Spine and Spinal Cord

Trauma

Spinal Cord Tracts

Dermatomes and Myotomes

Neurogenic Shock Versus Spinal

Shock
Neurogenic shock results from impairment of the
descending sympathetic pathways in the cervical or
upper thoracic spinal cord.
This condition results in the loss of vasomotor tone
which leads to hypotension and in sympathetic
innervation to the heart resulting in bradycardia.
Neurogenic shock is rare in spinal cord injury below the
level of T6.

Neurogenic Shock Versus Spinal

Shock
The blood pressure may often be restored by the judicious
use of vasopressors after moderate volume replacement.
Atropine may be used to counteract hemodynamically
significant bradycardia.
Spinal shock refers to the flaccidity (loss of muscle tone)
and loss of reflexes seen after spinal cord injury in which
the duration of this state is variable

Effects on The Organ Systems

Hypoventilation due to paralysis of the intercostal muscles may
result from an injury involving the lower cervical or upper
thoracic spinal cord.
If the upper or middle cervical cord is injured, the diaphragm
also is paralyzed because of involvement of the C3 to C5
segments which innervate the diaphragm via the phrenic nerve.
The inability to perceive pain may mask a potentially serious
injury elsewhere in the body, such as the usual signs of an acute
abdomen.

Spinal Cord Syndromes

Central cord syndrome is characterized by lower motor neuron
(flaccid) paralysis of upper limbs with upper motor neuron
(spastic) paralysis of lower limbs and intact perianal
sensation (sacral sparing).
This syndrome occurs after a hyperextension injury in a patient with
preexisting cervical canal stenosis (often due to degenerative
osteoarthritic changes).
Recovery usually follows a characteristic pattern, with the lower
extremities recovering strength first, bladder function next, and the
proximal upper extremities and hands last.

Spinal Cord Syndromes

Anterior cord syndrome is characterized by
paraplegia and a dissociated sensory loss with a
loss of pain and temperature sensation. Dorsal
column function (position, vibration, and deep pressure
sense) is preserved.
Anterior cord syndrome is due to infarction of the cord
in the territory supplied by the anterior spinal artery.
This syndrome has the poorest prognosis.

Spinal Cord Syndromes

Brown-Squard syndrome results from hemisection
of the cord, usually as a result of a penetrating trauma.
In its pure form, the syndrome consists of ipsilateral
motor loss (corticospinal tract) and ipsilateral loss of
position sense (dorsal column), associated with
contralateral loss of pain and temperature
sensation beginning one to two level below the level of
injury (spinothalamic tract).

General Management
IMMOBLIZATION
Suspected spine injury should be immobilized above
and below the suspected injury site until a fracture is
excluded by x-ray examination. Spinal protection should
be maintained until a cervical spine injury is excluded.
Proper immobilization is achieved with the patient in the
neutral positionthat is, supine without rotating or
bending the spinal column.

General Management
Immobilization of the neck with a semirigid collar does not
ensure complete stabilization of the cervical spine.
Immobilization using a spine board with appropriate bolstering
devices is more effective in limiting certain neck motions. The
use of long spine boards is recommended.
Cervical spine injury requires continuous immobilization of the
entire patient with a semirigid cervical collar, head
immobilization, backboard, tape, and straps before and during
transfer to a definitive-care facility.

General Management
The airway is of critical importance in patients with
spinal cord injury, and early intubation should be
accomplished if there is evidence of respiratory
compromise.
During intubation, the neck must be maintained in a
neutral position and If necessary, a sedative or paralytic
agent (short-acting, reversible) may be administered,
while ensuring adequate airway protection, control, and
ventilation.

General Management
Removal of the board is often done as part of the secondary
survey when the patient is logrolled for inspection and
palpation of the back.
The safe movement, or logrolling, of a patient with an unstable
or potentially unstable spine requires planning and the
assistance of four or more individuals, depending on the size of
the patient.
Neutral anatomic alignment of the entire vertebral column must
be maintained while rolling and lifting the patient.

General Management

General Management
INTRAVENOUS FLUIDS
In patients in whom spine injury is suspected,
intravenous fluids are administered as they would
usually be for resuscitation of trauma patients.
If active hemorrhage is not detected or suspected,
persistent hypotension should raise the suspicion of
neurogenic shock. Patients with hypovolemic shock
usually have tachycardia, whereas those with
neurogenic shock classically have bradycardia.

General Management
If the blood pressure does not improve after a fluid
challenge, the judicious use of vasopressors may be
indicated.
Phenylephrine hydrochloride, dopamine, or norepinephrine
is recommended. Overzealous fluid administration may
cause pulmonary edema in patients with neurogenic shock.
A urinary catheter is inserted to monitor urinary output
and prevent bladder distention.