Spine and Spinal Trauma

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Spine and Spinal Trauma

• Rebecca Burton-MacLeod
• R1, Emergency Medicine
• Aug 21, 2003

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Numbers

• 10,000 new cases each year in US
• over 1 million pts with blunt trauma and
  potential c-spine injury seen in US EDs
• of these pts, lt1 have acute or spinal injury
• SIGNIFICANT CONSEQUENCES!

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Who?

• Age gt65
• male
• white or other ethnicity

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How?

• MVA 50
• falls 20
• sporting accidents 15
• remainder from acts of human violence
• predisposing factors--arthritic disease, OP, Ca

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Anatomy.oh no!

• 33 vertebrae--7cervical, 12thoracic, 5lumbar,
  5sacral (fused), 4coccyx (fused)
• intervertebral discs separate them, and ligaments
  support
• spinal cord goes from midbrain to L2 level
• anterior column (vertebral bodies, discs,
  ant/post longitudinal ligs) and posterior column
  (pedicles, transverse processes, facets, laminae,
  spinous processes, spinal canal, nuchal/capsular
  ligs, ligamentum flavum)

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Spinal column
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Million question...

• Stable--disruption of only one of ant/post
  columns
• vs
• unstable--disruption of both columns at same
  level OR c1/2

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Classification of spinal column injuries

• Flexion
• extension
• flexion-rotation
• vertical compression

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Flexion injuries
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Flexion injuries

• Wedge
• teardrop

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Flexion injuries

• Clay shoveller (lat)
• clay shoveller (AP)

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Flexion injuries

• Bilateral facet dislocation

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Extension injuries
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Extension injuries

• Extension teardrop

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Extension injuries

• Hangmans

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Flexion-rotation injuries
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Flexion-rotation injuries

• Unilateral facet disloc

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Vertical compression injuries
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Vertical compression injuries

• Burst

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Vertical compression injuries

• Jefferson

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Spinal cord injuries

• Primary--mechanical disruption of axons as result
  of stretch, laceration, or vascular injury
• vs
• secondary--progressive injury caused by free
  radical formation, uncontrolled calcium influx,
  ischemia, lipid peroxidation

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Secondary spinal cord injuries

• Reversible/preventable factors
• hypogylcemia
• hypoxia
• hypotension
• hyperthermia
• mishandling by medical personnel

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Spinal cord injuries

• Complete--total loss of motor power and sensation
  distal to lesion
• vs
• incomplete--3 syndromes (central cord, anterior
  cord, Brown-Sequard), SCIWORA

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Complete spinal cord injuries

• If lasts gt24hrs, 99 will have no functional
  recovery
• must look for any evidence of cord function
• sacral sparing is key!
• Ddx spinal shock
• cannot diagnose complete injury until
  bulbocavernosus reflex is elicited

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Incomplete spinal cord injuries
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Incomplete spinal cord injuries

• Central cord syndrome
• affect upper extremitiesgtlower extremities
• 50 of patients with a severe central cord
  syndrome have a return of bowel and bladder
  control, become ambulatory, and regain some hand
  function
• may mimic complete cord injury

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Incomplete spinal cord injuries

• Anterior cord syndrome
• caused by
• cervical flexion injuries causing cord contusion
• protrusion of a bony fragment or herniated
  intervertebral disk into the spinal canal
• laceration or thrombosis of the anterior spinal
  artery
• systemic embolization or prolonged cross-clamping
  of the aorta

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Anterior cord s/o contd

• paralysis below level of injury
• hypalgesia below the level of injury
• preservation of posterior column functions
  (position, touch, and vibratory sensations)

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Incomplete spinal cord injuries

• Brown-Sequard syndrome
• hemisection of spinal cord
• often due to penetrating trauma, or may be due to
  of lat mass of c-spine
• ipsilateral paralysis and contralateral sensory
  hypesthesia below level of injury
• most retain bladder/bowel control

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SCIWORA

• Usually lt8yrs of age following c-spine injury
  no injury seen on complete plain radiographic
  series
• possibly due to immature anatomy and increased
  ligamentous elasticity
• causes transient spinal column subluxation,
  stretching of the spinal cord, and variable
  degrees of vascular compromise

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SCIWORA contd

• brief episode of upper extremity weakness or
  paresthesias, followed by the development of
  neurologic deficits that appear hours to days
  later

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on exam

• Vitals, GCS
• inspection--facial contusions, head injuries,
  trunk contusions, obvious deformities/penetrating
  injuries
• palpation--spine for step-off deformity, widened
  interspinous space
• neuro exam

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Motor exam
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Deep tendon reflexes

• UMN--present reflexes (but may be absent acutely
  during spinal shock)
• LMN--absent reflexes

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Sensory function

• Light touch--posterior column function
• painful touch--anterior spinothalamic function

