1. Spine and Spinal Cord Trauma

2. 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

3. Suspected Spinal Injury High speed crash Unconscious Multiple injuries Neurologic deficit Spinal pain/tenderness

4. 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

5. 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

6. Sensory Examination Levels vs sensation

7. Motor Examination Table outlining levels

8. Neurogenic Shock Hypotension associated with cervical/high thoracic spine injury Bradycardia Tx: fluid, atropine, pressors

9. Spinal Shock Neurologic, not hemodynamic phenomenon Occurs shortly after cord injury Flaccidity Loss of reflexes

10. Effects on other organ systems Inadequate ventilation Compromised abdominal evaluation Occult compartment syndrome

11. Classification of Injuries: Levels of injury Clinical exam Most caudal Normal bilaterally Motor/sensory function Bony = site of vertebral damage

12. Classification Incomplete –Any sensation –Position sense –Voluntary movement in lower extremity –Sacral sparing Complete –No motor/sensory function –No sacral sparing –May have reflexes

13. Spinal Cord Syndromes Central Anterior Brown-sequard Anatomy diagram

14. Classifications: morphology Fracture or fracture dislocation SCIWORA Penetrating

15. Classification: morphology Unstable if: –Xray evidence of injury –Neurologic injury –Severe pain on spine movement or palpation

16. Xray Guidelines A B C D S Normal C spine Xray

17. C spine Xrays Cross table lateral detects 85% Additional 2 views excludes most fractures May also require: –Swimmer’s –CT –Flex/ex –MRI

18. Cspine Xrays 10% have a second fracture Look for second fracture! One fracture mandates full spine films

19. Xray Guidelines Adequacy Alignment Bones Cartilage Contours Disc space Soft tissue Thoracolumbar spine Xray

20. Screening for Spinal Injury Algorithim –Paraplegia/quadraplegia –Presumed spinal instability –Identify bony fracture-subluxation –Consult neurosurgery or orthopedics

21. 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

22. 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

23. Screening for spinal injury Altered LOC –Complete spine films –Plain films –CT prn

24. Screening for Spinal Injury Radiographic –Normal Xray Clinical –Normal neurologic exam and –Absence of spinal pain/tenderness Caution! –Drugs, alcohol, distracting injuries

25. Management Immobilization –Entire patient –Propper padding –Maintain until cleared –Avoid prolonged use of backboard Decubitus ulcer

26. Medical Management Ensure A/B Maintain BP Atropine prn Methylprednisolone

27. Medical Management Intravenous fluids –Treat hypovolemia first –Consider neurogenic shock –Insert foley

28. Medical Management Steroids –Methylpred doses

29. Medical Management Transfer –Unstable fractures –Neurologic deficit –Avoid delay –Proper immobilization –Respiratory support as needed

30. Questions

31. Summary Treat life-threatening injuries first (ABCD) Immobilization Appropriate Xrays Document examination Consultation Transfer