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Spinal Injury

Spinal Injury. Dr Adrian Burger Senior Registrar Division of Emergency Medicine UCT/US 25 May 2007. Objectives. Anatomy Stats Clinical Imaging Summary.

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Spinal Injury

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  1. Spinal Injury Dr Adrian Burger Senior Registrar Division of Emergency Medicine UCT/US 25 May 2007

  2. Objectives • Anatomy • Stats • Clinical • Imaging • Summary

  3. Number of neurons in human spinal cord = 13,500,000Length of human spinal cord = 45 cm (male); 43 cm (female)Length of human vertebral column = 70 cm Length of cat spinal cord = 34 cmLength of rabbit spinal cord = 18 cm Weight of human spinal cord = 35 gm Weight of rabbit spinal cord = 4 gmWeight of rat spinal cord (400 gm body weight) = 0.7 gm Maximal Circumference of cervical enlargement = 38 mmMaximal Circumference of lumbar enlargement = 35 mm Pairs of Spinal Nerves = 31Number of Spinal Cord segments = 318 cervical segments 12 thoracic segments5 lumbar segments5 sacral segments1 coccygeal segment Anatomy 1

  4. Anatomy 2

  5. Consequences • Depends on • Complete/Incomplete • Level • Stabilised • Initial Management

  6. Respiratory – apnoea, hypoventilation Cardiac - neurogenic shock triad - autonomic dysreflexia - hypotension C3-C5 Intercostals T1 –T4 >T6 Early Consequences

  7. Later consequences • Bowel reflex or non-reflex dysfunction • Bladder retention • Bed sores • Contractions

  8. Causes of death • Dysrhythmias, apnoea • Pneumonia • VTE • Sepsis • CHD

  9. Neurology • Most frequent level of injury is C5, then C4, C6, T12, C7, L1 • Overall about half are cervical injuries • Incomplete quadraplegia (34.3%) • Complete quadraplegia (22.1%) • Complete paraplegia (25.1%) • Incomplete paraplegia (17.5%)

  10. Incomplete lesions • Anterior cord syndrome Corticospinal and spinothalamic pathways Loss of motor, pain and temperature below the level of the injury Preservation of position and vibration Key is potential reversibility of a haematoma or fragment • Central cord syndrome Injury to the central portion of the spinal cord Greater involvement of upper extremities than lower Bowel or bladder control usually is preserved Hyperextension injury of cervical spine with a narrow cord space Can occur without fracture or ligamentous disruption

  11. Incomplete lesions 2 • Brown-Séquard syndrome Hemisection of the spinal cord, usually penetrating trauma Contralateral loss of pain and temperature Ipsilateral loss of motor and posterior column functions • Cauda equina syndrome Injury to the lumbar, sacral, and coccygeal nerve roots Motor and sensory loss in the lower extremities Bowel and bladder dysfunction Saddle anaesthesia

  12. Sacral Sparing & Spinal Shock • Preservation of any function of the sacral roots, such as toe movement or perianal sensation • Implies the chance of functional neurologic recovery is good • Spinal shock is a temporary concussive-like condition in which cord-mediated reflexes, such as the anal wink, are absent • Spinal shock also may result in bradycardia and hypotension. The extent of cord injury-and prognosis-cannot be determined until these reflexes return

  13. Stats UK

  14. Stats USA • Vehicular crashes (50.4%) • Falls (23.8%) • Violence, primarily gunshot wounds (11.2%) • Sports (9.0%) • Other (5.6%)

  15. General Stats • Average age 16-30 • Males 80% • Life expectancy of someone with a SCI in Africa is 2-3 years • 60 % of admitted patients have neurological deficits • After the initial care require rehabilitation • Average hospital stay for rehab of a paraplegic patient is 4 months, for quadriplegics 6 months • Estimated that 2 000 SPINAL INJURIES are treated per annum NATIONALLY in the public sector ie, 1:20 000 of the population

  16. Minister of Transport Jeff Radebe, (MP)at the 2006 • Poor driver behaviour and attitude 95 % of crashes follow a traffic violation • Our statistics reflect that 7 000 people involved in crashes are left permanently disabled every year. At least 650 of these have SCI

