Spine and Spinal Cord Trauma

ObjectivesAnatomy/physiologyEvaluate a patient with spinal injuryIdentify common spinal injuries and Xray featuresAppropriately manage the spinal-injured patientDetermine appropriate disposition

Suspected Spinal InjuryHigh speed crashUnconsciousMultiple injuriesNeurologic deficitSpinal pain/tenderness

Spinal injury5% worsen neurologically at hospitalProtection is a priorityDetection is a secondary prioritySpinal evaluation complicated by TBIRemove spine boards ASAP

Cord Injury SeverityComplete = no motor function or sensory function below the injury levelIncomplete = any preservation of functionSacral sparing may be the only preservation of function

Sensory ExaminationLevels vs sensation

Motor ExaminationTable outlining levels

Neurogenic ShockHypotension associated with cervical/high thoracic spine injuryBradycardiaTx: fluid, atropine, pressors

Spinal ShockNeurologic, not hemodynamic phenomenonOccurs shortly after cord injuryFlaccidityLoss of reflexes

Effects on other organ systemsInadequate ventilationCompromised abdominal evaluationOccult compartment syndrome

Classification of Injuries: Levels of injuryClinical examMost caudalNormal bilaterallyMotor/sensory functionBony = site of vertebral damage

ClassificationIncompleteAny sensationPosition senseVoluntary movement in lower extremitySacral sparingCompleteNo motor/sensory functionNo sacral sparingMay have reflexes

Spinal Cord SyndromesCentralAnteriorBrown-sequardAnatomy diagram

Classifications: morphologyFracture or fracture dislocationSCIWORAPenetrating

Classification: morphologyUnstable if:Xray evidence of injuryNeurologic injurySevere pain on spine movement or palpation

Xray GuidelinesAABBCCDSNormal C spine Xray

C spine XraysCross table lateral detects 85%Additional 2 views excludes most fracturesMay also require:SwimmersCTFlex/exMRI

Cspine Xrays10% have a second fractureLook for second fracture!One fracture mandates full spine films

Xray GuidelinesAdequacyAlignmentBonesCartilageContoursDisc spaceSoft tissueThoracolumbar spine Xray

Screening for Spinal InjuryAlgorithim Paraplegia/quadraplegiaPresumed spinal instabilityIdentify bony fracture-subluxationConsult neurosurgery or orthopedics

Screening for Spinal InjuryAlert, sober neurologically normal patient:No neck pain or tendernessNo distracting injuryNo pain with voluntary movementNo further Xrays required

Screening for spinal injuryAlert, sober, neurologically normal patientNeck or spin pain or tenderness to palpation or voluntary movementAfter removal of c-collar?If yes to any questionProtect cspine Obtain necessary Xray exams

Screening for spinal injuryAltered LOCComplete spine filmsPlain filmsCT prn

Screening for Spinal InjuryRadiographicNormal XrayClinicalNormal neurologic exam andAbsence of spinal pain/tendernessCaution!Drugs, alcohol, distracting injuries

ManagementImmobilizationEntire patientPropper paddingMaintain until clearedAvoid prolonged use of backboardDecubitus ulcer

Medical ManagementEnsure A/BMaintain BPAtropine prnMethylprednisolone

Medical ManagementIntravenous fluidsTreat hypovolemia firstConsider neurogenic shockInsert foley

Medical ManagementSteroidsMethylpred doses

Medical ManagementTransferUnstable fracturesNeurologic deficitAvoid delayProper immobilizationRespiratory support as needed

Questions

SummaryTreat life-threatening injuries first (ABCD)ImmobilizationAppropriate XraysDocument examinationConsultationTransfer