Managing (Acute) Traumatic Spinal Injuries

1. Managing (Acute) Traumatic Spinal Injuries Dr. Richard Bwana Ombachi Lecturer and Consultant Spine & Orthopaedic surgeon

2. Introduction • Spine -Vertebral Column/Nervous Tissue • 5% worsen in the hospital • Protection is priority –Diagnosis a secondary priority • Treat the spine of an alive patient – Identify live threatening conditions • Effects of spinal injury • Inadequate ventilation • Compromised abdominal evaluation • Mask compartment syndrome • Patient Referral

3. Trauma • Vertebral Column Trauma and • Nervous Tissue Trauma • Somatic Nervous System • Spinal Cord tracts • Nerve roots / Nerves • Autonomic Nervous System • sympathetic

5. Spinal Injuries Devastating effect • Protection primary priority • Management starts at the scene of the accident

6. Spinal Cord Injury • Primary Injury- physical injury by mechanical forces • Contusion • Compression • Stretch • Laceration – • penetrating foreign bodies, • missiles, • fragments or displaced bone

7. Secondary Injury • Additional neural tissue damage from biologic response • Changes local blood flow • Tissue oedema • Metabolite concetration lethal to the neural tissues leading to further injury

8. Statistics • Aetiology • RTA 45% ( motor cycle accidends ) • Falls 20% • Sports 15 % • Assault 15% • Gender ratio M: F 4:1 • Neurologic Injury • Cervical 40% • Thoracolumbar 20%

9. PRINCIPLES OF MANAGEMENT • Suspect Spinal Injuries and Protect further injury • Immobilize the spine • Assess the patient (ATLS Protocal) • Manage live threatening conditions while caring for spine • Image patient to identify the injuries • Manage/Reffer injuries as appropriate

10. Suspect Spinal Injuries • History of transient neurological symptoms • Neck pain or back pain • Multiply Injured patient • An inconsolable child • Inability to assess pain because of a secondary distracting injury or intoxication • Head injury or severe facial or scalp lacerations or neck injuries • Trauma +Unconscious : assume spinal injury until proven otherwise • Abnormal neurological finding • Diaphragmatic breathing • Physical signs of spinal trauma (e.g., ecchymosis and abrasions, step deformity, gap deformity. • hypotension, hypothermia, and bradycardia- upper thoracic/ cervical injuries neurogenic shock • Penile erection and incontinence of the bowel or bladder suggest a significant spinal injury

11. Tale Tell Signs on Examination • Patient should be log rolled by at least 4 people for back examination • leakage of CSF or blood behind the tympanic membrane- a skull fracture. • paraplegia/ quadriplegia • Painful spinous process • Palpable defects ( gaps or steps) indicate disruption of the supporting ligamentous complex. • Scalp wounds, neck injuries, seat belt marks etc. • Diaphragmatic Breathing

12. Immobilize the Spine • Protection Priority • Neck immobilization firm collar + head strapped to bolsters/ sand bags on either side to the board • Immobilize in neutral position don’t correct deformities- ? AS, ? RS children, ? Spondylosis • Children - board should have a depression to accomodate big head – avoid flexing neck. • Patients should not be kept on the board longer than two hours as pressure sores start to develope two hours on the board (Spine board transporting tool)

16. NEUROLOGICAL EXAMINATION • Done to determine level and severity of injury. • Sensation to light touch and pain should be documented comparing each spinal level and side • Motor examination using MRC grading. • Deep tendon reflexes and pathological reflexes also should be checked. • Motor and sensory evaluation of the rectum and perirectal area is mandatory (complete/incomplete Injuries)

17. Asia Chart • ASIA Chart.pdf

18. Spinal Shock • Spinal dysfunction based on physiological rather than structural disruption. • Recognized by return of the reflexes caudal to the level of injury usually 24 -48 hours (BCR or the anal wink)

19. Neurogenic Shock • Injuries above T6 disrupt the sympathetic nervous system to the heart and the vascular system – Neurogenic shock • Sympathetic disruption leads to uncounterted vagal action leading to Bradycardia, Hypotension, Vasodilatation • Maintain Mean Preasure above 70mmHg • Do not over infuse pt use ionotropic drugs

20. Vertebral Column Examination • Done in Secondary Survey • Use log rolling technique • Detect • Bruises/ Lacerations • Swellings / Bogginess • Step or Gap Deformity • Tenderness • Remove spine board at this stage if not referring

21. Radiological Imaging Indications • No x-rays if • No neurological deficit • Conscious • Cooperative • Able to concentrate • If no neck or back tenderness • Altered sensorium, then • X-ray the whole spine • Pain or tenderness, no neurological deficit Xray affected areas consider flex-ext

22. X-rays • AABBCCDs • Adequacy, Alignment, Bony abnormality, Base of Skull, Cartilage, contours, Disc space, Soft tissues - Cross-Table Lateral: 85% sensitive -AP + Lat 92 % sensitivity -excludes most fractures -Swimmer’s for C7-T1 - Open mouth view upper cervical -Obliques not necessary in trauma -CXR / Abd Xrays not adequate for evaluation spine

23. CT SCAN / MRI • CT Scan • Clearance in patients with questionable or inadequate plain radiographs • Assess occipitocervical and cervicothoracic junctions • MRI • Spinal cord injury – disruptions, oedema, haematomas • Intervertebral disc disruption • Posterior ligamentous disruption • Canal compromise and neural tissue compression

24. Summary of Management • High Index of Suscipicion • Immobilize the spine to protect spine (Protection Priority) • Examine for Spinal and none spinal injuries. • Neurological Examination +Vertebral Examination • Institute rescuscitation as condition demands giving preference to life threatening conditions While taking care of the spine. • Do not over infuse the patient with neurogenic shock- use ionotropic agents as indicated • Image the spine to identify and confirm suspected injuries. (Maintain Spine Board untill imaging is complete) • Remove Spine Board within two hours to avoid decibitus ulcers • Pressure sore management • Bladder management • Respiratory system management • GIT • Psychological support • Definative stabilization according to the injury • Steroids in some centres