Spinal cord injury HOANG TRONG AI QUOC, MD EMERGENCY DEPARTMENT

Spinal cord injury HOANG TRONG AI QUOC, MD EMERGENCY DEPARTMENT
HUE CENTRAL HOSPITAL, VIETNAM 2011

Objectives Describe the basic spinal anatomy and physiology
Evaluate a patient with suspected spinal injury Identify the common types of spinal injuries and their X-ray features. NEXUS and Canadian C-spine rules Stable vs Unstable fractures Appropriately manage the spinal-injured patient during the first hour from injury. Determine the appropriate disposition of the patient with spine trauma

Introduction Vertebral column injury, with or without neurological deficits, must always be sought and excluded in a patient with Multiple trauma. Any injury above the clavicle Age and gender: 65-80% occur in men 60% occur in years of age Mechanisms: MVC (48%) Falls (21%) Penetrating injuries (15%) Sports injuries (14%)

Epidemiology 40% of trauma patients with neuro deficits will have temporary or permanent SCI Many more vertebral injuries that do not result in cord injury 10-15% have non-contiguous injuries Multiple injuries in non-adjacent vertebrae Most commonly injured vertebrae C5-C7 C1-C2 T12-L2

Beware Excessive manipulation and inadequate immobilization of a patient with a spinal cord injury can cause additional neurological damage and worsen the patient’s outcome

Anatomy and physiology
The spinal column: 7 cervical, 12 thoracic, and 5 lumbar vertebrae as well as the sacrum and the coccyx. For many reasons, the cervical spine is most vulnerable to injury The thoracolumbar junction is a fulcrum between the inflexible thoracic region and the stronger lumbar levels. This makes it more vulnerable to injury, with 15% of all spinal injuries occurring in this region.

Cervical Spine 7 vertebrae very flexible C1: also known as the atlas C2: also known as the axis

Thoracic Spine 12 vertebrae ribs connected to spine provides rigid framework of thorax

Lumbar Spine 5 vertebrae largest vertebral bodies carries most of the body’s weight Sacrum 5 fused vertebrae common to spine and pelvis Coccyx 4 fused vertebrae “tailbone”

Vertebral body posterior portion forms part of vertebral foramen increases in size from cervical to sacral spinous process transverse process Vertebral foramen opening for spinal cord Intervertebral disk shock absorber (fibrocartilage)

Anatomy and physiology Spinal ligament
Intrasegmental - Ligamentum flavum - Intertransverse ligament - Interspinous ligament Intersegmental 􀁺 ALL 􀁺 PLL 􀁺 Supraspinous ligament

Anatomy and physiology Spinal Cord
Spinal cord ends at L1 Three tracts can be readily assessed clinically. - The corticospinal tract - The spinothalamic tract - The posterior columns Complete spinal cord injury: no sensory or motor function below a certain level, Incomplete spinal cord injury: If any motor or sensory function remains, prognosis for recovery is much better. Sparing of sensation in the perianal region (sacral sparing) may be the only sign of residual function.

Blood supplied by vertebral and spinal arteries Gray matter: core pattern resembling butterfly White matter: longitudinal bundles of myelinated nerve fibers

Thoracic and lumbar levels supply sympathetic nervous system fibers Cervical and sacral levels supply parasympathetic nervous system fibers

Anatomy and physiology Spinal Cord Pathways
Spinothalmic Tracts (anterolateral) Convey nerve impulse for sensing pain, temperature & light touch Impulses cross over in the spinal cord not the brain Lateral tracts :conduct impulses of pain and temperature Anterior tracts: carry impulses of light touch and pressure

Ascending Nerve Tracts (sensory input) Carry sensory impulses from body structures Posterior column (dorsal) Conveys nerve impulses for proprioception, discriminative touch, pressure, vibration, & two-point discrimination Cross over at the medulla from one side to the other (impulses from left side of body ascend to the right side of the brain)

Descending Motor Tracts (motor output) Conveys motor impulses from brain to the body Pyramidal tracts: Corticospinal & Corticobulbar Corticospinal tracts cause precise voluntary movement and skeletal muscle activity lateral tract crosses over at medulla - Extrapyramidal tracts Rubrospinal, pontine reticulospinal, medullary reticulospinal, lateral vestibulospinal and tectospinal

