Spine and Spinal Cord Trauma. Objectives Anatomy/physiology Evaluate a patient with spinal injury...
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Transcript of Spine and Spinal Cord Trauma. Objectives Anatomy/physiology Evaluate a patient with spinal injury...
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
• Multiple injuries
• Neurologic deficit
• Spinal pain/tenderness
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
• 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
• Levels vs sensation
Motor Examination
• Table outlining levels
Neurogenic Shock
• Hypotension associated with cervical/high thoracic spine injury
• Bradycardia
• Tx: fluid, atropine, pressors
Spinal Shock
• Neurologic, not hemodynamic phenomenon
• Occurs shortly after cord injury
• Flaccidity
• Loss of reflexes
Effects on other organ systems
• Inadequate ventilation
• Compromised abdominal evaluation
• Occult compartment syndrome
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
Spinal Cord Syndromes
• Central• Anterior• Brown-sequard
• Anatomy diagram
Classifications: morphology
• Fracture or fracture dislocation
• SCIWORA
• Penetrating
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
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
• 10% have a second fracture
• Look for second fracture!
• One fracture mandates full spine films
Xray Guidelines
• Adequacy• Alignment• Bones• Cartilage• Contours• Disc space• Soft tissue
• Thoracolumbar spine Xray
Screening for Spinal Injury
• Algorithim – Paraplegia/quadraplegia– Presumed spinal instability– Identify bony fracture-subluxation– Consult neurosurgery or orthopedics
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 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 injury
• Altered LOC– Complete spine films– Plain films– CT prn
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
Medical Management
• Ensure A/B
• Maintain BP
• Atropine prn
• Methylprednisolone
Medical Management
• Intravenous fluids– Treat hypovolemia first– Consider neurogenic shock– Insert foley
Medical Management
• Steroids– Methylpred doses
Medical Management
• Transfer– Unstable fractures– Neurologic deficit– Avoid delay– Proper immobilization– Respiratory support as needed
Questions
Summary
• Treat life-threatening injuries first (ABCD)
• Immobilization
• Appropriate Xrays
• Document examination
• Consultation
• Transfer