Spinal Injury

1. Spinal Injury Dr Adrian Burger Senior Registrar Division of Emergency Medicine UCT/US 25 May 2007

2. Objectives Anatomy Stats Clinical Imaging Summary

3. Anatomy 1 Number of neurons in human spinal cord = 13,500,000Length of human spinal cord = 45 cm (male); 43 cm (female)Length of human vertebral column = 70 cm Length of cat spinal cord = 34 cmLength of rabbit spinal cord = 18 cm Weight of human spinal cord = 35 gm Weight of rabbit spinal cord = 4 gmWeight of rat spinal cord (400 gm body weight) = 0.7 gm Maximal Circumference of cervical enlargement = 38 mmMaximal Circumference of lumbar enlargement = 35 mm Pairs of Spinal Nerves = 31Number of Spinal Cord segments = 318 cervical segments 12 thoracic segments5 lumbar segments5 sacral segments1 coccygeal segment

4. Anatomy 2

5. Consequences Depends on Complete/Incomplete Level Stabilised Initial Management

6. Early Consequences Respiratory � apnoea, hypoventilation Cardiac - neurogenic shock triad - autonomic dysreflexia - hypotension C3-C5 Intercostals T1 �T4 >T6

7. Later consequences Bowel reflex or non-reflex dysfunction Bladder retention Bed sores Contractions

8. Causes of death Dysrhythmias, apnoea Pneumonia VTE Sepsis CHD

9. Neurology Most frequent level of injury is C5, then C4, C6, T12, C7, L1 Overall about half are cervical injuries Incomplete quadraplegia (34.3%) Complete quadraplegia (22.1%) Complete paraplegia (25.1%) Incomplete paraplegia (17.5%)

10. Incomplete lesions Anterior cord syndrome Corticospinal and spinothalamic pathways Loss of motor, pain and temperature below the level of the injury Preservation of position and vibration Key is potential reversibility of a haematoma or fragment Central cord syndrome Injury to the central portion of the spinal cord Greater involvement of upper extremities than lower Bowel or bladder control usually is preserved Hyperextension injury of cervical spine with a narrow cord space Can occur without fracture or ligamentous disruption

11. Incomplete lesions 2 Brown-S�quard syndrome Hemisection of the spinal cord, usually penetrating trauma Contralateral loss of pain and temperature Ipsilateral loss of motor and posterior column functions Cauda equina syndrome Injury to the lumbar, sacral, and coccygeal nerve roots Motor and sensory loss in the lower extremities Bowel and bladder dysfunction Saddle anaesthesia

12. Sacral Sparing & Spinal Shock Preservation of any function of the sacral roots, such as toe movement or perianal sensation Implies the chance of functional neurologic recovery is good Spinal shock is a temporary concussive-like condition in which cord-mediated reflexes, such as the anal wink, are absent Spinal shock also may result in bradycardia and hypotension. The extent of cord injury-and prognosis-cannot be determined until these reflexes return

13. Stats UK

14. Stats USA Vehicular crashes (50.4%) Falls (23.8%) Violence, primarily gunshot wounds (11.2%) Sports (9.0%) Other (5.6%)

15. General Stats Average age 16-30 Males 80% Life expectancy of someone with a SCI in Africa is 2-3 years 60 % of admitted patients have neurological deficits After the initial care require rehabilitation Average hospital stay for rehab of a paraplegic patient is 4 months, for quadriplegics 6 months Estimated that 2 000 SPINAL INJURIES are treated per annum NATIONALLY in the public sector ie, 1:20 000 of the population

16. Minister of Transport Jeff Radebe, (MP)at the 2006 Poor driver behaviour and attitude 95 % of crashes follow a traffic violation Our statistics reflect that 7 000 people involved in crashes are left permanently disabled every year. At least 650 of these have SCI

