Spinal TraumaBy: Abdullah Mohammad

Shifa College of Medicine

2014-001

Case

A19-year-old college student, was rock climbing when he fell 30 feet to the ground. Paramedics arriving at the scene found him lying in the supine position, unable to move any extremities and complaining of neck pain. He was awake, alert, and oriented to his current location, the date and day of the week, and the details of his fall. His responses to questioning were appropriate. He complained that he could not feel his arms and legs. His pupils were equal and reactive to light. He showed no other signs of injury except for several scrapes on his arms. His vital signs revealed a blood pressure of 110 / 72, heart rate of 82 beats per minute, respirations of 18 per minute. The paramedics applied a cervical collar, placed him on a back board, immobilized his head, and transported him to the trauma center by helicopter.

Introduction

Traumatic Spinal Cord Injury accounts for 15,000 new cases each year.

Mortality/Morbidity 94% of patients survive the initial hospitalization Life Expectancy is greatly reduced.

Renal Failure was the leading cause of death in the past. Currently, Pneumonia, Pulmonary Emboli, and septicemia

are the major causes.

Commonly men 16–30 years old (M:F Ratio 4:1)

Mechanism of Injury Vehicle crashes: 48% Falls: 21% Penetrating trauma: 15% Sports injury: 14%

25% of all spinal cord injuries occur from improper handling of the spine and patient after injury.

Functional Anatomy of the Spinal Cord

• Function• Skeletal support structure• Major portion of axial skeleton• Protective container for spinal cord

Regional Variations

Upper Cervical Spinal Anatomy is designed to facilitate motion.

Injury is uncommon and the canal is spacious.

Cervicothoracic junction is transitional zone from mobile to fixed and is prone to injury.

Thoracic spine is rigid because of stabilizing influence of the thorax.

Associated vascular and visceral injuries are common but require major energy transfer.

The thoracolumbar junction is another transitional zone and is also prone to injury.

Vertebral Column

Denis: Three Column Concept of spinal stability.

The spinal cord can be divided into three columns:

Anterior, middle and posterior.

Spinal stability is dependent on at least two intact columns.

When two of the three columns are disrupted, it will allow abnormal segmental motion, i.e. instability.

Failure of two or more columns generally results in instability.

Diagrammatic representation of the Three Column Concept of spinal stability.

Stable vs. Unstable Injuries

Stable Injuries Vertebral components won’t be displaced by normal

movement. An undamaged spinal cord is not in danger. There is no development of incapacitating deformity or

pain.

Unstable Injuries Further displacement of the injury may occur. Loss of 50% of vertebral height. Angulation of thoracolumbar junction of > 20 degrees. Failure of at least 2 of Denis’s 3 columns. Compression fracture of three sequential vertebrae can

lead to post traumatic kyphosis.

Types of Spinal Cord Injury

The primary Injury When the skeletal structures fail to dissipate the energy

of the primary mechanical insult. Results in direct energy transfer to neuronal elements.

Flexion Extension Axial Loading Rotation or traction Compression of the Cord

Secondary Injury Hemorrhage, oedema, and Ischemia secondary to the

insult. Therapeutic strategies are directed at reducing

secondary injury.

Mechanisms of Spinal Injury

Extremes of MotionHyperextension: Common in the neck Anterior ligaments and disc may be damaged.Hyperflexion: If posterior ligament is intact , wedging of

vertebral body occurs.If torn , may cause subluxation.

Axial compression: Causes burst fractures. Bony fragments may

be pushed into spinal canal.Flexion with rotation: Causes dislocation with or without fracture.Flexion with posterior distraction:

May disrupt middle and posterior columnShear

Spinal Cord Injuries

Symptoms and Signs

Neurologic function

Above the injury: intact.

Below the injury: absent or markedly diminished.

Specific manifestations depend on the exact level

and whether cord injury is complete or incomplete.

Vertebral injury typically is painful, but patients who

are distracted by other painful injuries (eg, long bone

fractures) or whose level of consciousness is altered

by intoxicants or head injury may not complain of

pain.

