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Spine and Spinal Cord Trauma. Objectives. Anatomy/physiology Evaluate a patient with spinal injury Identify common spinal injuries and Xray features Appropriately manage the spinal-injured patient Determine appropriate disposition. Suspected Spinal Injury. High speed crash Unconscious

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Presentation Transcript
objectives
Objectives
  • Anatomy/physiology
  • Evaluate a patient with spinal injury
  • Identify common spinal injuries and Xray features
  • Appropriately manage the spinal-injured patient
  • Determine appropriate disposition
suspected spinal injury
Suspected Spinal Injury
  • High speed crash
  • Unconscious
  • Multiple injuries
  • Neurologic deficit
  • Spinal pain/tenderness
spinal injury
Spinal injury
  • 5% worsen neurologically at hospital
  • Protection is a priority
  • Detection is a secondary priority
  • Spinal evaluation complicated by TBI
  • Remove spine boards ASAP
cord injury severity
Cord Injury Severity
  • Complete = no motor function or sensory function below the injury level
  • Incomplete = any preservation of function
    • Sacral sparing may be the only preservation of function
sensory examination
Sensory Examination
  • Levels vs sensation
motor examination
Motor Examination
  • Table outlining levels
neurogenic shock
Neurogenic Shock
  • Hypotension associated with cervical/high thoracic spine injury
  • Bradycardia
  • Tx: fluid, atropine, pressors
spinal shock
Spinal Shock
  • Neurologic, not hemodynamic phenomenon
  • Occurs shortly after cord injury
  • Flaccidity
  • Loss of reflexes
effects on other organ systems
Effects on other organ systems
  • Inadequate ventilation
  • Compromised abdominal evaluation
  • Occult compartment syndrome
classification of injuries levels of injury
Classification of Injuries: Levels of injury

Clinical exam

Most caudal

Normal bilaterally

Motor/sensory function

Bony = site of vertebral damage

classification
Incomplete

Any sensation

Position sense

Voluntary movement in lower extremity

Sacral sparing

Complete

No motor/sensory function

No sacral sparing

May have reflexes

Classification
spinal cord syndromes
Central

Anterior

Brown-sequard

Anatomy diagram

Spinal Cord Syndromes
classifications morphology
Classifications: morphology
  • Fracture or fracture dislocation
  • SCIWORA
  • Penetrating
classification morphology
Classification: morphology
  • Unstable if:
    • Xray evidence of injury
    • Neurologic injury
    • Severe pain on spine movement or palpation
xray guidelines
A

A

B

B

C

C

D

S

Normal C spine Xray

Xray Guidelines
c spine xrays
C spine Xrays
  • Cross table lateral detects 85%
  • Additional 2 views excludes most fractures
  • May also require:
    • Swimmer’s
    • CT
    • Flex/ex
    • MRI
cspine xrays
Cspine Xrays
  • 10% have a second fracture
  • Look for second fracture!
  • One fracture mandates full spine films
xray guidelines19
Adequacy

Alignment

Bones

Cartilage

Contours

Disc space

Soft tissue

Thoracolumbar spine Xray

Xray Guidelines
screening for spinal injury
Screening for Spinal Injury
  • Algorithim
    • Paraplegia/quadraplegia
    • Presumed spinal instability
    • Identify bony fracture-subluxation
    • Consult neurosurgery or orthopedics
screening for spinal injury21
Screening for Spinal Injury
  • Alert, sober neurologically normal patient:
    • No neck pain or tenderness
    • No distracting injury
    • No pain with voluntary movement
  • No further Xrays required
screening for spinal injury22
Screening for spinal injury
  • Alert, sober, neurologically normal patient
    • Neck or spin pain or tenderness to palpation or voluntary movement
    • After removal of c-collar?
    • If yes to any question
      • Protect cspine
      • Obtain necessary Xray exams
screening for spinal injury23
Screening for spinal injury
  • Altered LOC
    • Complete spine films
    • Plain films
    • CT prn
screening for spinal injury24
Screening for Spinal Injury
  • Radiographic
    • Normal Xray
  • Clinical
    • Normal neurologic exam and
    • Absence of spinal pain/tenderness
  • Caution!
    • Drugs, alcohol, distracting injuries
management
Immobilization

Entire patient

Propper padding

Maintain until cleared

Avoid prolonged use of backboard

Decubitus ulcer

Management
medical management
Medical Management
  • Ensure A/B
  • Maintain BP
  • Atropine prn
  • Methylprednisolone
medical management27
Medical Management
  • Intravenous fluids
    • Treat hypovolemia first
    • Consider neurogenic shock
    • Insert foley
medical management28
Medical Management
  • Steroids
    • Methylpred doses
medical management29
Medical Management
  • Transfer
    • Unstable fractures
    • Neurologic deficit
    • Avoid delay
    • Proper immobilization
    • Respiratory support as needed
summary
Summary
  • Treat life-threatening injuries first (ABCD)
  • Immobilization
  • Appropriate Xrays
  • Document examination
  • Consultation
  • Transfer