1. Spine and Spinal Trauma
Rebecca Burton-MacLeod
R1, Emergency Medicine
Aug 21, 2003

2. Numbers ~10,000 new cases each year in US
over 1 million pts with blunt trauma and potential c-spine injury seen in US EDs
of these pts, <1% have acute # or spinal injury
SIGNIFICANT CONSEQUENCES!

3. Who?
Age >65
male
white or “other” ethnicity

4. How? MVA 50% falls 20% sporting accidents 15%
remainder from acts of human violence
predisposing factors--arthritic disease, OP, Ca

5. Anatomy….[oh no!]
33 vertebrae--7cervical, 12thoracic, 5lumbar, 5sacral (fused), 4coccyx (fused)
intervertebral discs separate them, and ligaments support
spinal cord goes from midbrain to L2 level
anterior column (vertebral bodies, discs, ant/post longitudinal ligs) and posterior column (pedicles, transverse processes, facets, laminae, spinous processes, spinal canal, nuchal/capsular ligs, ligamentum flavum)

6. Spinal column

7. Million $ question...
Stable--disruption of only one of ant/post columns vs
unstable--disruption of both columns at same level OR c1/2 #

8. Classification of spinal column injuries
Flexion
extension
flexion-rotation
vertical compression

9. Flexion injuries

10. Flexion injuries
Wedge #
teardrop #

11. Flexion injuries
Clay shoveller # (lat)
clay shoveller # (AP)

12. Flexion injuries
Bilateral facet dislocation

13. Extension injuries

14. Extension injuries
Extension teardrop #

15. Extension injuries
Hangmans #

16. Flexion-rotation injuries

17. Flexion-rotation injuries
Unilateral facet disloc

18. Vertical compression injuries

19. Vertical compression injuries
Burst #

20. Vertical compression injuries
Jefferson #

21. Spinal cord injuries
Primary--mechanical disruption of axons as result of stretch, laceration, or vascular injury vs
secondary--progressive injury; caused by free radical formation, uncontrolled calcium influx, ischemia, lipid peroxidation

22. Secondary spinal cord injuries
Reversible/preventable factors:
hypogylcemia
hypoxia
hypotension
hyperthermia
mishandling by medical personnel

23. Spinal cord injuries
Complete--total loss of motor power and sensation distal to lesion vs
incomplete--3 syndromes (central cord, anterior cord, Brown-Sequard), SCIWORA

24. Complete spinal cord injuries
If lasts >24hrs, 99% will have no functional recovery
must look for any evidence of cord function
sacral sparing is key!
Ddx: spinal shock
cannot diagnose complete injury until bulbocavernosus reflex is elicited

25. Incomplete spinal cord injuries

26. Incomplete spinal cord injuries
Central cord syndrome:
affect upper extremities>lower extremities
50+% of patients with a severe central cord syndrome have a return of bowel and bladder control, become ambulatory, and regain some hand function
may mimic complete cord injury

27. Incomplete spinal cord injuries
Anterior cord syndrome
caused by:
cervical flexion injuries causing cord contusion
protrusion of a bony fragment or herniated intervertebral disk into the spinal canal
laceration or thrombosis of the anterior spinal artery
systemic embolization or prolonged cross-clamping of the aorta

28. Anterior cord s/o cont’d
paralysis below level of injury
hypalgesia below the level of injury
preservation of posterior column functions (position, touch, and vibratory sensations)

29. Incomplete spinal cord injuries
Brown-Sequard syndrome:
hemisection of spinal cord
often due to penetrating trauma, or may be due to # of lat mass of c-spine
ipsilateral paralysis and contralateral sensory hypesthesia below level of injury
most retain bladder/bowel control

30. SCIWORA
Usually <8yrs of age following c-spine injury; no injury seen on complete plain radiographic series
possibly due to immature anatomy and increased ligamentous elasticity
causes transient spinal column subluxation, stretching of the spinal cord, and variable degrees of vascular compromise

31. SCIWORA cont’d
brief episode of upper extremity weakness or paresthesias, followed by the development of neurologic deficits that appear hours to days later

32. on exam
Vitals, GCS
inspection--facial contusions, head injuries, trunk contusions, obvious deformities/penetrating injuries
palpation--spine for step-off deformity, widened interspinous space
neuro exam

33. Motor exam

34. Deep tendon reflexes
UMN--present reflexes (but may be absent acutely during spinal shock)
LMN--absent reflexes

35. Sensory function Light touch--posterior column function
painful touch--anterior spinothalamic function

36. Investigations
Plain radiography CT
MRI

37. Radiography NEXUS: 34,069 pts with blunt trauma
818 pts with c-spine injuries
sensitivity %, specificity 12.9%
23 pts (3 potentially unstable) had injuries not visualized on radiography (2.81% of all pts with radiography performed)

