Assessment of Spinal Injury

1. Assessment of Spinal Injury Stephen Schutts, Master Sergeant, WA ANG National Registry Emergency Medical Technician - Paramedic 1

2. Objectives • Identify the anatomical levels of the spine. • Understand the function of the spinal cord/column. • View Types and Mechanisms of injury that can cause spine injury. • Discuss the difference between Spinal Column Injury vs Spinal Cord Injury. 2

3. Objectives • Overview of Spinal Regions and Injuries • Step by step view of the EMS Spinal Immobilization Assessment Protocol • Discuss Common Treatment/Management Mistakes 3

4. Introduction • Spinal injuries are devastating • Improper management can have horrible and permanent results • Appropriate use of spinal immobilization can mean the difference between a patient who fully recovers and one who must spent the rest of his/her life paralyzed 4

5. Low-speed fender bender An elderly man trips over a lamp cord and falls When in doubt back board ‘em 5 Are all 8 patients assumed to have spinal injuries? Does this man have a spinal injury? Do all such falls cause spinal injuries? Not necessarily, apply EMS Spinal Immobilization. Mechanism based assessment (the current method)

6. Anatomy & Physiology- General Structure & Function Spinal Column • Made up of 26 vertebrae stacked on top of one another • Divided into 5 areas; cervical, thoracic, lumbar, sacral, and coccyx 6

8. Anatomy & Physiology-“Long Bone” Think of the Spinal Column as on “Long Bone” with “Joints” at each end • The Cervical spine makes up one “joint” • The Hip makes up the other 8

9. Anatomy & Physiology- Cervical Spine (7) • “Joint” at the superior end of the spinal “Long Bone” • Very flexible • Allows flexion, extension, and rotation of the head • The head acts as a weighted lever during acceleration/ deceleration • Common site of spinal injuries 9

11. C-1 “Atlas” C-2 “Axis” • C-1 supports the full weight of the head • C-1 and C-2 allow head rotation and fine flexion and extension • 11

12. Anatomy & Physiology- Thoracic Spine (12) • Much less flexible than C-Spine • Stabilized by rib cage (especially down to T-10) • Spinal canal narrow through T-Spine • Spinal cord tightly fitted into narrow space • Spinal cord ends about T-12 or L-1 12

14. Anatomy & Physiology- Lumbosacral Spine • 5 Lumbar vertebrae plus sacrum and coccyx • More flexible than T-spine • More room in spinal canal • Spinal cord ends about T-12 or L-1 • flexible nerve roots (Cauda equina) flow through LS spine 14

16. Anatomy & Physiology- Spinal Cord • Bundles of nerve fibers originating in the brain • Bundles or tracts travel in right and left pairs • Spinal Tract pairs crossover midline at various specific levels • always in specific anatomical areas • understanding of the structure of these tracts helps in assessing spinal cord injuries 16

18. Mechanism of Injury • Physical manner and forces involved in producing injuries or potential injuries • Valuable tool in determining if the a particular set of circumstances could have caused a spinal injury • Mechanisms likely to produce spinal injuries occur in MVAs, falls, violence, and sports (including diving accidents) 18

19. Hyperflexion

20. Hyperextension

21. Hyperotation

22. Axial Loading

23. Axial Distraction

24. Sudden/Extreme Lateral Bending • Excessive/abnormal lateral movement of the spine • Can affect any portion of the spine • Example: T-bone MVAs 24

25. Spinal Column Injury • Bony spinal injuries may or may not be associated with spinal cord injury • These bony injuries include: • Compression fractures of the vertebrae • Comminuted fractures of the vertebrae • Subluxation (partial dislocation) of the vertebrae • Other injuries may include: • Sprains- over-stretching or tearing of ligaments • Strains- over-stretching or tearing of the muscles 25

26. Spinal Cord Injury • Cutting, compression, or stretching of the spinal cord • Causing loss of distal function, sensation, or motion • Caused by: • Unstable or sharp bony fragments pushing on the cord, or • Pressure from bone fragments or swelling that interrupts the blood supply to the cord causing ischemia 26

27. Primary Spinal Cord Injury • Immediate and irreversible loss of sensation and motion • Cutting, compression, or stretching of the spinal cord • Occurs at the time of impact/injury 27

28. Secondary Spinal Cord Injury • Injury Delayed • Occurs later due to swelling, ischemia, or movement of sharp or unstable bone fragments • May be avoided if spine immobilized during extrication, packaging, treatment, and transport 28

29. Incomplete Spinal Cord Injury • Complete injury to specific spinal tracts with reduced function distally • Other tracts continue to function normally with distal function intact 29

30. Spinal Region Overview • Cervical Spine Injuries • Thoracic Spine Injuries • Lumbosacral Spine Injuries • Spinal Injury Summary 30

31. Cervical Spine Injuries • C-spine very flexible • Most frequently injured area of spine • Most injuries at C-5/C-6 level 31

32. Thoracic Spine Injuries • T-spine less flexible • Narrow spinal canal • Cord injury occurs with minimal displacement • Common mechanisms • Any cord damage usually complete at this level • Most T-spine injuries occur at T-9/T-10 32

33. Lumbosacral Spine Injuries • LS spine flexible nerve roots in roomy spinal canal • May have bony injury w/o cord or nerve root damage • Secondary injury still possible • Neurological injury rare w/ isolated sacral injuries 33

34. Assessment Overview • Decision to apply spinal immobilization in past based was solely on mechanism of injury • Utilize EMS Spinal Immobilization Algorithm to determine when spinal immobilization is NOT needed 34

35. Spinal Immobilization Algorithm Patient Mentation: Decreased Level of Consciousness? NoYes ----------------------------Immobilize ETOH/Drug Impairment? NoYes ----------------------------Immobilize Subjective Assessment: Cervical/Thoracic/Lumbar Spinal pain? No Yes ----------------------------Immobilize Numbness/Tingling/Burning/Weakness? NoYes -----------------------------Immobilize Objective Assessment: Cervical/Thoracic/Lumbar Deformity or Tenderness? NoYes -----------------------------Immobilize Other Severe Injury? NoYes -----------------------------Immobilize Other Severe Injury? NoYes -----------------------------Immobilize Pain w/Cervical Range of Motion? NoYes -----------------------------Immobilize MAY TREAT/TRANSPORT WITHOUT SPINAL PRECAUTIONS 35

36. Principles of Treatment • Protect spinal cord from secondary injury • We have little or no effect on primary injury • Focus on prevention of secondary injury 36

37. Complete Spinal Immobilization • Must act as if whole spine unstable • Immobilize entire spine • To do this we must immobilize the head, neck, shoulders/chest, and pelvis /hips 37

38. Common Treatment/Management Mistakes • Improperly sized C-Collar • Spine not supported due to improper positioning on backboard • Inadequate strapping allows excessive movement • Movement possible due to little or no padding to shim the body • C-spine movement by inadequate or improperly applied head immobilization device • C-spine hyperextension due to improperly applied C-collar or head immobilization device 38

39. Common Treatment/Management Mistakes (cont.) • Readjusting torso straps after immobilization of the head, causing misalignment of the spine • Securing head to backboard prior to securing shoulders, torso, hips, and legs 39

40. Any Questions???