-6 – reduces vital capacity if < 500ml patient is ventilated  Intercostal nerve paralysis  Atelectasis – poor cough  V/Q mismatch  Reduced compliance of lung – muscle fatigue.

28. Neurogenic shock  Lesions above D6  Minutes – hours (fall of catecholamines may take 24 hrs)  Disruption of sympathetic outflow from D1 - L2  Unapposed vagal tone  Peripheral vasodilatation  Hypotension, Bradycardia & Hypothermia  BUT consider haemmorhagic shock if – injury below D6, other major injuries, hypotension with spinal fracture alone without neurological injury.

29. Spinal shock  Transient physiological reflex depression of cord function – ‘concussion of spinal cord’  Loss anal tone, reflexes, autonomic control within 24-72hr  Flaccid paralysis bladder & bowel and sustained Priapism  Lasts even days till reflex neural arcs below the level recovers.

30. Assessment & Managemnt  Failure to suspect leads to failure to detect injuries  ABCDE – Logroll and remove the spinal board  Look for markers of spinal injury  Secondary survey  Adequate Xray’s  Emergency treatment  Surgery  Definitive care & rehab.

31. Clinical features  Pain in the neck or back radiating due to nerve root irritation  Sensory disturbance distal to neurological level  Weakness or flaccid paralysis below the level

32. Signs in an Unconcious patients  Diaphragmatic breathing (Abdomen expands > Chest)  Neurological shock (Low BP & HR)  Flexed upper limbs (loss of extensor innervation below C 5 )  Responds to pain above the clavicle only  Priapism – may be incomplete.

33. Signs of spinal injury  Forehead wounds – think of hyperextension injury  Localized bruise  Deformities of spine - Priapism  Beevor’s sign – tensing the abdomen umbilicus moves upwards in D 10 lesions

34. Prehospital transfer  Awareness of the crew & by A&E staff  Modified left lateral position at scene  Kendrick or Russell’s extrication device  Scoop stretcher slotted together around the patient  Agitated patient left alone with hard collar  Repeated assessment enroute  Head down if they vomit  Remove objects from clothes to avoid pressure sores  Avoid opiates in high lesions  Avoid oral suction in tetraplegics – vagal reflex

35. Care in A&E  Careful manual handling especially if unconcious  Jaw thrust is safer  Correct gross spinal deformities  Call the anaesthetist if diaphragmatic paralysis or RR>35  Use flexible fibreoptic scopes in unstable fractures  Cathetrize to avoid overstretching of detrusor  IV fluids – paralytic ileus in first 48hrs.  Passive movements to rule out fractures  Small iv doses of opiates

36. Assessment  Document the level of injury  Rule out other injuries – DPL in abdominal injuries as there is paralytic ileus and absent peritioneal irritation.  Associated injuries in dorsal spine fracture are : - Renal injuries - Chest and Sternal injuries - Wide Mediatinum due to fracture haematoma. - Retroperitoneal injuries

37. Radiology  Be thorough – Adequacy, Alignment,Bones, Cartilages and soft tissues and distances  SCIWORA in kids  Low threshold for xray in rheumatoid & Ankylosing spond  Flexion injury common in lower cervical spine  Extension injury in upper cervical Spine  Junction of mobile & fixed part are prone to injury eg. C7 T1 & D12 L1.

38. Emergency treatment  ABCDE  Keep warm  Treat if BP<80mmHg & HR <50bpm  Spring loaded gardener wells calipers for traction  H2 Antagonists & Heparin  Methylprednisolone 30mg/kg iv bolus over 15min immediately  45minutes after the bolus a 5.4mg/kg/h infusion over 23 hrs in first 3 hours after the injury.  5.4mg/kg/hr for 47hrs if 4 - 8hrs following the injury.