Spinal Injury & Spinal Cord Injury For General Practice นพ.เกรียงไกร วิทยาไพโรจน์ Spine Unit , ORTHO-KKU

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 6

PROTECTION  PRIORITY Detection  Secondary “Log-rolling” 7

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 Direction of Impact 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 Neurological assessment 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

Loss of sympathetic outflow Comparison of neurogenic and hypovolemic shock Neurogenic Hypovolemic Etiology Loss of sympathetic outflow Loss of blood volume Blood pressure Hypotension Heart rate Bradycardia Tachycardia Skin temperature Warm Cold Urine output Normal Low

Definitions of terms Neurologic level Skeletal level Complete injury 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 ไปก่อน 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 : Variable sensory loss Sacral sparing 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)

YES NO Radiography UNABLE NO YES ABLE No Radiography 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 YES 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 NO Radiography YES UNABLE Able to actively rotate neck? • 45 degrees left and right ABLE No Radiography

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 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 Assess spaces between the spinous processes 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 49

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