Spine and Spinal Cord Trauma

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

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

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

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

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

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