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Spine and Spinal Trauma

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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):

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