Evaluation of Spinal Injury & Emergency Management
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Transcript of Evaluation of Spinal Injury & Emergency Management
Dr. Atif Shahzad
PGR Orthopaedic, SHL
Spinal injury” may be defined as-Injury to the Spinal
column (Bony Column)/Spinal Cord, or both of them.
can be divided into-
Spinal Column Injury.
Spinal Cord Injury.
Combined (Both Column & Cord) Injury.
Traumatic Spinal Cord Injury accounts for 12,000 new cases each year.
Mortality/Morbidity◦ 94% of patients survive the initial hospitalization
◦ Life Expectancy is greatly reduced. Renal Failure ,leading cause of death in the past.
Currently, Pneumonia, Pulmonary Emboli, and septicemia are the major causes.
Commonly men 16–30 years old (M:F Ratio 4:1)
Mechanism of Injury◦ Vehicle crashes: 40.4%
◦ Falls: 27.9%
◦ Penetrating trauma: 15%
◦ Sports injury: 8%
Most common vertebrae involved are
C5, C6, C7, T12, and L1 because of greatest ROM.
25% of all spinal injuries occur from improper handling of the
spine and patient after injury.
The spinal cord can be
divided into three columns:
◦ Anterior
◦ Middle
◦ Posterior.
Spinal stability is dependent
on at least two intact
columns.
When two of the three
columns are disrupted, it
will allow abnormal
segmental motion, i.e.
instability.
CERVICAL SPINE INJURIES
55% in cervical region
C-spine very flexible
Mobile & exposed
Most frequently injured area of
spine
Most injuries at C-5/C-6 level
15% in thoracic region
Less mobile & protected
Narrow spinal canal
Cord injury with minimal
displacement
Common mechanisms
Any cord damage usually
complete at this level
Most T-spine injuries occur at
T-9/T-10
15% in thoracolumbar region
Fulcrum
Transition zone prone to injury
15% in lumbosacral region
LS spine flexible nerve roots
in roomy spinal canal
May have bony injury w/o
cord or nerve root damage
Secondary injury still possible
Neurological injury rare with
isolated sacral injuries
Upper Cervical Region
Designed to facilitate motion
Canal is spacious.
Injury is uncommon
Cervicothoracic Junction
Transitional zone from mobile to fixed
Prone to injury.
Thoracic Spine
Rigid because of stabilizing influence of the thorax.
Associated vascular and visceral injuries are common.
The Thoracolumbar Junction
Transitional zone and also prone to injury.
Spinal cord injury may be categorized as:
Incomplete Quadriplegia (incomplete cervical injury)-39.5%
Complete Quadriplegia-16.3%
Incomplete paraplegia (incomplete thoracic injury)-21.7%
Complete paraplegia-22.1%
Spinal injuries can be described as:
1. Fractures
2. Fracture – dislocations
3. Spinal cord injury without radiographic abnormalities
4. Penetrating injuries
These injuries can be further categorized as stable or unstable.
Stable Injuries◦ Vertebral components won’t be displaced by normal
movement.
◦ An undamaged spinal cord is not in danger.
◦ There is no development of incapacitating deformity or pain.
Unstable Injuries◦ Further displacement of the injury may occur.
◦ Loss of 50% of vertebral height.
◦ Angulation of thoracolumbar junction of > 20 degrees.
◦ Failure of at least 2 of Denis’s 3 columns.
◦ Compression fracture of three sequential vertebrae can lead to post traumatic kyphosis.
Pattern:A.
Primary lesion occur between C5 & C7 with secondary
injuries at T12 or the lumber spine.
Pattern:B.
Primary injury at T2-T4 with secondary injury in cervical
spine.
Pattern:C.
Primary injury occur between T12 & L2 with secondary
injuries from L4-L5.
The Primary Injury
When the skeletal structures fail to dissipate the energy of the primary mechanical insult.
Direct trauma & energy transfer to neuronal elements.