Location of Injury Possible Effects

At or above C5 Respiratory paralysis and quadriplegia

Between C5&C6 Paralysis of legs, wrists, and hands; weakened shoulder abduction and elbow flexion; loss of brachioradialis reflex

C6-C7 Paralysis of legs, wrists, and hands, but shoulder movement and elbow flexion usually possible; loss of biceps jerk reflex

C7-C8 Paralysis of legs and hands

C8-T1 With transverse lesions, Horner's syndrome (ptosis, miotic pupils, facial anhidrosis), paralysis of legs

T1-T12 Paralysis of leg muscles above and below the knee

At T12 to L1 Paralysis below the knee

Cauda equina Hyporeflexic or areflexic paresis of the lower extremities, usually pain and hyperesthesia in the distribution of the nerve roots, and usually loss of bowel and bladder control

At S3 to S5 or conus medullaris at L1

Complete loss of bowel and bladder control

.

Basic Patient Assessment

Approach every patient in the same manner using Advanced Trauma Life Support Principles (ATLS).

Assume every trauma patient has a spinal injury until proven otherwise.

All Assessment, Resuscitation and life saving procedures must be performed with full spinal immobilization.

Signs of spinal Injury: Polytrauma patient Neurological Deficit Multiple Injuries Head Injuries Facial Injury High energy Injury Abdominal Bruising from a seatbelt.

Spinal Immobilization

Unconscious and pain-free patient.

The Unconscious patient: Full Assessment of the spine is difficult. Definitive clearance of the spine many not be possible

initially. Maintain Spinal Immobilization until MRI rules out injury.

The Pain-free patient: There is no pain. Palpation of the spine is non-tender. Neurological examination is normal. There is pain free range of movement.

The mechanism and velocity of injury should be determined at an early stage.

Physical Examination

Initial Assessment Be aware that spinal injury may mask signs of intra-

abdominal injury.

Identification of Shock Three types of Shock may occur in spinal trauma:

Hypovolaemic Shock: Presents with hypotension, tachycardia, cold clammy peripheries. Caused by hemorrhage; treated with appropriate fluid replacement.

Neurogenic Shock: Hypotension w/ normal heart rate or bradycardia and warm peripheries. Caused by unopposed vagal tone resulting from cervical spinal cord injury above the level of the sympathetic outflow (C7/T1).

Spinal Shock: Characterized by paralysis, hypotonia, and areflexia. Lasts for only 24 hours. Assess patient neurologically. When it starts to resolve bulbocavernosus reflex returns.

Bulbocavernosus reflexThe bulbocavernosus reflex (BCR) or "Osinski reflex" is a polysynaptic reflex that is useful in testing for spinal shock and gaining information about the state of spinal cord injuries (SCI)

Spinal Examination

Spinal Examination Spine Log Roll must be performed to achieve proper

examination. Inspect and palpate entire spine. Swelling, tenderness, palpable steps or gaps suggest a

spinal injury. Note the presence of any wounds that might suggest

penetrating trauma.

Neurological Evaluation

American Spinal Injury Association neurological evaluation system is used.

Motor Function assesses key muscle groups. Grade (0-5)

Sensory Function assesses dermatomal map. (Pinprick and light touch) Score: 0-2

Rectal examination: Anal tone. Voluntary anal contraction. Perianal sensation.

What should be known after complete neurological examination?

Presence or absence of neurological injury. Probable level of injury. Injury is complete or incomplete. Level of impairment.

ASIA neurological impairment scale

A Absent motor and sensory function.

B Sensory function present, motor function absent.

C Sensory function present, motor function present but not useful. (MRC Grade<3/5)

D Sensory function present, motor function useful. (MRC Grade≥3/5)

E Normal Function.

Complete Cord Injury

Transection leads to immediate, complete, flaccid paralysis

(including loss of anal sphincter tone), loss of all sensation and

reflex activity, and autonomic dysfunction below the level of

the injury.

High cervical injury (at or above C5) , causing Respiratory insufficiency especially in patients with injuries at or

above C3.

Bradycardia and hypotension (neurogenic shock) .

Arrhythmias and BP instability may develop.

Flaccid paralysis gradually changes over hours or days to

spastic paralysis with increased deep tendon reflexes due to

loss of descending inhibition.

Later, if the lumbosacral cord is intact, flexor muscle spasms

appear and autonomic reflexes return.

