spinal injury dr. sundar karki
DESCRIPTION
Spinal injuryTRANSCRIPT
Emergency & GPBPKIHS, Dharan
Spinal Injury
Dr. Sundar KarkiMedical Officer
Outlines• Introduction• Epidemiology • Aetiology and distribution• Normal spinal anatomy• Common mechanism of injury• Prehospital management• Diagnosis of spinal injury• Management and prognosis• Common type of spinal fracture
Introduction
• Spinal injuries are devastating• Spinal injury may be defined as injury to the
spinal column (bone column)/spinal cord or both
• Improper management can have horrible and permanent result
• Appropriate use of immobilization can mean difference between a patient who fully recovers and other spent whole life paralyzed.
Epidemiology
• 40 cases per million in US• Most common cervical region(55%)• Mortality rate 40-50%• Between the ages 16-30. M:F=4:1• Most frequent age is 19• Current estimates are 250,000 - 400,000
individuals living with Spinal Cord Injury or Spinal Dysfunction.
Ateiolgy and Distribution
Normal Spinal Anatomy
▪33 separate irregular bones▪Vertebral foramen: canal formed for spinal cord
Cervical Vertebrae
▪C1-7,located in the neck
▪Small vetrebral body Extensive joint surface
▪C1: atlas C2: axis
Thoracic Vertebrae
▪Rib bearing vertebrae
▪Designed to remain stiff and straight
Lumbar vertebrae
▪Weight bearing vertebrae
▪Lamina, facets and SPsare major parts
Spinal Ligament
Spinal cord and Nerves▪31 pairs of nerves ▪motor and sensory both▪Ligaments provide support▪Cord is nerve tissue▪Extend from foramen magnum to the L1 and end in the form of conus medullaris
Common Mechanism• Compression • Flexion • Extension • Rotation • Lateral bending • Distraction • Penetration
Spinal Column Injury Bony spinal injuries may or may not be Bony spinal injuries may or may not be
associated with spinal cord injuryassociated with spinal cord injury These bony injuries include:These bony injuries include:
– Compression fractures Compression fractures – Comminuted fractures Comminuted fractures – Subluxation (partial dislocation) Subluxation (partial dislocation)
Other injuries may include:Other injuries may include:– Sprains- over-stretching or tearing of Sprains- over-stretching or tearing of
ligamentsligaments– Strains- over-stretching or tearing of Strains- over-stretching or tearing of
the musclesthe muscles
HyperflexionWhiplash injury:(C3-7)Traumatic injury to the soft tissue in the cervical regionHyperflexion, hyperextentionNo fractures or dislocationsMost common automobile injuryRecover 3-6 months
Hyperextension Atlanto-occipital dislocation: frequently results in prehospital cardiorespiratory arrest 3 times more common in children than adults Unstable
Hyper rotation Atlanto-Axial dislocation: Transverse ligament injury more common in children than
adults 1/3 of patients have deficit Unstable
Spinal Cord injury• Cutting compression or stretching of spinal cord• Causing loss of distal function sensation or
motion • Caused by: -unstable or sharp bony fragment
pushing the cord - Pressure from bone fragments or swelling Pressure from bone fragments or swelling
that interrupts the blood supply to the cord that interrupts the blood supply to the cord causing ischemiacausing ischemia
Spinal cord injury ▪Primary spinal cord injury - cutting, compression or stretching of
spinal cord
▪Secondary spinal cord injury -occurs later due to swelling, ischemia or
movement of unstable bony fragments
Spinal Cord injury severity▪Complete - less common - loss of motor and sensory function
below the level of injury
▪Incomplete - some preservation of motor and sensory
function
Spinal cord injury without radiological abnormality(SCIWORA)• referred to spinal cord injury without
radiographic or CT evidence of fracture or dislocation
• With advent of MRI, term has become ambiguous
• "Spinal cord injury without neuroimaging abnormality" more correct name
• Mostly in pediatric population (range: birth to 16 years old)
• Common in cervical and thoracic region
Spinal cord injury without radiological abnormality(SCIWORA)• Following findings on MRI have been recognized
as causing primary or secondary spinal cord injury:
-Intervertebral disk rupture -Spinal epidural hematoma -Cord contusion -Hematomyelia • Prognosis of SCIWORA is actually better than
patients with spinal cord injury and radiologic evidence of traumatic injury
Suspected Spinal Injury• High speed crash• Compression injury (diving, fall on buttock)• Significant blunt trauma• Very violent mechanism• Unconscious• Neurological deficit• Spinal pain/tenderness
Pre-hospital management• Protect spine at all times during the
management of patients with multiple injuries
• Up to 5% 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
Pre-hospital management
• Cervical spine immobilization
• Transportation of spinal cord-injured patients
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
Philadelphia hard collar
Transportation of spinal cord-injured patients
• Emergency Medical Systems (EMS)• Paramedical staff• Primary trauma center• Spinal injury center
• PROTECTION PRIORITY• Detection Secondary
• Rigid cervical collar• “Log rolling”• Rigid transportation board remove• Rigid transfer slide
Immobilization at hospital
Diagnosis of Spinal injury: clinical evaluation• Inspection and palpation: occiput to coccyx - tenderness - gap or step - edema and bruising - spasm of associated muscle
Diagnosis of Spinal injury: clinical evaluation• Neurological Examination - sensation - motor function - reflexes - rectal examination
Neurological: Sensory
Neurological: Motor
Neurological Examination: Rectal
• Tone: the presence of rectal tone in itself does not indicate incomplete injury
• Sensation• Voilition: a voluntary contraction of
sphincter or the presence of rectal sensation supports the presence of a communication between the lower spinal cord and supraspinal centers
Neurological examination: Rectal
• Bulbocavernosus reflex -refers to anal sphincter contraction in response to
squeezing the glans penis or tugging on the Foley;
-reflex involves S-1, S-2, and S-3 nerve roots and is spinal cord- mediated reflex arc
-absence of this reflex documents continuation of spinal shock or spinal injury at the level of the reflex arc itself.
