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Spine and Spinal Cord Trauma

Objectives
Anatomy/physiology
Evaluate a patient with spinal injury
Identify common spinal injuries and Xray
features
Appropriately manage the spinal-injured
patient
Determine appropriate disposition

Suspected Spinal Injury

High speed crash


Unconscious
Multiple injuries
Neurologic deficit
Spinal pain/tenderness

Spinal injury

5% worsen neurologically at hospital


Protection is a priority
Detection is a secondary priority
Spinal evaluation complicated by TBI
Remove spine boards ASAP

Cord Injury Severity


Complete = no motor function or sensory
function below the injury level
Incomplete = any preservation of function
Sacral sparing may be the only preservation of
function

Sensory Examination
Levels vs sensation

Motor Examination
Table outlining levels

Neurogenic Shock
Hypotension associated with cervical/high
thoracic spine injury
Bradycardia
Tx: fluid, atropine, pressors

Spinal Shock

Neurologic, not hemodynamic phenomenon


Occurs shortly after cord injury
Flaccidity
Loss of reflexes

Effects on other organ systems


Inadequate ventilation
Compromised abdominal evaluation
Occult compartment syndrome

Classification of Injuries: Levels


of injury
Clinical exam
Most caudal
Normal bilaterally
Motor/sensory function
Bony = site of vertebral damage

Classification
Incomplete
Any sensation
Position sense
Voluntary movement in
lower extremity
Sacral sparing

Complete
No motor/sensory
function
No sacral sparing
May have reflexes

Spinal Cord Syndromes


Central
Anterior
Brown-sequard

Anatomy diagram

Classifications: morphology
Fracture or fracture dislocation
SCIWORA
Penetrating

Classification: morphology
Unstable if:
Xray evidence of injury
Neurologic injury
Severe pain on spine movement or palpation

Xray Guidelines

A
A
B
B
C
C
D
S

Normal C spine Xray

C spine Xrays
Cross table lateral detects 85%
Additional 2 views excludes most fractures
May also require:

Swimmers
CT
Flex/ex
MRI

Cspine Xrays
10% have a second fracture
Look for second fracture!
One fracture mandates full spine films

Xray Guidelines

Adequacy
Alignment
Bones
Cartilage
Contours
Disc space
Soft tissue

Thoracolumbar spine
Xray

Screening for Spinal Injury


Algorithim

Paraplegia/quadraplegia
Presumed spinal instability
Identify bony fracture-subluxation
Consult neurosurgery or orthopedics

Screening for Spinal Injury


Alert, sober neurologically normal patient:
No neck pain or tenderness
No distracting injury
No pain with voluntary movement

No further Xrays required

Screening for spinal injury


Alert, sober, neurologically normal patient
Neck or spin pain or tenderness to palpation or
voluntary movement
After removal of c-collar?
If yes to any question
Protect cspine
Obtain necessary Xray exams

Screening for spinal injury


Altered LOC
Complete spine films
Plain films
CT prn

Screening for Spinal Injury


Radiographic
Normal Xray

Clinical
Normal neurologic exam and
Absence of spinal pain/tenderness

Caution!
Drugs, alcohol, distracting injuries

Management
Immobilization

Entire patient
Propper padding
Maintain until cleared
Avoid prolonged use of
backboard

Decubitus ulcer

Medical Management

Ensure A/B
Maintain BP
Atropine prn
Methylprednisolone

Medical Management
Intravenous fluids
Treat hypovolemia first
Consider neurogenic shock
Insert foley

Medical Management
Steroids
Methylpred doses

Medical Management
Transfer

Unstable fractures
Neurologic deficit
Avoid delay
Proper immobilization
Respiratory support as needed

Questions

Summary

Treat life-threatening injuries first (ABCD)


Immobilization
Appropriate Xrays
Document examination
Consultation
Transfer