นพ.

เกรี ยงไกร วิทยาไพโรจน์
Spine Unit , ORTHO-KKU

Spinal Injury
&
Spinal Cord
Injury



For General Practice
Outline
• Goal of spine trauma care
• Pre-hospital management
• Clinical and neurologic assessment
• Acute spinal cord injury
– Term, type and clinical characteristic
• Common cervical spine fracture and
dislocation

Goal of spine trauma care
• Protect further injury during evaluation and
management

• Identify spine injury or document absence of
spine injury

• Optimize conditions for maximal neurologic
recovery

Goal of spine trauma care
• Maintain or restore spinal alignment

• Minimize loss of spinal mobility

• Obtain healed & stable spine

• Facilitate rehabilitation
Suspected Spinal Injury
• High speed crash
• Unconscious
• Multiple injuries
• Neurological deficit
• Spinal pain/tenderness
Pre-hospital management
• Protect spine at all times during the
management of patients with multiple injuries

• Up to 15% of spinal injuries have a second
(possibly non adjacent) fracture elsewhere in
the spine

• Ideally, whole spine should be immobilized in
neutral position on a firm surface

• PROTECTION  PRIORITY
• Detection  Secondary



“Log-rolling”



Pre-hospital management
• Cervical spine immobilization

• Transportation of spinal cord-injured
patients

Cervical spine immobilization
• “Safe assumptions”
– Head injury and unconscious
– Multiple trauma
– Fall
– Severely injured worker
– Unstable spinal column

• Hard backboard, rigid cervical collar and lateral
support (sand bag)

• Neutral position
Philadelphia hard collar
Transportation of spinal cord-injured
patients
• Emergency Medical Systems (EMS)
• Paramedical staff
• Primary trauma center
• Spinal injury center

Clinical assessment
• Advance Trauma Life Support (ATLS)
guidelines
• Primary and secondary surveys
• Adequate airway and ventilation are the
most important factors
• Supplemental oxygenation
• Early intubation is critical to limit secondary
injury from hypoxia

Physical examination
• Information
• Mechanism
– energy, energy
• Direction of Impact
• Associated Injuries
Is the patient awake or
“unexaminable”?
• What’s the difference ?
– Awake
• ask/answer question
• pain/tenderness
• motor/sensory exam

– Not awake
• you can ask (but they won’t answer)
• can’t assess tenderness
• no motor/sensory exam
OW!
------
“Unexaminable”




“No exam”
Physical examination
• Inspection and palpation
– Occiput to Coccyx
– Soft tissue swelling and bruising
– Point of spinal tenderness
– Gap or Step-off
– Spasm of associated muscles

• Neurological assessment
– Motor, sensation and reflexes
– PR

• Do not forget the cranial nerve (C0-C1 injury)



Neurogenic Shock
• Temporary loss of autonomic function of the
cord at the level of injury
– results from cervical or high thoracic injury
• Presentation
– Flaccid paralysis distal to injury site
– Loss of autonomic function
• hypotension
• vasodilatation
• loss of bladder and bowel control
• loss of thermoregulation
• warm, pink, dry below injury site
• bradycardia




18
Neurogenic Hypovolemic
Etiology Loss of sympathetic
outflow
Loss of blood volume
Blood
pressure
Hypotension Hypotension
Heart rate Bradycardia Tachycardia
Skin
temperature
Warm Cold
Urine
output
Normal Low
Comparison of neurogenic and hypovolemic shock
Definitions of terms
• Neurologic level
– Most caudal segment with normal sensory and
motor function both sides
• Skeletal level
– Radiographic level of greatest vertebral damage
• Complete injury
– Absence of sensory and motor function in the
lowest sacral segment
• Incomplete injury
– Partial preservation of sensory and/or motor
function below the neurologic level

Neurologic assessment
• Spinal shock
– Bulbocavernosus reflex

• Complete VS incomplete cord injury
– ต้องพ้นภาวะ spinal shock ไปก่ อน
– Sacral sparing
• Voluntary anal sphincter control
• Toe flexor
• Perianal sensation
• Anal wink reflex