Is the patient awake or “unexaminable”?
• What’s the difference ?– Awake
• ask/answer question• pain/tenderness• motor/sensory exam
– Not awake• you can ask (but they won’t answer)• can’t assess tenderness• no motor/sensory exam
OW!
------
Neurologic assessment and grading
• 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
American Spinal Injury association grade
Incomplete Cord Injury: Anterior cord syndrome
• Loss of motor, pain and temperature
• Preserved propioception and deep touch
Incomplete cord injury: Brown-Sequard syndrome
• Loss of ipsilateral motor and propioception
• Loss of contralateral pain and temperature
Incomplete cord injury: Central cord syndrome
• Weakness : – upper > lower
• Variable sensory loss
• Sacral sparing
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
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; 286:1841-1846
NEXUS• NEXUS Criteria:
1. Absence of tenderness in the posterior midline2. Absence of a neurological deficit3. 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 sort of 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
Any low-risk factor that allows safeassessment 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
Able to actively rotate neck?• 45 degrees left and right
No Radiography
Radiography
NO
YES
ABLE
YES
NO
UNABLE
National Emergency XRadiography Utilization Study
(NEXUS)
Both have:• Excellent negative predictive value for
excluding patients identified as low risk
The Canadian C-spine rule
&
Clearance of Cervical Spine Injury inConscious, 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
Cervical Spine Imaging Options
– Plain films• AP, lateral and open mouth view
– Optional: Oblique and Swimmer’s
– CT• Better for occult fractures
– MRI• Very good for spinal cord, soft tissue and ligamentous
injuries
– Flexion-Extension Plain Films• to determine stability
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 swimmer’s view or CT
Swimmer’s 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 issignificant anywhere
Lateral Cervical Spine X-Ray
• Anterior subluxation of one vertebra on another indicates facet dislocation– < 50% of the width of a
vertebral body unilateral facet dislocation
– > 50% bilateral facet dislocation
Bones
Disc
• Disc Spaces– Should be
uniform • Assess spaces
between the spinous processes
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.
Open mouth view
• Adequacy: all of the : all of the dens and lateral dens and lateral borders of C1 & C2borders of C1 & C2
• Alignment: lateral : lateral masses of C1 and C2masses of C1 and C2
• Bone: Inspect dens for lucent fracture lines
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
• 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
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• Clinical assessment and neurological
examination • Spinal Imaging and send laboratory
investigation• GI intervention: put nasogastric tube to
prevent aspiration• Pain Management - Opiates and NSAIDs
Management of SCI
• 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– Bolus followed by a 45-min pause – Then infusion 5.4mg/kg IV for 23 hours
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
Spinal and Neurogenic shock
Hemodynamic state in neurogenic shock • Unopposed parasympathetic outflow can lead to
dysrythmias and hypotension(most common within 14 hours)
• Loss of sympathetic innervation to the heart (T1 through T4 cord levels) leaves the parasympathetic cardiac innervation via the vagus nerve unopposed, resulting in bradycardia, or an absence of reflex tachycardia.
• Most common dysrythmia is bradycardia
Hemodynamic instability: intervention
• First line volume resusciation ( 1-2 liter)
• Second line: vasopressor (dopamine/norepinephrine) to
counter loss of sympathetic tone and provide chronotropic support to the heart
Hemodynamics and cord perfusion
• Avoid hypotension• Maintain MAP 85-90mmHg for first 7
days if possible
Bradycardia: intervention
• Prevention -avoid vagal stimulation - hyperventilate and hyperoxygenate before
suctioning - premedicate patient with known
hypersensitivity to vagal stimuli ▪Symptomatic bradycardia atropine 0.5- 1.0 mg IV
Indication for Surgery• Decompression of neural elements( spinal
cord and nerves)• Stabilization of bony element( spine)• Deformity correction• Thoracolumbar spine fracture/dislocation
Prognosis of recovery• Patient with complete cervical spine injuries that
remain within the first 24 hours of admission are unlikely to regain significant ambulatory function
• Cervical injuries have a higher potential for recovery than do thoracic or thoracolumbar injuries
• Younger patient fare much better than older• Intermedullary hemorrhage signifies a worse
neurological outcome
Jefferson Fracture
• Burst fracture of C1 ring
• cervical spine is subjected to an axial load, as would occur from a direct blow to the top of the head
• Unstable fracture
• Need CT scan
Hangman’s Fracture
• Hyperextension 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• Type 2 fracture through the base
– Most common• Type 3 fracture through the base and body of
axis– Best prognosis
Odontoid Fracture Type II
Odontoid Fracture Type III
Burst Fracture
• Fracture of C3-C7 from axial loading
• Spinal cord injury is common from posterior displacement of fragments into the spinal canal
• Unstable
Clay Shoveler’s Fracture
• Avulsion off the end of one of the lower cervical spinous processes
• C7>C6>T1
• Stable fracture
Flexion Teardrop Fracture
• Flexion injury causing a fracture of the anteroinferior portion of the vertebral body
• Unstable because usually associated with posterior ligamentous injury
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