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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
  • Vertebral Column Trauma and
  • Nervous Tissue Trauma
    • Somatic Nervous System
      • Spinal Cord tracts
      • Nerve roots / Nerves
    • Autonomic Nervous System
      • sympathetic

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

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
    • 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