SPINE TRAUMA

1. SPINE TRAUMA Moderator: Dr.Bhalla www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. Spinal cord is 18 inches lying in the vertebral column Extends from foramen magnum to L1-L2 vertebra Spinal cord has 31segments 8cervical, 12thoracic, 5lumbar, 5sacral and 1coccygeal C3-C5-Phrenic nerve C5-T1-motor to upper limb T1-T5-sympathetic supply to heart L2-S2- motor supply to lower extremities Spinalcord anatomy

3. 1 anterior spinal artery 2 posterior spinal artery Radicular branches Artery of adamkiewicz Blood supply

4. Ascending tracts Desending tracts Anatomy

5. Incidence • Affects 10000 a year • Age group-16-30 years • Male: female=4:1 • Automobile accidents are the most common cause in person <65 years • Falls are the most common cause in person>65years

6. Causes • Motor vehicle collision 47% • Fall from height 23% • Penetrating injuries 14%(gun shot, bullet injuries)

7. Mechanisms of injury • Distraction-hyperextension of spine as in hangings • Compression-caused by axial loadings as in falls • Torsional-high energy motor vehicle collisions • Penetrating-stab or gunshot wounds

8. Sites of spinal cord injury • M/C junction between flexible and inflexible segments • Mid-thoracic injuries are less common because of the rotational stabilisation provided by rib cage and intercostal musculature • So injuries are much common above and below the thoracic vertebra --lower cervical and upper thoracic

9. Pathophysiology of SCI • Primary injury • Spinal vascular disruption may result in diminished arterial supply or venous drainage • Cellular edema will lead to increased pressure within the spinal canal, with compromise to blood flow

10. Pathophysiology of SCI

11. Pathophysiology of SCI • Secondary injury • Hypotension • Hypoxia • Anemia • During intubation

12. Degree of Injury • Complete transection • Total paralysis and loss of sensory and motor function although arms or rarely completely paralyzed • Incomplete (partial transection) • Mixed loss of voluntary motor activity and sensation

13. High cervical Low cervical High thoracic Low thoracic lumbar Acute phase Subacute phase Chronic phase Complete transection

14. Complete transection of SC • High cervical lesions • Resp insufficiency • Quadriplegia • Horners syndrome • Hypotension – no tachycardia (T1-T5) • Temperature regulation is altered • GI- ileus, abd distension • GU- bladder bowel incontinence • Blood -DVT

15. Complete transection of SC… • Low cervical • No diaphragmatic involvement • High thoracic (above T7) • Paraparesis • Autonomic invol. • Low thoracic and lumbar • Bladder and bowel invol. • Autonomic sys. Spared

16. Spinal shock Loss spinal reflexes causes flaccid paralysis Resp difficulty Bladder bowel involved Fever –loss of perspiration 3-6 Weeks Neurogenic shock Loss of vasomotor tone Hypotension without tachycardia Close monitoring of HR Typically 3 days- 3 weeks Acute phase

17. Sub acute phase • Flaccidity of spinal shock is replaced by spasticity • Usually returns in 3 weeks • Hyperreflexia and increased muscular tone are noted with extensor plantor response

18. Autonomic Dysreflexia • It is characterised by massive firing of sympathetic neurons after distention, stimulation or manipulation of bladder and bowel • Cutaneous stimulation with painful or cold stimuli can lead to massive sympathetic firing • Mediated at brain stem level

19. An acute emergency Occurs only after spinal shock has resolved The increase in ICP and blood pressure can lead to cerebral hemorrhage Classic signs pounding headache marked hypertension diaphoresis (particularly of the forehead) Bradycardia Flushing Piloerection nausea and nasal congestion Autonomic Dysreflexia

20. Mass reflex • Occurs after spinal cord transection • Mild noxious stimuli may trigger, withdrawal, defecation, sweating • Advantages • Elicit voiding and defecation • Control of micturition and defecation

21. Incomplete cord patterns • Anterior cord syndrome • Posterior cord syndrome • Brown-Sequard syndrome • Cauda equina syndrome

22. Compression of the ant. Cord motor paralysis at lesion and below Pain and loss of temperature sensation below site. Touch, position, vibration and motion remain intact. Anterior cord syndrome

23. Assoc with cervical hyperextension injuries Dorsal area of cord is damaged resulting in loss of proprioception Pain, temperature sensation and motor function remain intact. Posterior cord syndrome

