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

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Managing acute traumatic spinal injuries

Managing (Acute) Traumatic Spinal Injuries

Dr. Richard Bwana Ombachi

Lecturer and Consultant Spine & Orthopaedic surgeon


Introduction

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


  • Trauma

    Trauma

    • Vertebral Column Trauma and

    • Nervous Tissue Trauma

      • Somatic Nervous System

        • Spinal Cord tracts

        • Nerve roots / Nerves

      • Autonomic Nervous System

        • sympathetic


    Managing acute traumatic spinal injuries

    • Spinal Injuries Devastating effect

    • Protection primary priority

    • Management starts at the scene of the accident


    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


    Managing acute traumatic spinal injuries

    • 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


    Statistics

    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%


    Principles of management

    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

    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

    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 / 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


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