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Spinal Trauma

Spinal Trauma. Outline. Incidence Types Clinical signs Radiological signs Spinal shock Management. Incidence. 10 - 15 per million 18 - 35 years Male - 3:1 RTA 51% - cars Domestic 16% Industrial 11% Sports 16% - diving incidents Self harm 5%. Types. Cervical 40%

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Spinal Trauma

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  1. Spinal Trauma

  2. Outline • Incidence • Types • Clinical signs • Radiological signs • Spinal shock • Management

  3. Incidence • 10 - 15 per million • 18 - 35 years • Male - 3:1 • RTA 51% - cars • Domestic 16% • Industrial 11% • Sports 16% - diving incidents • Self harm 5%

  4. Types • Cervical 40% • Thoracic 10% • Lumbar 3% • Dorso lumbar 35% • Any 14%

  5. Anatomy • Spinal cord ends below lower border of L1 • Cauda equina is below L1 • Mid dorsal spinal cord & neural canal space are of same diameter hence prone for complete lesion • Mechanical injury - early ischaemia, cord edema - cord necrosis • Neurological recovery unpredictable in cauda equina ie. peripheral nerves

  6. Cervical spine anatomy • Anterior column - Anterior longitudinal ligament+ Anterior annular ligament and anterior half of VB. • Middle column – Posterior long. Lig. + Posterior annular ligament +Posterior half of VB. • Posterior Column – Lig flavum + superior & Interspinous lig + intertransverse capsular lig + neural arch + pedicle & spinous process.

  7. Significance • Unstable if middle column + either Anterior or Posterior column is damaged • Rupture of interspinous ligament is : - associated with avulsion of spinous process - Unstable spine - Further flexion increases neurological injury

  8. Level of Spinal injury • Neurological level is at the most lowest segment with normal motor & sensory function • Difficult to determine : - as most muscle efferents receive fibres from more than one level - Closed cord lesions may extend over several cms. - Dermatomes have imprecise boundaries.

  9. Cord level • C2 – C7 = add +1 for cord level • T1 – T6 = add +2 • T7 – T9 = add +3 • T10 = L1, L2 level • T11 = L3, L4 level • L1 = sacro coccygeal segments

  10. Degrees of injury • Complete - flaccid paralysis + total loss of sensory & motor functions • Incomplete - mixed loss - Anterior sc syndrome - Posterior sc syndrome - Central cord syndrome - Brown sequard’s syndrome - Cauda equina syndrome

  11. Anterior spinal cord syndrome • Flexion rotational force to spine • Due to compression fracture of vertebral body or anterior dislocation • Anterior spinal artery compression • Loss of power, reduced pain and temperature below the lesion.

  12. Posterior cord syndrome • Hyperextension injuries • Posterior vertebral body fracture • Loss of proprioception and vibration sense • Severe ataxia

  13. Central cord syndrome • Older age with cervical spondylosis • Hyperextension with minor trauma • Cord is compressed by osteophytes from vertebral body against thick ligamentum flavum. • Damages the central cervical tract • UMN lesion to legs (spastic) • LMN to arms (flaccid paralysis)

  14. Brown sequards syndrome • Hemisection of the cord • Stab injury and lateral mass fractures • Uninjured side has good power but absent pinprick and temperature. • Spinothalamic tracts cross to opposite side of the cord three segments below.

  15. Types of bony injury • Flexion • Extension • Flexion with rotation • Compression

  16. Pathophysiology • Primary Neurological damage Direct trauma, haematoma & SCIWORA < 8yrs old In 4hrs - Infarction of white matter occurs In 8hrs - Infarction of grey matter and irreversible paralysis • Secondary damage Hypoxia Hypoperfusion Neurogenic shock Spinal shock

  17. Hypoxia • Lesions above C5 – damage to diaphragm leads to 20% reduction in vital capacity Rx Phrenic n. pacing • Lesions at D4-6 – reduces vital capacity if < 500ml patient is ventilated • Intercostal nerve paralysis • Atelectasis – poor cough • V/Q mismatch • Reduced compliance of lung – muscle fatigue.

  18. Neurogenic shock • Lesions above D6 • Minutes – hours (fall of catecholamines may take 24 hrs) • Disruption of sympathetic outflow from D1 - L2 • Unapposed vagal tone • Peripheral vasodilatation • Hypotension, Bradycardia & Hypothermia • BUT consider haemmorhagic shock if – injury below D6, other major injuries, hypotension with spinal fracture alone without neurological injury.

  19. Spinal shock • Transient physiological reflex depression of cord function – ‘concussion of spinal cord’ • Loss anal tone, reflexes, autonomic control within 24-72hr • Flaccid paralysis bladder & bowel and sustained Priapism • Lasts even days till reflex neural arcs below the level recovers.