Haematoma & SCIWORA < 8yrs old
In 4hrs -Infarction of white matter occurs
In 8hrs -Infarction of grey matter and irreversible paralysis.
The Secondary Injury
Hypoxia
Hemorrhage & Hypoperfusion
Oedema
Neurogenic shock secondary to the insult.
Therapeutic strategies are directed at reducing secondary injury.
Hyperextension:
Common in the neck
Anterior ligaments and disc may be damaged.
Hyperflexion:
If posterior ligament is intact , wedging of vertebral body
occurs. If torn , may cause subluxation.
Axial compression:
Causes burst fractures. Bony fragments may be pushed
into spinal canal.
Flexion with rotation:
Causes dislocation with or without fracture.
Flexion with posterior distraction:
May disrupt middle and posterior column
Bony spinal injuries may or may not be associated with spinal cord injuryBony injuries include:
◦ Compression fractures ◦ Comminuted fractures ◦ Subluxation (partial dislocation)
Other injuries may include:
◦ Sprains, over-stretching or tearing of ligaments◦ Strains, over-stretching or tearing of the muscles
Alcohol intoxication
Drug abuse
High-risk activities
Diving
Contact sports
Osteoporosis
Approach every patient in the same manner using
Advanced Trauma Life Support Principles
(ATLS).
Assume every trauma patient has a spinal injury until
proven otherwise.
All Assessment, Resuscitation and life saving
procedures must be performed with full
immobilization.
◦ Polytrauma patient
◦ Compression injury (diving, fall on buttock)
◦ Neurological Deficit
◦ Multiple Injuries
◦ Head Injuries & unconsciousness
◦ Facial Injury
◦ High energy Injury
◦ Blunt Trauma Abdomen
◦ Abdominal Bruising from a seatbelt.
◦ Spinal pain/tenderness
Activate trauma team.
Move patient off spinal board as soon as clinically safe
Airway maintenance with C-spine immobilization
Definitive airway early if respiratory compromise
Injury higher than C6 need intubation and ventilation)
Maintain hard collar, sandbag/bolsters and tape
Breathing and Ventilation
Oxygen + ventilator support
Monitor RR, respiratory effort, cough
Circulation with haemorrhage control
If hypotension – hypovolaemic vs neurogenic
shock
Assume hypovolaemia 1st : search for source blood
loss + replace fluids
- If SC injury: guide fluid replacement with CVP
monitoring (controversial)
- Inotropes may be required
- Before IDC – perform rectal examination and
assess rectal sphincter tone and sensation
Disability
- GCS /pupils
- Look for paralysis/paresis/priapism/anal sphincter tone/
bulbocavernosus reflex
Exposure/Environment
– Keep warm (blankets, fluid warmer)
Peripherally vasodilated, unable to regulate temp
if injury above T4
Full non invasive monitoring
ECG
Trauma X-ray series – lateral cervical spine, chest, pelvis
Bedside FAST scan (sources of bleeding)
NGT
IDC
Focused AMPLE Hx
Ask
Mechanism
Does your neck or back hurt?
Can you feel me touching your fingers and toes?
Can you move your hands and feet?
Assess full spine
A. Log roll and palpate spine/ paraspinal region
look for deformity/ crepitus/pain/contusions
/penetrating wounds
B. Assess for pain, paralysis and parasthesia
Location
Neurological level
Test sensation
Test motor function
Test deep tendon reflexes
DOCUMENT carefully and REPEAT
Head to toe examination – assess for associated injuries
Advanced spinal imaging:
- CT scan (defines bony injury)
- MRI scan (defines neurological injury)
Consider CVP monitoring.
◦ Spine Log Roll must be
performed to achieve
proper examination.
◦ Inspect and palpate entire
spine.
◦ Swelling, tenderness,
palpable steps or gaps
suggest a spinal injury.
◦ Note the presence of any
wounds that might
suggest penetrating
trauma.