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Investigations

• Plain radiography
• CT
• MRI

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Radiography

• NEXUS
• 34,069 pts with blunt trauma
• 818 pts with c-spine injuries
• sensitivity 98.0-99.6, specificity 12.9
• 23 pts (3 potentially unstable) had injuries not
  visualized on radiography (2.81 of all pts with
  radiography performed)

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Radiography

• NEXUS criteria for c-spine xrays
• all 5 criteria must be met, or else xray
• absence of midline tenderness
• normal alertness
• no evidence of intoxication
• no focal neurological deficit
• no painful distracting injuries
• poorly reproducible

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Radiography

• Canadian C-spine rules
• 8924 pts enrolled with trauma to head/neck,
  stable vitals, GCS15
• excluded pts--lt16yrs, penetrating trauma, known
  vertebral disease
• 151 clinically important c-spine injuries (1.7)
• sensitivity 100, specificity 42.5
• identified 27 of 28 unimportant c-spine injuries
  (missed c3 avulsion )
• potential radiography rate 58.2 (down from
  68.9!!)

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Radiography

• Canadian c-spine rules for radiography
• high risk factors? (gt65yrs, dangerous mechanism,
  paresthesias)
• must have radiography
• low risk factors? (simple rear-end MVC, sitting
  in ED, ambulatory since injury, delayed onset
  pain, absence midline c-spine tenderness)
• then may assess range of motion
• rotate neck to left and right? (45degrees both
  directions)
• do not require radiography

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Radiography

• Standard trauma series (Carolines excellent
  review!!)
• lateral
• AP
• open-mouth odontoid
• oblique view--posterior laminar fracture, a
  unilateral facet dislocation, or a real
  subluxation
• flexion-extension views--if severe pain but
  normal 3views

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CT

• Indications
• inadequate radiography (as high as 25 for
  visualization of c7-t1)
• suspicious radiography findings
• fracture/displacement demonstrated by standard
  radiography
• high clinical suspicion of injury, despite normal
  radiography
• pts undergoing CT of head/abdomen may be
  considered

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CT

• Pros
• evaluate spinal canal
• evaulates paravertebral soft tissues
• limited movement required

• Cons
• limited views of vert body displacement
• poor visualization of horizontal
• overcome by spiral CT

May eventually replace radiography, but not
current standard of care as initial investigation
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CT

• right lateral mass

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MRI

• Excellent for evaluation of neurological injury
• useful for ligamentous injury, bony compression,
  epidural and subdural hemorrhage, and vertebral
  artery occlusion

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MRI

• C-spinal cord hemorrhage

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Management Goals

• Preservation of pts life
• optimizing potential for recovery of neurologic
  function

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Management

• Prehospital
• high index of suspicion
• spinal immobilization--c-collar and backboard
  with sandbags and tape

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ED Management

• ABCs
• above level of c3 often loss of resp drive
• avoid hyperextension of neck if intubation
  necessary
• above level of t6 often functional
  sympathectomy--systemic hypotension
• treat with Trendelenburg position and crystalloid
  infusion

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ED Management

• Pharm (NASCIS II and III)
• 487 pts--overall analysis negative
• 193 pts--positive effect post hoc analysis
• modest improvement in functional recovery at 1yr
• loading dose 30mg/kg IV within 8hrs of injury
• if loading dose started within 3hrs, then
  5.4mg/kg/h IV drip for 24hrs
• if loading dose started 3-8hrs post-injury, then
  5.4mg/kg/h IV drip for 48hrs
• no benefit if given gt8hrs after injury, or for
  penetrating injuries
• Class II evidence (guideline)

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ED Management

• Other pharmacological agents suggested
• lazaroid (lipid peroxidation inhibitor)
• ganglioside
• no clear benefit, if any

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Complications of spinal cord injuries

• Pulmonary edema
• GI tract and bladder atonia
• pressure necrosis on skin
• DVT/PE

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Disposition

• Referral to spine injury centre
• minor ligamentous injuries--outpt pain mgmt
• minor --hospitalization for appropriate work-up
  and pain mgmt

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?
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References

• Berlin. 2003. CT versus radiography for initial
  evaluation of c-spine trauma What is the
  standard of care? AJR 180911-5.
• Fehlings, MG. 2001. Editorial Recommendations
  regarding the use of methylprednisolone in acute
  spinal cord injury Making sense out of the
  controversy. Spine 26(24S)S56-7.
• Lowery DW et al. 2001. Epidemiology of cervical
  spine injury victims. Ann Emerg Med
  jul38(1)12-6.
• Marx. 2002. Rosens Emergency Medicine
  Concepts and clinical practice, 5th ed. Mosby,
  Inc.
• Mower WR et al. 2001. Use of plain radiography
  to screen for cervical spine injuries. Ann Emerg
  Med Jul38(1)1-7.
• Nockels, RP. 2001. Nonoperative management of
  acute spinal cord injury. Spine 26(24S)S31-7.
• Stiell IG et al. The Canadian c-spine rule for
  radiography in alert and stable trauma patients.
  JAMA 286(15)1841-8.