Incomplete Cord Transection

Partial motor and sensory loss occurs, and deep tendon reflexes may be exuberant. Rapid swelling of the cord results in total neurologic dysfunction resembling complete cord injury (spinal shock )

Central Cord Syndrome Brown-Sequard Syndrome Anterior Spinal syndrome Posterior Cord Syndrom Cauda Equina Syndrome

Anterior Cord Syndrome

Flexion Compression injuries to the cervical spine may damage anterior spinal artery cutting off blood to anterior 2/3rd of spinal cord.

Loss of motor function and sensation of pain, light touch, and temperature below injury site

Retain positional, and vibration sensation Poor prognosis

Central Cord Syndrome

Hyperextension of the cord results in pinching of the cord in pre-existing degenerative narrowing od the spinal cord.

Upper limbs and hands profoundly affected. Distal motor function in the legs usually spared. Fair Prognosis

Brown-Sequard’s Syndrome

Penetrating injury that affects one side of the cord Ipsilateral motor loss vibration and position sense. Contralateral pain and temperature sensation loss Best prognosis

Posterior Cord Syndrome

Least frequent syndrome

Injury to the posterior (dorsal) columns

Loss of proprioception

Pain, temperature, sensation and motor function below the level of the lesion remain intact

Cauda Equina Syndrome

Diagnostic Imaging

85% of significant spinal injuries will be seem on standard lateral cervical spine.

CT Scan should be obtained. Most Sensitive in spinal trauma. Complex patterns and fractures can be understood.

MRI Best at visualizing soft-tissue elements of the spine. Possible to view spinal cord hemorrhage, epidural and

prevertebral hematomas. Not good at assessing bony structures.

In spinal traumas radiographs and CT scans usually give sufficient information and MRI is not required.

Management of the Spinal Injury Patient

Objectives Preserve neurological function. Relieve reversible nerve or cord compression. Stabilize the spine. Rehabilitate the patient.

An important goal is to prevent secondary injury to the spine or spinal cord.

Pre-hospital care

In unstable injuries, flexion or extension of the spine can contuse or transect the cord.

Which can result in paraplegia, quadriplegia, or even death from spinal injury.

Immobilize spine immediately.

A rigid collar should be used to immobilize the cervical spine.

Patients with thoracic or lumbar spine injuries should be shifted by logroll technique on a flat ,firm padded back board in supine position.

Transfer to a trauma center Immediately.

Pre hospital medical care should be directed at avoiding hypoxia and hypotension, both of which can further stress the injured cord.

Emergency Department Care

1. ABC

2. Intubation if needed.

3. Spinal stabilization.

4. Secondary survey.

5. Logroll – look for bruising , palpate for step and tenderness.

6. Look for associated injuries, such as brain, thoracic, or abdominal injuries.

7. Imaging; X-rays , CT , MRI.

8. Repeated neurologic examination helps determine the presence of deficits its progression /resolution.

9. Hypotension and bradycardia may indicate neurogenic shock.

10. Maintain the systolic blood pressure at a value of at least 90 mm Hg with a heart rate of 60-100 beats per minute.

11. Bradycardia may be treated by the use of atropine.

12. Attempt to maintain urine output at a minimum of 30 mL/h. If all of the above parameters are difficult to maintain, consider support with inotropic agents.

13. These patients are also at risk for hypothermia and should be warmed to maintain a core temperature of at least 96°F. Place a Foley catheter to help with voiding.

Management

With no neurological deficit: If stable-pain relief , collar or brace. If unstable-reduce and hold secure until bone /

ligaments heal with surgery or traction.

With complete sensory or motor loss: Usually an unstable injury Only consider conservative management for high

thoracic injuries. Early operative stabilization to help with nursing ,

prevent spinal deformity and pain. Speeds up rehab.

With incomplete neurological loss: Stable injury-conservative bed rest , brace. Unstable injury-early reduction and stabilization.

Surgical Approach

The goals of operative treatment are to decompress the spinal cord canal and to stabilize the disrupted vertebral column.

Also consider the need for stabilization procedures.

Categories of procedures for spine stabilization

The 4 basic types of stabilization procedures are

1. posterior lumbar interspinous fusion, 2. posterior rods3. cage4. The Z-plate anterior thoracolumbar plating

system. Each has different advantages and disadvantages.