  17. South Africa MRC 1999

  18. Cape Metropole 2000

  19. Trauma Injuries, Red Cross Children's Hospital1 April 1999 - 31 March 2000 (12 months) • MVA       Pedestrian745      Passenger - Restrained 18    Passenger - Unrestrained 106    Passenger - Bakkie/Minibus77    Cycle151    Motor Cycle 2    Other - Boat, Train, Plane, Horse25    Total MVA   1125 (16%) • Assault      Blunt 126    Sharp25    Rape/Sexual 38    Human Bite 3    Other 33    Total Assault   2253 • Burns      Flame 117    Fluid 497    Heat Contact 37    Electrical 13    Chemical 21    Explosion 10    Other 11    Total -706 • Falls  Off Ben 283    Stairs115    Attendants Arms 68    Playground Equipment 252    Mobiles93    Other Heights 613  Other Level 1071 Total - Falls   2495 (35%) • Struck by/against objects 688  Caught between objects 212    Sharp Instruments 250  Firearms42 Machinery9 Dogbite90 Other bite 7    • Immersion/drowning    Suffocation1    Food foreign body 33    Other foreign body 351    Other cause549  Unknown290    Total  7075  

  20. NEXUS No midline cervical tenderness No focal neurologic deficit Normal alertness No intoxication No painful distracting injury CCS Any high-risk factor?(i.e., age > 65, severe mechanism, or focal neurologic signs)? Can the patient be assessed safely for range of motion (simple mechanism, sitting position in the ED, ambulatory at any time, delayed onset of neck pain, or absence of midline cervical spine tenderness)? Can the patient actively rotate the neck 45 degrees to the left and the right? X Ray or not?

  21. Children • Not validated in either study • Small numbers of children • Can’t assess under 2 years • Rare injury in children

  22. High risk PMH • Elderly • Rheumatoid arthritis • Down's syndrome • Osteoporosis • Metastatic cancer

  23. Low Risk • Simple rear end • Sitting in ED • Ambulatory at any time • Delayed onset of neck pain

  24. Which X Rays? • 3 View (LAT, AP, ODONTOID) in adults • 2 View in children, ? 1 View • Sensitivity 90% • Add CT 99.9% sensitive • 10% non-contiguous # incidence

  25. Adjuvants • Swimmers view • CT scan • MRI • Flexion/Extension views

  26. AP and LAT • Evaluation A Alignment B Bones C Cartilage S Soft Tissue

  27. AP & Odontoid

  28. On Lateral view Soft Tissue ADI Swischuck’s Line Measurements

  29. Mechanism of Injury • Flexion type

  30. Rotation/Flexion Lateral Flexion Mechanisms of Injury

  31. Axial Load Hyperextension Other mechanisms

  32. C5 on C6

  33. L1 Compression Fracture

  34. Lumbar Vertebral Body #

  35. So why do we take “spinal precautions”? • Never can tell… • Preserve intact cord • Cost

  36. Log Roll Collar

  37. A = Airway B = Breathing C = Circulation D = Disability E = Exposure A = Altered mental state. Check for drugs or alcohol. M = Mechanism. Does the potential for injury exist? U = Underlying conditions. Are high risk factors for fractures present? S = Symptoms. Is pain, paresthesia, or neurologic compromise part of the picture? T = Timing. When did the symptoms begin in relation to the event? It is AMUST to Suspect SCI!

  38. Acute Treatment • First treat life threatening conditions • Then do no harm • Spinal immobilise – 5% deteriorate • A-B-C-D-E • A-M-U-S-T • Transport by air

  39. Acute Medications • O2 • RSI – beware scoline • Crystalloids – judiciously • Atropine, pacemaker • Inotropes • Ganglioside GM-1, naloxone, CCB & glutamate receptor antagonists • And……..

  40. Steroids? • Definitely not for penetrating trauma! • Blunt trauma? • 1975 First National Acute Spinal Cord Injury Study (NASCIS) established • Followed by NASCIS 2 and NASCIS 3, which was completed in 1998 • Bottom line……

  41. Steroids • Everyone wants to try and get just somebenefit… • So it’s not advocated as a standard of care but it is an option <8 hours • Dosage 30mg/kg over 15 min + 5.4mg/kg/hour for 24 or 48 hours

  42. Surgery • Some unclear roles • Some clear roles anterior cord syndrome thoracolumbar spine fracture/dislocation

  43. Summary • Suspect SCI and look for it • Spinal precautions in vast majority • Use and familiarize decision rules • Use your common sense • Examine your patient • Ask for help

  44. References • www.drivinghome.co.uk/html/cj_injury.shtml • http://www.worldortho.com/ • http://www.playersfund.org.za/spineline/spineline.asp • http://www.emedicine.com/emerg/topic553.htm • http://www.doh.gov.za/mts/reports/spinal.html • http://quad.stormnet.co.za/info.htm • http://www.transport.gov.za/comm-centre/sp/2006/sp0907.html • American Academy of Emergency Medicine: http://www.aaem.org/positionstatements/steroidsinacuteinjury.shtml • American College of Surgeons: Advanced Trauma Life Support, 7th ed. Chicago, 2004 • Canadian & American Spinal Research Organization • Markovchick & Pons: Emergency Medicine Secrets 4E

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