Neurologic assessment
• American Spinal Injury Association grade
– Grade A – E

• American Spinal Injury Association score
– Motor score (total = 100 points)
• Key muscles : 10 muscles
– Sensory score (total = 112 points)
• Key sensory points : 28 dermatomes

Incomplete cord injury
• Anterior cord syndrome
• Brown-Sequard syndrome
• Central cord syndrome

Anterior cord syndrome

• Loss of motor, pain
and temperature

• Preserved
propioception and
deep touch

Brown-Sequard syndrome

• Loss of ipsilateral
motor and
propioception

• Loss of contralateral
pain and
temperature

Central cord syndrome

• Weakness :
– upper > lower

• Variable sensory
loss

• Sacral sparing

Radiographic imaging
• Who needs an x- ray of the spine ?

 NEXUS -The National Emergency X- Radiograph
Utilization Study
– Prospective study to validate a rule for the decision to obtain
cervical spine x- ray in trauma patients
– Hoffman, N Engl J Med 2000; 343:94-99
 Canadian C-Spine rules
– Prospective study whereby patients were evaluated for 20
standardized clinical findings as a basis for formulating a
decision as to the need for subsequent cervical spine
radiography
– Stiell I. JAMA. 2001; 286:1841-1846

NEXUS
• NEXUS Criteria:
1. Absence of tenderness in the posterior midline
2. Absence of a neurological deficit
3. Normal level of alertness (GCS score = 15)
4. No evidence of intoxication (drugs or alcohol)
5. No distracting injury/pain
NEXUS
• Patient who fulfilled all 5 of the criteria were
considered low risk for C-spine injury
 No need C-spine X-ray

• For patients who had any of the 5 criteria
 radiographic imaging was indicated
( AP, lateral and open mouth views)
The Canadian C-spine Rule for alert and stable trauma patients where cervical
spine injury is a concern.
• Any high-risk factor that mandates radiography?
• Age>65yrs or
• Dangerous mechanism or
• Paresthesia in extremities
Any low-risk factor that allows safe
assessment of range of motion?
• Simple rear-end MVC, or
• Sitting position in ER, or
• Ambulatory at any time, or
• Delayed onset of neck pain, or
• Absence of midline C-spine tenderness
Able to actively rotate neck?
• 45 degrees left and right
No Radiography
Radiography
NO
YES
ABLE
YES
NO
UNABLE
National Emergency X
Radiography Utilization Study
(NEXUS)
Both have:
• Excellent negative predictive value for
excluding patients identified as low risk
The Canadian C-spine rule
&
Clearance of Cervical Spine Injury in
Conscious, Symptomatic Patients
1. Radiological evaluation of the cervical spine is
indicated for all patients who do not meet the
criteria for clinical clearance as described
above

2. Imaging studies should be technically adequate
and interpreted by experienced clinicians
Cervical Spine Imaging Options
– Plain films
• AP, lateral and open mouth view
– Optional: Oblique and Swimmer’s

– CT
• Better for occult fractures

– MRI
• Very good for spinal cord, soft tissue and
ligamentous injuries

– Flexion-Extension Plain Films
• to determine stability

Radiolographic evaluation
X-ray Guidelines (cervical)
AABBCDS

• Adequacy, Alignment
• Bone abnormality, Base of skull
• Cartilage
• Disc space
• Soft tissue
Adequacy
• Must visualize entire C-spine
• A film that does not show the
upper border of T1 is
inadequate
• Caudal traction on the arms
may help
• If can not, get swimmer’s view
or CT


Swimmer’s view
Alignment
• The anterior vertebral line,
posterior vertebral line, and
spinolaminar line should
have a smooth curve with
no steps or discontinuities

• Malalignment of the
posterior vertebral bodies is
more significant than that
anteriorly, which may be
due to rotation