American Spinal Injury Association neurological evaluation
system is used.
◦ Motor Function assesses key muscle groups. Grade (0-5)
◦ Sensory Function assesses dermatomal map. Pinprick and
light touch Score: 0-2
Important dermatome landmarks are
Nippleline–T4
Xiphoidprocess-T7
Umbilicus–T10
Inguinalregion–T12,L1
Perineum and perianal region (S2,S3&S4)
◦ Deep Tendon Reflexes
◦ Rectal examination:
Anal tone.
Voluntary anal contraction.
Perianal sensation.
What should be known after complete neurological
examination?
◦ Presence or absence of neurological injury.
◦ Probable level of injury.
◦ Injury is complete or incomplete.
◦ Level of impairment.
Pain (and bony tenderness on examination)
Tingling, numbness and weakness in peripheries
Loss of sensation or paralysis below level of injury
Impaired breathing – C3/4/5 (diaphragm)
Incontinence
Priapism
“Level" of cord lesion is conventionally the most caudal location with normal motor and sensory function.
Motor level = the last level with at least 3/5 (against gravity) function
This is the most important for clinical purposes
Sensory level = the last level with preserved sensation
Radiographic level = the level of fracture on plain X-Rays/ CT scan / MRI
Spine level does not correspond to spinal cord level below the cervical region.
Loss of neural tissue –obvious.
Vertical level –Higher up, greater the damage.
Transverse plane –What Diameter has a lesion.
Spinal shock may mimic a complete cord lesion with total loss
of motor & sensory function distal to injury. However if lesion
is incomplete some function will return
99% of patients with a complete lesion over 24 h will not
show functional recovery
Patients with partial lesion may regain substantial or even
normal neurological function even though the initial
neurological deficit may be severe
Presence of bulbocavernousreflex or anal-cutaneous reflex
indicates sacral sparing and a more favorable prognosis.
The bulbocavernosus
reflex (BCR) is a
polysynaptic reflex
that is useful in testing
for spinal shock and
gaining information
about the state of
spinal cord injuries
(SCI)
BULBOCAVERNOSUS REFLEX
LOCATION OF INJURY
POSSIBLE EFFECTS
At or above C5 Respiratory paralysis and quadriplegia
Between C5& C6 Paralysis of legs, wrists, and hands; weakened shoulder abduction and elbow flexion; loss of brachioradialis reflex
C6-C7 Paralysis of legs, wrists, and hands, but shoulder movement and elbow flexion usually possible; loss of biceps jerk reflex
C7-C8 Paralysis of legs and hands
C8-T1 With transverse lesions, Horner's syndrome (ptosis, miotic pupils, facial anhidrosis), paralysis of legs
T1-T12 Paralysis of leg muscles above and below the knee
At T12 to L1 Paralysis below the knee
Cauda equina Hyporeflexic or areflexic paresis of the lower extremities, usually pain and hyperesthesia in the distribution of the nerve roots, and usually loss of bowel and bladder control
At S3-S5 or conus medullaris at L1
Complete loss of bowel and bladder control
Level Of Muscle Group
C5 Elbow flexors (biceps, brachialis)
C6 Wrist extensors (extensor carpi radialis longus and
brevis)
C7 Elbow extensors (triceps)
C8 Finger flexors (flexor digitorum profundus to middle
finger)
T1 Small finger abductors (abductor digiti minimi)
L2 Hip flexors (iliopsoas)
L3 Knee extensors (quadriceps)
L4 Ankle dorsiflexors (Tibialis anterior)
L5 Long toe extensors (extensor hallucis longus)
S1 Ankle plantar flexors (gastrocnemius, soleus)
85% of significant spinal injuries will be seem on standard lateral cervical spine.
CT Scan should be obtained. ◦ Most Sensitive in spinal trauma. ◦ Complex patterns and fractures can be understood.
