Spine Unit , ORTHO-KKU

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Spinal Injury Spinal Cord Injury
For General Practice

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• Spine Unit , ORTHO-KKU

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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
• Common cervical spine fracture and dislocation

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Goal of spine trauma care

• Protect further injury during evaluation and
  management
• Identify spine injury or document absence of
  spine injury
• Optimize conditions for maximal neurologic
  recovery

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Goal of spine trauma care

• Maintain or restore spinal alignment
• Minimize loss of spinal mobility
• Obtain healed stable spine
• Facilitate rehabilitation

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Suspected Spinal Injury

• High speed crash
• Unconscious
• Multiple injuries
• Neurological deficit
• Spinal pain/tenderness

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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

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• PROTECTION ? PRIORITY
• Detection ? Secondary
• Log-rolling

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Pre-hospital management

• Cervical spine immobilization
• Transportation of spinal cord-injured patients

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Cervical spine immobilization

• Safe assumptions
• Head injury and unconscious
• Multiple trauma
• Fall
• Severely injured worker
• Unstable spinal column
• Hard backboard, rigid cervical collar and lateral
  support (sand bag)
• Neutral position

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Philadelphia hard collar
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Transportation of spinal cord-injured patients

• Emergency Medical Systems (EMS)
• Paramedical staff
• Primary trauma center
• Spinal injury center

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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

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Physical examination

• Information
• Mechanism
• ?energy, ?energy
• Direction of Impact
• Associated Injuries

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Is the patient awake or unexaminable?

• Whats the difference ?
• Awake
• ask/answer question
• pain/tenderness
• motor/sensory exam
• Not awake
• you can ask (but they wont answer)
• cant assess tenderness
• no motor/sensory exam

OW!
------
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• Unexaminable
• ?
• No exam

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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
• Do not forget the cranial nerve (C0-C1 injury)

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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

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Comparison of neurogenic and hypovolemic shock
Neurogenic Hypovolemic
Etiology Loss of sympathetic outflow Loss of blood volume
Blood pressure Hypotension Hypotension
Heart rate Bradycardia Tachycardia
Skin temperature Warm Cold
Urine output Normal Low
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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

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Neurologic assessment

• Spinal shock
• Bulbocavernosus reflex
• Complete VS incomplete cord injury
• ??????????? spinal shock ??????
• Sacral sparing
• Voluntary anal sphincter control
• Toe flexor
• Perianal sensation
• Anal wink reflex

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Neurologic assessment

• American Spinal Injury Association grade
• Grade A E
• American Spinal Injury Association score
• Motor score (total 100 points)
• Key muscles 10 muscles
• Sensory score (total 112 points)
• Key sensory points 28 dermatomes

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Incomplete cord injury

• Anterior cord syndrome
• Brown-Sequard syndrome
• Central cord syndrome

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Anterior cord syndrome

• Loss of motor, pain and temperature
• Preserved propioception and deep touch

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Brown-Sequard syndrome

• Loss of ipsilateral motor and propioception
• Loss of contralateral pain and temperature

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Central cord syndrome

• Weakness
• upper gt lower
• Variable sensory loss
• Sacral sparing

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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 34394-99
• Canadian C-Spine rules
• Prospective study whereby patients were evaluated
  for 20 standardized clinical findings as a basis
  for formulating a decision as to the need for
  subsequent cervical spine radiography
• Stiell I. JAMA. 2001 2861841-1846

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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

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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)

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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?
• Agegt65yrs or
• Dangerous mechanism or
• Paresthesia in extremities

NO
YES
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
NO
Radiography
YES
UNABLE
Able to actively rotate neck? 45 degrees left
and right
ABLE
No Radiography
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National Emergency XRadiography Utilization
Study(NEXUS)

The Canadian C-spine rule

• Both have
• Excellent negative predictive value for excluding
  patients identified as low risk

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Clearance of Cervical Spine Injury inConscious,
Symptomatic Patients

• 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

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Cervical Spine Imaging Options

• Plain films
• AP, lateral and open mouth view
• Optional Oblique and Swimmers
• CT
• Better for occult fractures
• MRI
• Very good for spinal cord, soft tissue and
  ligamentous injuries
• Flexion-Extension Plain Films
• to determine stability

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Radiolographic evaluation

• X-ray Guidelines (cervical)
• AABBCDS
• Adequacy, Alignment
• Bone abnormality, Base of skull
• Cartilage
• Disc space
• Soft tissue

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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

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Swimmers view
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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 gt3.5mm is
• significant anywhere

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Lateral Cervical Spine X-Ray

• Anterior subluxation of one vertebra on another
  indicates facet dislocation
• lt 50 of the width of a vertebral body ?
  unilateral facet dislocation
• gt 50 ? bilateral facet dislocation

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Bones
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Disc

• Disc Spaces
• Should be uniform
• Assess spaces between the spinous processes

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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)

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AP C-spine Films

• Spinous processes should line up
• Disc space should be uniform
• Vertebral body height should be uniform. Check
  for oblique fractures.

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Open mouth view

• Adequacy all of the dens and lateral borders of
  C1 C2
• Alignment lateral masses of C1 and C2
• Bone Inspect dens for lucent fracture lines

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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

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MRI

• Ideally all patients with abnormal neurological
  examination should be evaluated with MRI scan

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Management of SCI

• Primary Goal
• Prevent secondary injury
• Immobilization of the spine begins in the initial
  assessment
• Treat the spine as a long bone
• Secure joint above and below
• Caution with partial spine splinting

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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 lt9
• Increased RR with hypoxia
• PCO2 gt 50
• VC lt 10 mL/kg
• IV Access fluids titrated to BP 90-100 mmHg

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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 lt 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

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Principle of treatment

• Spinal alignment
• deformity/subluxation/dislocation ?reduction
• Spinal column stability
• unstable ? stabilization
• Neurological status
• neurological deficit ? decompression

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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

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Burst Fracture

• Fracture of C3-C7 from axial loading
• Spinal cord injury is common from posterior
  displacement of fragments into the spinal canal
• Unstable

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Clay Shovelers Fracture

• Flexion fracture of spinous process
• C7gtC6gtT1
• Stable fracture

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Flexion Teardrop Fracture

• Flexion injury causing a fracture of the
  anteroinferior portion of the vertebral body
• Unstable because usually associated with
  posterior ligamentous injury

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Bilateral Facet Dislocation

• Flexion injury
• Subluxation of dislocated vertebra of greater
  than ½ the AP diameter of the vertebral body
  below it
• High incidence of spinal cord injury
• Extremely unstable

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Hangmans Fracture

• Extension injury
• Bilateral fractures of C2 pedicles
• (white arrow)
• Anterior dislocation of C2 vertebral body (red
  arrow)
• Unstable

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Odontoid Fractures

• Complex mechanism of injury
• Generally unstable
• Type 1 fracture through the tip
• Rare
• Type 2 fracture through the base
• Most common
• Type 3 fracture through the base and body of axis
• Best prognosis

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Odontoid Fracture Type II
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Odontoid Fracture Type III
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Thank you for your attention