38. Radiography NEXUS criteria for c-spine xrays:
all 5 criteria must be met, or else xray:
absence of midline tenderness
normal alertness
no evidence of intoxication**
no focal neurological deficit
no painful distracting injuries**
** poorly reproducible

39. Radiography Canadian C-spine rules:
8924 pts enrolled with trauma to head/neck, stable vitals, GCS=15
excluded pts--<16yrs, penetrating trauma, known vertebral disease
151 clinically important c-spine injuries (1.7%)
sensitivity 100%, specificity 42.5%
identified 27 of 28 unimportant c-spine injuries (missed c3 avulsion #)
potential radiography rate 58.2% (down from 68.9%!!)

40. Radiography Canadian c-spine rules for radiography:
high risk factors? (>=65yrs, dangerous mechanism, paresthesias)
**must have radiography
low risk factors? (simple rear-end MVC, sitting in ED, ambulatory since injury, delayed onset pain, absence midline c-spine tenderness)
**then may assess range of motion
rotate neck to left and right? (45degrees both directions)
**do not require radiography

41. Radiography Standard trauma series (Caroline’s excellent review!!):
lateral AP
open-mouth odontoid
oblique view--posterior laminar fracture, a unilateral facet dislocation, or a real subluxation
flexion-extension views--if severe pain but normal 3views

42. CT
Indications:
inadequate radiography (as high as 25% for visualization of c7-t1)
suspicious radiography findings
fracture/displacement demonstrated by standard radiography
high clinical suspicion of injury, despite normal radiography
pts undergoing CT of head/abdomen may be considered

43. CT Pros Cons evaluate spinal canal
evaulates paravertebral soft tissues
limited movement required
Cons
limited views of vert body displacement
poor visualization of horizontal #
**overcome by spiral CT
*May eventually replace radiography, but not current standard of care as initial investigation*

44. CT
# right lateral mass

45. MRI Excellent for evaluation of neurological injury
useful for: ligamentous injury, bony compression, epidural and subdural hemorrhage, and vertebral artery occlusion

46. MRI
C-spinal cord hemorrhage

47. Management Goals Preservation of pts life
optimizing potential for recovery of neurologic function

48. Management Prehospital: high index of suspicion
spinal immobilization--c-collar and backboard with sandbags and tape

49. ED Management ABC’s: above level of c3 often loss of resp drive
avoid hyperextension of neck if intubation necessary
above level of t6 often “functional sympathectomy”--systemic hypotension
treat with Trendelenburg position and crystalloid infusion

50. ED Management Pharm: (NASCIS II and III):
487 pts--overall analysis negative
193 pts--positive effect post hoc analysis
modest improvement in functional recovery at 1yr
loading dose 30mg/kg IV within 8hrs of injury
if loading dose started within 3hrs, then 5.4mg/kg/h IV drip for 24hrs**
if loading dose started 3-8hrs post-injury, then 5.4mg/kg/h IV drip for 48hrs**
no benefit if given >8hrs after injury, or for penetrating injuries
**Class II evidence (guideline)

51. ED Management Other pharmacological agents suggested:
lazaroid (lipid peroxidation inhibitor)
ganglioside
**no clear benefit, if any

52. Complications of spinal cord injuries
Pulmonary edema
GI tract and bladder atonia
pressure necrosis on skin
DVT/PE

53. Disposition Referral to spine injury centre
minor ligamentous injuries--outpt pain mgmt
minor #--hospitalization for appropriate work-up and pain mgmt

54. ?

55. References
Berlin CT versus radiography for initial evaluation of c-spine trauma: What is the standard of care? AJR 180:911-5.
Fehlings, MG Editorial: Recommendations regarding the use of methylprednisolone in acute spinal cord injury: Making sense out of the controversy. Spine 26(24S):S56-7.
Lowery DW et al Epidemiology of cervical spine injury victims. Ann Emerg Med jul;38(1):12-6.
Marx Rosen’s Emergency Medicine: Concepts and clinical practice, 5th ed. Mosby, Inc.
Mower WR et al Use of plain radiography to screen for cervical spine injuries. Ann Emerg Med Jul;38(1):1-7.
Nockels, RP Nonoperative management of acute spinal cord injury. Spine 26(24S):S31-7.
Stiell IG et al. The Canadian c-spine rule for radiography in alert and stable trauma patients. JAMA 286(15):