  20. Assessment & Managemnt • Failure to suspect leads to failure to detect injuries • ABCDE – Logroll and remove the spinal board • Look for markers of spinal injury • Secondary survey • Adequate Xray’s • Emergency treatment • Surgery • Definitive care & rehab.

  21. Clinical features • Pain in the neck or back radiating due to nerve root irritation • Sensory disturbance distal to neurological level • Weakness or flaccid paralysis below the level

  22. Signs in an Unconcious patients • Diaphragmatic breathing • Neurological shock (Low BP & HR) • Spinal shock - Flaccid areflexia • Flexed upper limbs (loss of extensor innervation below C5) • Responds to pain above the clavicle only • Priapism – may be incomplete.

  23. Signs of spinal injury • Forehead wounds – think of hyperextension injury • Localized bruise • Deformities of spine - Gibbus, feel a step & Priapism • Beevors sign – tensing the abdomen umbilicus moves upwards in D10 lesions

  24. Prehospital transfer • Awareness of the crew & by A&E staff • Modified left lateral position at scene • Kendrick or Russell’s extrication device • Scoop stretcher slotted together around the patient • Agitated patient left alone with hard collar • Repeated assessment enroute • Head down if they vomit • Remove objects from clothes to avoid pressure sores • Avoid opiates in high lesions • Avoid oral suction in tetraplegics – vagal reflex

  25. Care in A&E • Careful manual handling especially if unconcious • Jaw thrust is safer • Correct gross spinal deformities • Call the anaesthetist if diaphragmatic paralysis or RR>35 • Use flexible fibreoptic scopes in unstable fractures • Ryles tube if abdominal distension causes respiratory probl • Cathetrize to avoid overstretching of detrusor • IV fluids – paralytic ileus in first 48hrs. • Passive movements to rule out fractures • Small iv doses of opiates

  26. Assessment • Document the level of injury • Rule out other injuries – DPL in abdominal injuries as there is paralytic ileus and absent peritioneal irritation. • Associated injuries in dorsal spine fracture are : - Renal injuries - Chest and Sternal injuries - Wide Mediatinum due to fracture haematoma. - Retroperitoneal injuries

  27. Radiology • Be thorough – Adequacy, Alignment,Bones, Cartilages and soft tissues and distances • SCIWORA in kids • Low threshold for xray in rheumatoid & Ankylosing spond • Flexion injury common in lower cervical spine • Extension injury in upper cervical Spine • Junction of mobile & fixed part are prone to injury eg. C7 T1 & D12 L1.

  28. Radiographs in spinal injuries • Lateral C spine views in diagnostic in 80% • Complete set of C spine xray are 90% diagnostic • CT of the c spine is 98% diagnostic • 22.5* logrolled view for better views of the facets • 45* view shows the intervertebral foramen & facets

  29. Normal Cervical Spine • Peg & lateral mass distance <2mm and symmetrical • Peg & arch of atlas distance <2mm in adults < 4mm in kids • Above C4 the width is <half of the VB width below C4 its equal to one VB width • Pseudosubluxation of C2 on C3 is normal in young kids& it disappears on extension • C1 and C2 interspinous space <10mm wide • Distance between occiput and atlas <5mm • Anterior compression of VB >40% suggest burst fracture

  30. Abnormal C spine • Unilateral facet dislocation < half of the vertebral body shifted on the lateral view • Bilateral facet dislocation > half shifted forwards • Wide interspinous gap is unstable (crush fracture or subluxation) suggestive of rupture of the posterior cervical ligament rupture and haematoma formation. • Severe flexion injury – fractures the anteroinferior margin of the vertebral body • Severe extension injury – fractures the anterosuperior margin of the VB.

  31. Emergency treatment • ABCDE • Keep warm • Treat if BP<80mmHg & HR <50bpm • Spring loaded gardener wells calipers for traction • H2 Antagonists & Heparin • Methylprednisolone 30mg/kg iv bolus over 15min immediately • 45minutes after the bolus a 5.4mg/kg/h infusion over 23 hrs in first 3 hours after the injury. • 5.4mg/kg/hr for 47hrs if 4 - 8hrs following the injury.

  32. Whiplash injury • Sudden hyperextension and flexion • Increasing neck pain for the first 24hours • Associated headache, pain radiating to both shoulders and paraesthesia in hands • Reduced lateral flexion • Anterior longitudinal ligaments are torn causes dysphagia • Forward flexion against resistance is painful • 90% are asymptomatic after 2years • 10% still have pain • Some still claim money hence the need for proper documentations.

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