MRI◦ Best at visualizing soft-tissue elements of the spine. ◦ Possible to view spinal cord hemorrhage, epidural and
prevertebral hematomas. ◦ Not good at assessing bony structures.
In spinal traumas radiographs and CT scans usually give sufficient information and MRI is not required.
Spinal cord injury without radiographic or CT evidence of
fracture or dislocation
With advent of MRI, term has become
"Spinal cord injury without neuroimaging abnormality" more
correct name.
Mostly in pediatric population ( Birth to 16 years)
Common in cervical and thoracic region
Following findings on MRI have been recognized as
causing primary or secondary spinal cord injury:
-Intervertebral disk rupture
-Spinal epidural hematoma
-Cord contusion
-Hematomyelia
Prognosis of SCIWORA is actually better than patients
with spinal cord injury and radiologic evidence of
traumatic injury.
Objectives Stabilize the spine.
To prevent further trauma
Preserve neurological function.
Relieve reversible nerve or cord compression.
To observe symptoms of progressive neurologic deficit.
To improve sensory and perceptual awareness
Prevention of complications
Promote comfort
Rehabilitate the patient.
An important goal is to prevent secondary injury to the spine or spinal cord.
Emergency Department acute care is to avoid
secondary spinal injury
Protection Priority
Detection Secondary
1. Immobilization
2. Intravenous fluids
3. Medications
4. Early advise, prompt referral/
transfer
Fluid resuscitation
• Maintenance fluids only unless shock ,MAP 85-90 mmHg
• If shocked – establish if hypovolaemic OR neurogenic
Insert IDC
• Monitor urinary output
• Prevent bladder distension
Insert NGT
• Prevent gastric distension (+/- paralytic ileus)
• Prevent aspiration (sphincter paralysis)
Medications Corticosteroids - insufficient evidence for routine use
Reducing extent of permanent paralysisHigh dose methylprednisoloneImproved motor neurological outcome if given within 8 hours.Given as bolus dose and then IV infusion for 24-48 hours
- 24 hour IVI if Tx within 3 hours of injury- 48 hours IVI if Tx within 3-8 hours of injury
Increased risk of sepsis due to immunosuppressive effectsCI: heavily contaminated open injuries, perforated bowel, sepsis
Consult with spinal specialist.
AnalgesiaOpiates and NSAIDS.
The goals of operative treatment Decompress the spinal cord canal
Stabilize the disrupted vertebral column.
Fixation of Vertebra
Fixation of Spine
Artificial disc implantation.
The 4 basic types of stabilization procedures are 1. Posterior lumbar interspinous fusion,
2. Posterior rods
3. Cage
4. The Z-plate anterior thoracolumbar plating system. Each has different advantages and disadvantages.
With no neurological deficit:
If stable-pain relief , collar or brace.
If unstable-reduce and hold secure until bone / ligaments heal with surgery or traction.
With complete sensory or motor loss:
Usually an unstable injury
Only consider conservative management for high thoracic injuries.
Early operative stabilization to help with nursing , prevent spinal deformity and pain.
Speeds up rehab.
With incomplete neurological loss:
Stable injury-conservative bed rest , brace.
Unstable injury-early reduction and stabilization.
COMPLETE Neurology
Total flaccid paralysis
Total anaesthesia
Total analgesia
No tendon reflexes
MUST WAIT UNTIL SPINAL SHOCK RESOLVED to diagnose
INCOMPLETE Neurology
Partial paralysis
Altered sensation (light touch or pin prick)
Sacral sparing
BETTER prognosis, may recover
Improperly sized C-Collar
Spine not supported due to improper positioning on
backboard
Inadequate strapping allows excessive movement
Movement possible due to little or no padding to shim the
body
C-spine movement by inadequate or improperly applied
head immobilization device
C-spine hyperextension due to improperly applied C-collar
or head immobilization devicE
Readjusting torso straps after immobilization of the head,
causing misalignment of the spine
Securing head to backboard prior to securing shoulders,
torso, hips, and legs
THANKS