Managing (Acute) Traumatic Spinal Injuries
Dr. Richard Bwana Ombachi Lecturer and Consultant Spine &
Orthopaedic surgeon
IntroductionSpine -Vertebral Column/Nervous Tissue5% worsen in the hospitalProtection is priority –Diagnosis a secondary
priorityTreat the spine of an alive patient – Identify
live threatening conditionsEffects 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 Injuries Devastating effectProtection primary priorityManagement starts at the scene of the
accident
Spinal Cord InjuryPrimary Injury- physical injury by mechanical
forces ContusionCompressionStretchLaceration –
penetrating foreign bodies, missiles, fragments or displaced bone
Secondary InjuryAdditional neural tissue damage from biologic
response Changes local blood flow Tissue oedema Metabolite concetration lethal to the neural tissues
leading to further injury
StatisticsAetiology
RTA 45% ( motor cycle accidends )Falls 20%Sports 15 %Assault 15%
Gender ratio M: F 4:1Neurologic Injury
Cervical 40%Thoracolumbar 20%
PRINCIPLES OF MANAGEMENT Suspect Spinal Injuries and Protect further
injuryImmobilize the spineAssess the patient (ATLS Protocal)Manage live threatening conditions while
caring for spineImage patient to identify the injuriesManage/Reffer injuries as appropriate
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 ExaminationPatient should be log rolled by at least 4 people
for back examinationleakage of CSF or blood behind the tympanic
membrane- a skull fracture. paraplegia/ quadriplegiaPainful 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 SpineProtection PriorityNeck immobilization firm collar + head strapped
to bolsters/ sand bags on either side to the boardImmobilize in neutral position don’t correct
deformities- ? AS, ? RS children, ? SpondylosisChildren - 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 EXAMINATIONDone 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 ChartASIA Chart.pdf
Spinal ShockSpinal 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 ShockInjuries 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 70mmHgDo not over infuse pt use ionotropic drugs
Vertebral Column ExaminationDone in Secondary SurveyUse log rolling techniqueDetect
Bruises/ LacerationsSwellings / BogginessStep or Gap DeformityTenderness
Remove spine board at this stage if not referring
Radiological Imaging IndicationsNo 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 deficitXray affected areas consider flex-ext
X-raysAABBCCDs
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 / MRICT Scan
Clearance in patients with questionable or inadequate plain radiographs
Assess occipitocervical and cervicothoracic junctions
MRISpinal cord injury – disruptions, oedema,
haematomasIntervertebral disc disruptionPosterior ligamentous disruptionCanal compromise and neural tissue compression
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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