.

Spine Unit , ORTHO-KKU

Spinal Injury
&
Spinal Cord
Injury



For General Practice
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

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

Goal of spine trauma care
Maintain or restore spinal alignment

Minimize loss of spinal mobility

Obtain healed & stable spine

Facilitate rehabilitation
Suspected Spinal Injury
High speed crash
Unconscious
Multiple injuries
Neurological deficit
Spinal pain/tenderness
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

PROTECTION PRIORITY
Detection Secondary



Log-rolling



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

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

Physical examination
Information
Mechanism
energy, energy
Direction of Impact
Associated Injuries
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!
------
Unexaminable




No exam
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)



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




18
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
Comparison of neurogenic and hypovolemic shock
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

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

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

Incomplete cord injury
Anterior cord syndrome
Brown-Sequard syndrome
Central cord syndrome

Anterior cord syndrome

Loss of motor, pain
and temperature

Preserved
propioception and
deep touch

Brown-Sequard syndrome

Loss of ipsilateral
motor and
propioception

Loss of contralateral
pain and
temperature

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 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
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)
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 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
Able to actively rotate neck?
45 degrees left and right
No Radiography
Radiography
NO
YES
ABLE
YES
NO
UNABLE
National Emergency X
Radiography 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 in
Conscious, 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 Swimmers

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 swimmers view
or CT


Swimmers 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 is
significant 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 dens and
lateral borders of
C1 & C2
Alignment: lateral
masses 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 FiO
2

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
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 < 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
Principle of treatment
Spinal alignment
deformity/subluxation/dislocation reduction

Spinal column stability
unstable stabilization

Neurological status
neurological deficit decompression
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
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 Shovelers Fracture
Flexion fracture of
spinous process

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
the AP diameter of the
vertebral body below it
High incidence of spinal
cord injury
Extremely unstable
Hangmans Fracture
Extension 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
THANK YOU
FOR YOUR ATTENTION