• A step-off of >3.5mm is
significant anywhere
Lateral Cervical Spine X-Ray
• Anterior subluxation of one
vertebra on another indicates
facet dislocation
– < 50% of the width of a vertebral
body  unilateral facet
dislocation
– > 50%  bilateral facet
dislocation
Bones
Disc
• Disc Spaces
– Should be uniform
• Assess spaces
between the
spinous processes

Soft tissue
• Nasopharyngeal space
(C1)
– 10 mm (adult)

• Retropharyngeal space
(C2-C4)
– 5-7 mm

• Retrotracheal space
(C5-C7)
– 14 mm (children)
– 22 mm (adults)
AP C-spine Films
• Spinous processes
should line up
• Disc space should be
uniform
• Vertebral body height
should be uniform.
Check for oblique
fractures.
Open mouth view
• Adequacy: all of
the dens and
lateral borders of
C1 & C2
• Alignment: lateral
masses of C1 and
C2
• Bone: Inspect dens
for lucent fracture
lines
CT Scan
• Thin cut CT scan should
be used to evaluate
abnormal, suspicious or
poorly visualized areas
on plain film

• The combination of plain
film and directed CT scan
provides a false negative
rate of less than 0.1%
MRI
• Ideally all patients with
abnormal neurological
examination should be
evaluated with MRI
scan
Management of SCI
• Primary Goal
– Prevent secondary injury

• Immobilization of the spine begins in the initial
assessment
– Treat the spine as a long bone
• Secure joint above and below
– Caution with “partial” spine splinting

Management of SCI
• Spinal motion restriction: immobilization devices
• ABCs
– Increase FiO
2

– Assist ventilations as needed with c-spine control
– Indications for intubation :
• Acute respiratory failure
• GCS <9
• Increased RR with hypoxia
• PCO2 > 50
• VC < 10 mL/kg
– IV Access & fluids titrated to BP ~ 90-100 mmHg
Management of SCI
• Look for other injuries: “Life over Limb”
• Transport to appropriate SCI center once
stabilized
• Consider high dose methylprednisolone
– Controversial as recent evidence questions benefit
– Must be started < 8 hours of injury
– Do not use for penetrating trauma
– 30 mg/kg bolus over 15 minute
– After bolus: infusion 5.4mg/kg IV for 23 hours
Principle of treatment
• Spinal alignment
– deformity/subluxation/dislocation reduction

• Spinal column stability
– unstable  stabilization

• Neurological status
– neurological deficit  decompression
Jefferson Fracture
• Burst fracture of C1 ring

• Unstable fracture

• Increased lateral ADI on
lateral film if ruptured
transverse ligament and
displacement of C1 lateral
masses on open mouth view

• Need CT scan
Burst Fracture
• Fracture of C3-C7 from
axial loading

• Spinal cord injury is
common from posterior
displacement of fragments
into the spinal canal

• Unstable



Clay Shoveler’s Fracture
• Flexion fracture of
spinous process

• C7>C6>T1

• Stable fracture



Flexion Teardrop Fracture
• Flexion injury causing a
fracture of the
anteroinferior portion of
the vertebral body

• Unstable because
usually associated with
posterior ligamentous
injury

Bilateral Facet Dislocation
• Flexion injury
• Subluxation of dislocated
vertebra of greater than
½ the AP diameter of the
vertebral body below it
• High incidence of spinal
cord injury
• Extremely unstable
Hangman’s Fracture
• Extension injury

• Bilateral fractures of
C2 pedicles
(white arrow)

• Anterior dislocation of
C2 vertebral body
(red arrow)

• Unstable
Odontoid Fractures
• Complex mechanism of injury
• Generally unstable
• Type 1 fracture through the tip
– Rare
• Type 2 fracture through the base
– Most common
• Type 3 fracture through the base and body
of axis
– Best prognosis


Odontoid Fracture Type II
Odontoid Fracture Type III
THANK YOU
FOR YOUR ATTENTION