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Outline
Goal of spine trauma care Pre-hospital management Clinical and neurologic assessment Acute spinal cord injury
Term, type and clinical characteristic
Pre-hospital management
Protect spine at all times during the management of patients with multiple injuries Up to 15% of spinal injuries have a second (possibly non adjacent) fracture elsewhere in the spine Ideally, whole spine should be immobilized in neutral position on a firm surface
Log-rolling
Pre-hospital management
Cervical spine immobilization Transportation of spinal cord-injured patients
Hard backboard, rigid cervical collar and lateral support (sand bag) Neutral position
Clinical assessment
Advance Trauma Life Support (ATLS) guidelines Primary and secondary surveys Adequate airway and ventilation are the most important factors Supplemental oxygenation Early intubation is critical to limit secondary injury from hypoxia
Physical examination
Information Mechanism
energy, energy
OW!
------
Unexaminable
No exam
Physical examination
Inspection and palpation
Occiput to Coccyx Soft tissue swelling and bruising Point of spinal tenderness Gap or Step-off Spasm of associated muscles
Neurological assessment
Motor, sensation and reflexes PR
Neurogenic Shock
Temporary loss of autonomic function of the cord at the level of injury
results from cervical or high thoracic injury
Presentation
Flaccid paralysis distal to injury site Loss of autonomic function hypotension vasodilatation loss of bladder and bowel control loss of thermoregulation warm, pink, dry below injury site bradycardia
Comparison of neurogenic and hypovolemic shock Neurogenic Etiology Blood pressure Heart rate
Skin temperature
Hypovolemic
Loss of sympathetic Loss of blood volume outflow Hypotension Bradycardia Warm Normal Hypotension Tachycardia Cold Low 18
Urine output
Definitions of terms
Neurologic level
Most caudal segment with normal sensory and motor function both sides
Skeletal level
Radiographic level of greatest vertebral damage
Complete injury
Absence of sensory and motor function in the lowest sacral segment
Incomplete injury
Partial preservation of sensory and/or motor function below the neurologic level
Neurologic assessment
Spinal shock
Bulbocavernosus reflex
Neurologic assessment
American Spinal Injury Association grade
Grade A E
Brown-Sequard syndrome
Loss of ipsilateral motor and propioception Loss of contralateral pain and temperature
Radiographic imaging
Who needs an x- ray of the spine ?
NEXUS -The National Emergency X- Radiograph Utilization Study
Prospective study to validate a rule for the decision to obtain cervical spine x- ray in trauma patients Hoffman, N Engl J Med 2000; 343:94-99
NEXUS
NEXUS Criteria: 1. Absence of tenderness in the posterior midline 2. Absence of a neurological deficit 3. Normal level of alertness (GCS score = 15) 4. No evidence of intoxication (drugs or alcohol) 5. No distracting injury/pain
NEXUS
Patient who fulfilled all 5 of the criteria were considered low risk for C-spine injury No need C-spine X-ray For patients who had any of the 5 criteria radiographic imaging was indicated ( AP, lateral and open mouth views)
The Canadian C-spine Rule for alert and stable trauma patients where cervical spine injury is a concern.
Any high-risk factor that mandates radiography? Age>65yrs or Dangerous mechanism or Paresthesia in extremities
NO
Any low-risk factor that allows safe assessment of range of motion? Simple rear-end MVC, or Sitting position in ER, or Ambulatory at any time, or Delayed onset of neck pain, or Absence of midline C-spine tenderness
YES NO Radiography
YES
Able to actively rotate neck? 45 degrees left and right
UNABLE
ABLE No Radiography
&
The Canadian C-spine rule
Both have: Excellent negative predictive value for excluding patients identified as low risk
Clearance of Cervical Spine Injury in Conscious, Symptomatic Patients 1. Radiological evaluation of the cervical spine is indicated for all patients who do not meet the criteria for clinical clearance as described above 2. Imaging studies should be technically adequate and interpreted by experienced clinicians
CT
MRI
Very good for spinal cord, soft tissue and ligamentous injuries
Radiolographic evaluation
X-ray Guidelines (cervical)
AABBCDS
Adequacy, Alignment Bone abnormality, Base of skull Cartilage Disc space Soft tissue
Adequacy
Must visualize entire C-spine A film that does not show the upper border of T1 is inadequate Caudal traction on the arms may help If can not, get swimmers view or CT
Swimmers view
Alignment
The anterior vertebral line, posterior vertebral line, and spinolaminar line should have a smooth curve with no steps or discontinuities Malalignment of the posterior vertebral bodies is more significant than that anteriorly, which may be due to rotation A step-off of >3.5mm is significant anywhere
Bones
Disc
Disc Spaces
Should be uniform
Soft tissue
Nasopharyngeal space (C1) 10 mm (adult) Retropharyngeal space (C2-C4) 5-7 mm Retrotracheal space (C5-C7) 14 mm (children) 22 mm (adults)
AP C-spine Films
Spinous processes should line up Disc space should be uniform Vertebral body height should be uniform. Check for oblique fractures.
CT Scan
Thin cut CT scan should be used to evaluate abnormal, suspicious or poorly visualized areas on plain film The combination of plain film and directed CT scan provides a false negative rate of less than 0.1%
MRI
Ideally all patients with abnormal neurological examination should be evaluated with MRI scan
Management of SCI
Primary Goal
Prevent secondary injury
Management of SCI
Spinal motion restriction: immobilization devices ABCs
Increase FiO2 Assist ventilations as needed with c-spine control Indications for intubation : Acute respiratory failure GCS <9 Increased RR with hypoxia PCO2 > 50 VC < 10 mL/kg IV Access & fluids titrated to BP ~ 90-100 mmHg
Management of SCI
Look for other injuries: Life over Limb Transport to appropriate SCI center once stabilized Consider high dose methylprednisolone
Controversial as recent evidence questions benefit Must be started < 8 hours of injury Do not use for penetrating trauma 30 mg/kg bolus over 15 minute After bolus: infusion 5.4mg/kg IV for 23 hours
Principle of treatment
Spinal alignment
deformity/subluxation/dislocation reduction
Neurological status
neurological deficit decompression
Jefferson Fracture
Burst fracture of C1 ring Unstable fracture Increased lateral ADI on lateral film if ruptured transverse ligament and displacement of C1 lateral masses on open mouth view Need CT scan
Burst Fracture
Fracture of C3-C7 from axial loading Spinal cord injury is common from posterior displacement of fragments into the spinal canal Unstable
Hangmans Fracture
Extension injury Bilateral fractures of C2 pedicles (white arrow) Anterior dislocation of C2 vertebral body (red arrow) Unstable
Odontoid Fractures
Complex mechanism of injury Generally unstable Type 1 fracture through the tip
Rare