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Assessment of Spinal Injury. Stephen Schutts, Master Sergeant, WA ANG National Registry Emergency Medical Technician - Paramedic 1. Objectives. Identify the anatomical levels of the spine. Understand the function of the spinal cord/column.
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Assessment of Spinal Injury Stephen Schutts, Master Sergeant, WA ANG National Registry Emergency Medical Technician - Paramedic 1
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
Objectives • Overview of Spinal Regions and Injuries • Step by step view of the EMS Spinal Immobilization Assessment Protocol • Discuss Common Treatment/Management Mistakes 3
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
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)
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
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
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
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
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
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
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
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
Sudden/Extreme Lateral Bending • Excessive/abnormal lateral movement of the spine • Can affect any portion of the spine • Example: T-bone MVAs 24
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
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
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
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
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
Spinal Region Overview • Cervical Spine Injuries • Thoracic Spine Injuries • Lumbosacral Spine Injuries • Spinal Injury Summary 30
Cervical Spine Injuries • C-spine very flexible • Most frequently injured area of spine • Most injuries at C-5/C-6 level 31
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
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
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
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
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
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
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
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