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?
Whats the difference ?
Awake
ask/answer question
pain/tenderness
motor/sensory exam

OW!

Not awake
you can ask (but they wont answer)
cant assess tenderness
no motor/sensory exam

------

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

Comparison of neurogenic and hypovolemic shock

Neurogenic
Etiology

Hypovolemic

Loss of sympathetic Loss of blood volume

outflow

Blood
pressure

Hypotension

Hypotension

Heart rate

Bradycardia

Tachycardia

Skin
temperature

Warm

Cold

Urine
output

Normal

Low
18

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

spinal shock
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

NO
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

YES
Able to actively rotate neck?
45 degrees left and right

ABLE
No Radiography

YES
NO

Radiography

UNABLE

National Emergency X
Radiography Utilization Study
(NEXUS)

&
The Canadian C-spine rule
Both have:
Excellent negative predictive value for
excluding patients identified as low risk

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 Swimmers

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 swimmers view
or CT

Swimmers 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 FiO2
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 Shovelers 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
the AP diameter of the
vertebral body below it
High incidence of spinal
cord injury
Extremely unstable

Hangmans 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