Managing acute traumatic spinal injuries
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Managing (Acute) Traumatic Spinal Injuries. Dr. Richard Bwana Ombachi Lecturer and Consultant Spine & Orthopaedic surgeon . Introduction. Spine -Vertebral Column/Nervous Tissue 5% worsen in the hospital Protection is priority –Diagnosis a secondary priority

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Managing acute traumatic spinal injuries

Managing (Acute) Traumatic Spinal Injuries

Dr. Richard Bwana Ombachi

Lecturer and Consultant Spine & Orthopaedic surgeon


  • 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

  • Trauma

    • Vertebral Column Trauma and

    • Nervous Tissue Trauma

      • Somatic Nervous System

        • Spinal Cord tracts

        • Nerve roots / Nerves

      • Autonomic Nervous System

        • sympathetic

    Spinal cord injury
    Spinal Cord Injury

    • Primary Injury- physical injury by mechanical forces

      • Contusion

      • Compression

      • Stretch

      • Laceration –

        • penetrating foreign bodies,

        • missiles,

        • fragments or displaced bone

    • 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


    • Aetiology

      • RTA 45% ( motor cycle accidends )

      • Falls 20%

      • Sports 15 %

      • Assault 15%

    • Gender ratio M: F 4:1

    • Neurologic Injury

      • Cervical 40%

      • Thoracolumbar 20%

    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

    Suspect spinal injuries
    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

    Tale tell signs on examination
    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

    Immobilize the spine
    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)

    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)

    Asia chart
    Asia Chart

    • ASIA Chart.pdf

    Spinal shock
    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)

    Neurogenic shock
    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

    Vertebral column examination
    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

    Radiological imaging indications
    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

    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

    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

    Summary of management
    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