24. Partial transection of cord BSS may be caused by a spinal cord tumor, penetrating injuries to spinal cord Paralysis and loss of vibration sense on same side of the body loss of pain and temparature (hemianesthesia) on the opposite side. Brown-Sequard syndrome

25. Approach to patient • ABC • Associated injuries • Spinal shock

26. Airway management • Suspected cervical spine injury Respiratory distress No respiratory distress ABC History Clinical exam Investigations

27. Signs and Symptoms • Neck or back pain • Penetrating injury of neck or back • Tenderness to palpation of spine • Loss of strength in extremities • Loss of feeling in extremities • Paralysis • Incontinence • SCIWORA (spinal cord injury without radiological abnormality) common in pediatric age group

28. How to exclude Cervical Spine Injuries NEXUS CRITERIA • Normal mental status • Not intoxicated • Normal neurological examination • No tenderness to palpation of C spine • No pain with active range of motion

29. Imaging • X-ray cervical spine • AP view • Lateral view • Odontoid view • CT scan • MRI

31. Anterior vertebral margins Posterior vertebral margins Spinolaminar junction lines Lateral view

32. cervical spine injuries

34. MANAGEMENT • A-Airway • B-Breathing • C-Circulation • To prevent secondary spinal cord injuries • Hypotension • Hypoxia • Anemia

35. Cervical spine immobilization • Patients neck should be immobilized at the earliest until complete evaluation has been made to exclude cervical spine injury • Soft collars • unsatisfactory as they permit 75%neck movement • Rigid collar • They reduce flexion extention to 70% reduces rotational movements by 54%

36. The best method of immobilization is Secure the patient in a hard board from head to feet With sand bags placed on either side of head Rigid collar around neck This method reduces neck movement to 5% of normal Cervical spine immobilization…

38. Spinal Immobilization • Transfer patient to long spine board as soon as feasible • Logroll in unison • Stabilize head and neck with sandbags or rolled blankets

39. Airway control • Clear the airway • Maintain adequate oxygenation • Initial maneuver of maintaining airway patency should not displace the cervical spine • Acceptable maneuvers include: • Lifting the chin (5mm) • Forward displacement of mandible • Placement of appropriate sized oral or nasal airways

40. Indications of tracheal intubation • GCS<8 • Loss of protective airway reflex • Hemorrhage into the airway • Pao2<60mmhg • Paco2>45mmhg • Seizures • Actual or impending airway obstruction

41. Airway control • Blind nasal vs orotracheal • Safest method is debatable • Depends on anesthesiologist opinion with which he is well versed • Advanced trauma and life support (1993) • Nasotracheal in a spontaneously breathing • Orotracheal in a apneic patient

42. Orotracheal intubation • Safest and surest method of intubating the trachea • It is the best method to secure the in an emergency setting • Manual in line stabilisation (MILS) technique should be used

43. It is the continuous immobilization of the neck during tracheal intubation that is important for reducing the incidence of secondary SCI MILS technique

44. Orotracheal intubation… • Preoxygenation for 3 minutes • Administration of a Intravenous induction agent • Application of cricoid pressure by the assistant • Administration of rapidly acting neuromuscular blocking drug • Laryngoscopy and Intubation of trachea

45. Elevation of laryngoscpe results in extention of atlanto occipital joint (2002) Edward Crosby, MD et al Canadian Journal of Anesthesia 49:733-744 (2002)

46. Difficulties • Cervical collar-reduces mouth opening • Cricoid pressure-distorts the view • MILS

47. Collar tape Sand bags MILS Optimal position Kj heath et al Anesthesia 1994

48. To improve the success rate • Remove the anterior part of collar • Gum elastic bougie Nolan et al Anesthesia 1993 • Mccoy laryngoscopy D A Gabbott et al Anesthesia 1996

49. Nasotracheal intubation • Sucessful in 90% of patients • Requires multiple attempts • Contraindication • Base of skull fracture and mid-facial injuries • Apnea • Disadvantages • Bleeding can occur in the airway making other methods of securing the airway difficult • Aspiration • Vomitting

50. Role of intubating LMA in emergency setting • Can be used safely for intubation • Provides a means for ventilation in case of failed tracheal intubation • Adv-will allow tracheal intubation in patient in patient with rigid cervical collar komotsu et al BJA;2004,93(5) 655-659 • Does not require a, secretion free or a blood free airway