SPINAL INJURY

Objectives of Learning

--Evaluate a patient with suspected spinal injury

i Identify the common types of spinal injuries and their X-ray features.

aAppropriately manage the spinal-injured patient during the first hour from injury.

pDetermine the appropriate disposition of the patient with spine trauma.

Incidence 10 - 15 per million 18 - 35 years Male - 3:1 RTA 51% - cars Industrial 11% Sports 16% - diving incidents Self harm 5%

Types

Cervical 40% Thoracic 10% Lumbar 3% thoraco lumbar 35%

Anatomy Spinal cord ends below lower border of L1 Cauda equina is below L1 Mid dorsal spinal cord & neural canal space are of

same diameter hence prone for complete lesion

Mechanical injury - early ischaemia, cord edema - cord necrosis

Neurological recovery unpredictable in cauda equina ie. peripheral nerves

Dennis classification Anterior column - Anterior longitudinal ligament+

Anterior annular ligament and anterior half of VB.

Middle column – Posterior long. Lig. + Posterior annular ligament +Posterior half of VB.

Posterior Column – Lig flavum + superior & Interspinous lig + intertransverse capsular lig + neural arch + pedicle & spinous process.

Unstable if middle column + either Anterior or Posterior column is damaged

Cord level

C2 – C7 = add +1 for cord level

T1 – T6 = add +2 T7 – T9 = add +3

T10 = L1, L2 level T11 = L3, L4 level

L1 = sacro coccygeal segments

Degrees of injury Complete - flaccid paralysis + total loss of sensory &

motor functions

Incomplete - mixed loss - Anterior sc syndrome - Posterior sc syndrome - Central cord syndrome - Brown sequard’s syndrome - Cauda equina syndrome

Anterior spinal cord syndrome Flexion rotational force to spine

Due to compression fracture of vertebral body or anterior dislocation

Anterior spinal artery compression

Loss of power, reduced pain and temperature below the lesion.

Posterior cord syndrome Hyperextension injuries

Posterior vertebral body fracture

Loss of proprioception and vibration sense

Severe ataxia

Central cord syndrome Older age with cervical spondylosis Hyperextension with minor trauma

Cord is compressed by osteophytes from vertebral body against thick ligamentum flavum.

Damages the central cervical tract

UMN lesion to legs (spastic) LMN to arms (flaccid paralysis)

Brown sequards syndrome Hemisection of the cord

Stab injury and lateral mass fractures

Uninjured side has good power but absent pinprick and temperature.

Spinothalamic tracts cross to opposite side of the cord three segments below.

Pathophysiology Primary Neurological damage Direct trauma, haematoma & SCIWORA < 8yrs old In 4hrs - Infarction of white matter occurs In 8hrs - Infarction of grey matter and irreversible paralysis

Secondary damage Hypoxia Hypoperfusion Neurogenic shock Spinal shock

Vertebral column injury, with or without neurological deficits, must always be sought and excluded in a patient with

pMultiple trauma. MAny injury above the clavicle ASpine injuryb

BewareExcessive manipulation and inadequate immobilization of a patient with a spinal cord injury can cause additional neurological damage and worsen the patient’s outcome Every patient with spine injury should be log-rolled every 2 hours, while maintaining the integrity of the spine, to reduce the risk of decubitusulcer formation.

Log rolling

� 25% of all spinal cord injuries occur from improper handling of the spine and patient after injury-MOBILIZATION-2ndary injury aRx based upon MOI that patient’s have a spinal injury aManage ALL spinal injuries with immediate and continued care

pathophysiology STABLE- UNSTABLE DENIS

Mechanisms of Spinal Injuries

--Traction ---stress ---direct------indirect - Hyperextension H Hyperflexion: H Excessive Rotation E Lateral bending L Axial loading A Compression common between T12 and L1 C Distraction D Combination C Distraction/Rotation or compression/flexion ---

Morphology

MSpinal injuries can be described as, SFractures FFracture dislocationse SCIWORA SPenetrating injuriess All injuries can stable or unstable, All patients with x-ray evidence of injury and all those

with neurologic deficits should be considered to have an unstable spinal injury.

HEALING EARLY MANAGEMENT

METHODS OF TEMPORARY IMMOBILIZATION

DIAGNOSIS HISTORY..EXAMINATION,,,shock NEUROLOGICAL EXAM UNCONSCIOUS PATIENT IMAGING

Suspect spinal injury with... S Sudden decelerations (MVCs, falls) S Compression injuries (diving, falls onto feet/buttocks) f Significant blunt trauma (football, hockey, snowboarding, jet skis) s Very violent mechanisms (explosions, ) V Unconscious patient U Neurological deficit N Spinal tenderness

Clinical features Pain in the neck or back radiating due to nerve root

irritation

Sensory disturbance distal to neurological level

Weakness or flaccid paralysis below the level

Signs in an Unconcious patients Diaphragmatic breathing Neurological shock (Low BP & HR) Spinal shock - Flaccid areflexia Flexed upper limbs (loss of extensor innervation

below C5) Responds to pain above the clavicle only Priapism – may be incomplete.

Signs of spinal injury Forehead wounds – think of hyperextension injury

Localized bruise

Deformities of spine - Gibbus, feel a step & Priapism

Beevors sign – tensing the abdomen umbilicus moves upwards in D10 lesions

Signs and Symptoms of a Spinal Cord Injury S Extremity paralysis E Pain with & without movement P Tenderness along spine TSpinal deformity S Priapism P Loss of bowel or bladder control L Nerve impairment to extremities

NerurogenicS hock vs Spinal Shock NNeurogenic shock results from impairment of the

descending sympathetic pathways in the spinal cord resulting in loss of vasomotor tone and loss of sympathetic innervation to the heart The result is ˜

Hypotension Bradycardia

Spinal Shock SThis refers to the flaccidity and loss of reflexes seen

after spinal cord injury. The “Shock”to the injured cord may make it appear completely functionless, although all areas are not necessarily destroyed. The duration of this state is variable.

Guidelines for screening patients with suspected Injury

The presence of paraplegia or quadriplegia is presumptive evidence of spinal instability --- ----

----Patients who are awake, alert, , and neurologically normal, and have no neck pain are extremely unlikely to have an acute c-spine fracture / subluxation.k

--Patients who are awake and alert, are neurologically normal, but do have neck pain should undergo lateral, AP, and open-mouth x-rays of the c-spine.

Guidelines for screening patients with suspected Injury

wPatients who are comatose, have an altered level of consciousness, or are too young to describe their symptoms should at least have a lateral and AP c-spine x-rayo

When in doubt, leave the collar on l Backboardsc Never force the neck

� --Attend to life-threatening injuries, --- minimize any movement of the spinal column • --

Establish and maintain proper immobilization of the patient until vertebral fractures or spinal cord injuries have been excludede

--Obtain a lateral c-spine x-ray, when indicated, as soon as life-threatening injuries are controlled, - --Document the patient’s history and physical examination so as to establish a baseline for any changes in the patient’s neurologic status.

PRINCIPLE OF DEFINITIVE TREATMENT OBJECTIVE Preserve,relive restore,stabize,rehablitate NO NEUROLOGICAL INJURY NEUROLOGICAL INJURY TRETMENT METHODS

Treatment

Methylprednisolone Load with 30 mg/kg as a bolus, followed by a

continuous drip of 5.4 mg/kg/hour for the subsequent 23 hours

Shown to lead to a statistically significant improvement in blunt trauma in neurologic outcome

Not studied in penetrating trauma Resulted in improvement of both motor and sensory

function in complete and incomplete lesions