17. South Africa MRC 1999

18. Cape Metropole 2000

19. Trauma Injuries, Red Cross Children's Hospital1 April 1999 - 31 March 2000 (12 months) MVA���� ��Pedestrian745������Passenger - Restrained 18����Passenger - Unrestrained 106����Passenger - Bakkie/Minibus77����Cycle151����Motor Cycle 2����Other - Boat, Train, Plane, Horse25���� Total MVA ��1125 (16%)������ Assault������Blunt 126����Sharp25����Rape/Sexual 38����Human Bite 3����Other 33����Total Assault ��2253 Burns������Flame 117����Fluid 497����Heat Contact 37����Electrical 13����Chemical 21����Explosion 10����Other 11����Total -706 Falls��Off Ben 283����Stairs115����Attendants Arms 68����Playground Equipment 252����Mobiles93����Other Heights 613��Other Level 1071 ���Total - Falls ��2495 (35%) Struck by/against objects 688��Caught between objects 212����Sharp Instruments 250��Firearms42�Machinery9�Dogbite90�Other bite 7��� Immersion/drowning����Suffocation1����Food foreign body 33����Other foreign body 351����Other cause549��Unknown290����Total��7075��

20. X Ray or not? NEXUS No midline cervical tenderness No focal neurologic deficit Normal alertness No intoxication No painful distracting injury CCS Any high-risk factor?(i.e., age > 65, severe mechanism, or focal neurologic signs)? Can the patient be assessed safely for range of motion (simple mechanism, sitting position in the ED, ambulatory at any time, delayed onset of neck pain, or absence of midline cervical spine tenderness)? Can the patient actively rotate the neck 45 degrees to the left and the right?

21. Children Not validated in either study Small numbers of children Can�t assess under 2 years Rare injury in children

22. High risk PMH Elderly Rheumatoid arthritis Down's syndrome Osteoporosis Metastatic cancer

23. Low Risk Simple rear end Sitting in ED Ambulatory at any time Delayed onset of neck pain

24. Which X Rays? 3 View (LAT, AP, ODONTOID) in adults 2 View in children, ? 1 View Sensitivity 90% Add CT 99.9% sensitive 10% non-contiguous # incidence

25. Adjuvants Swimmers view CT scan MRI Flexion/Extension views

26. AP and LAT

27. AP & Odontoid

29. Measurements On Lateral view Soft Tissue ADI Swischuck�s Line

30. Mechanism of Injury Flexion type

31. Mechanisms of Injury Rotation/Flexion Lateral Flexion

32. Other mechanisms Axial Load Hyperextension

33. C5 on C6

34. L1 Compression Fracture

35. Lumbar Vertebral Body #

36. So why do we take �spinal precautions�? Never can tell� Preserve intact cord Cost

37. Log Roll Collar

38. It is AMUST to Suspect SCI! A = Airway B = Breathing C = Circulation D = Disability E = Exposure A = Altered mental state. Check for drugs or alcohol. M = Mechanism. Does the potential for injury exist? U = Underlying conditions. Are high risk factors for fractures present? S = Symptoms. Is pain, paresthesia, or neurologic compromise part of the picture? T = Timing. When did the symptoms begin in relation to the event?

39. Acute Treatment First treat life threatening conditions Then do no harm Spinal immobilise � 5% deteriorate A-B-C-D-E A-M-U-S-T Transport by air

40. Acute Medications O2 RSI � beware scoline Crystalloids � judiciously Atropine, pacemaker Inotropes Ganglioside GM-1, naloxone, CCB & glutamate receptor antagonists And��..

41. Steroids? Definitely not for penetrating trauma! Blunt trauma? 1975 First National Acute Spinal Cord Injury Study (NASCIS) established Followed by NASCIS 2 and NASCIS 3, which was completed in 1998 Bottom line��

42. Steroids Everyone wants to try and get just some benefit� So it�s not advocated as a standard of care but it is an option <8 hours Dosage 30mg/kg over 15 min + 5.4mg/kg/hour for 24 or 48 hours

43. Surgery Some unclear roles Some clear roles anterior cord syndrome thoracolumbar spine fracture/dislocation

44. Summary Suspect SCI and look for it Spinal precautions in vast majority Use and familiarize decision rules Use your common sense Examine your patient Ask for help

45. References www.drivinghome.co.uk/html/cj_injury.shtml http://www.worldortho.com/ http://www.playersfund.org.za/spineline/spineline.asp http://www.emedicine.com/emerg/topic553.htm http://www.doh.gov.za/mts/reports/spinal.html http://quad.stormnet.co.za/info.htm http://www.transport.gov.za/comm-centre/sp/2006/sp0907.html American Academy of Emergency Medicine: http://www.aaem.org/positionstatements/steroidsinacuteinjury.shtml American College of Surgeons: Advanced Trauma Life Support, 7th ed. Chicago, 2004 Canadian & American Spinal Research Organization Markovchick & Pons: Emergency Medicine Secrets 4E