Example Motor and Sensory Pathways
To thalamus and cerebral cortex (sensory) Spinothalmic tract Motor Cortex Brain Stem Posterior column Corticospinal tract Spinal Cord LMN Pain - Temp Proprioception (conscious) Example Motor Pathway (corticospinal tract)

Spinal Nerves 31 pairs originate from the spinal cord
Carry both sensation and motor function Named according to level of spine from where they arise Cervical 1-8 Thoracic 1-12 Lumbar 1-5 Sacral 1-5 Coccygeal 1

Cord level C2 – C7 = add +1 for cord level T1 – T6 = add +2
T10 = L1, L2 level T11 = L3, L4 level L1 = sacro coccygeal segments

Dermatomes and key muscles

A dermatome is the area of skin innervated by the sensory axons within a particular segmental nerve root. They are important to determine level of injury

C5: Deltoids/biceps C6: Wrist extensors C7: Elbow extensors C8: Finger flexors T1: Finger Abductors L2: Hip flexors L3: Knee extensors L4: Ankle dorsiflexors L5: Long toe extensors S1: Ankle plantar flexors

Common mechanism Compression Flexion Extension Rotation
Lateral bending Distraction Penetration

Suspect spinal injury with...
Sudden decelerations (MVCs, falls) Compression injuries (diving, falls onto feet/buttocks) Significant blunt trauma (football, hockey, snowboarding, jet skis) Very violent mechanisms (explosions, cave-ins, lightning strike) Unconscious patient Neurological deficit Spinal tenderness

High index of suspicion…
Missed or delayed diagnosis most often attributed to: failure to suspect injury inadequate radiology incorrect interpretation of radiographs A missed spinal injury can have devastating long term consequences As such, spinal column injury must therefore be presumed until it is excluded

Spinal stabilization and management: pre hospital
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. Can be done manually or with a combination of semi-rigid cervical collar, side head supports, long spine board and strapping.

PROTECTION => PRIORITY DETECTION => SECONDARY • Rigid cervical collar • “Log-rolling” • Rigid transportation board • Rigid transfer slides

Immobilization devices should not take precedence over life saving procedures If neck is not in the neutral position, alignment should be made. If the patient is awake and cooperative, actively move their neck into line themselves. If the patient does not want to move neck because of pain – do not force movement of neck Initial immobilization of C-spine with a hard-collar is a priority during extrication Long spine boards are valuable primarily for extrication from vehicles. Rapid evacuation to a trauma center

Spinal stabilization and management: hospital
PROTECTION => PRIORITY DETECTION => SECONDARY • Rigid cervical collar • “Log-rolling” • Rigid transfer slides

Spinal stabilization and management: hospital
Spinal immobilization is a priority in trauma, spinal clearance is not The spine should be assessed and cleared when appropriate, given the injury characteristics and physiological state Imaging the spine does not take precedence over life saving diagnostic and therapeutic procedures

Clinical evaluation Inspection and palpation: Occiput to Coccyx
Tenderness to the vertebrae Gap or Step-off (both very rare) Edema and bruising Spasm of associated muscles Neurological assessment Sensation Motor Reflexes Rectal examination

Assessment Sensory: Dermatomes Motor: Key muscles

Assessment Rectal tone
Tone: the presence of rectal tone in itself does not indicate an incomplete injury Sensation Volition: A voluntary contraction of the sphincter or the presence of rectal sensation presence of communication lower spinal cord- supraspinal centers favorable prognosis Bulbocavernosus reflex: Positive: presence of reflex lack of supraspinal input to the sacral outflow complete spinal injury Negative: absent in spinal shock

SCI GRADING SYSTEM ASIA: AMERICAN SPINAL INJURY ASSOCIATION
Neurological Classification: Use the ASIA International standards Motor and sensory assessment ASIA Impairment Scale (A-E) Clinical Syndromes (patterns of incomplete injury)

SCI GRADING SYSTEM ASIA IMPAIRMENT SCALE
A = Complete: No motor or sensory function is preserved in the sacral segments S4-S5 B = Incomplete: Sensory but not motor function is preserved below the neurological level and includes sacral segments S4-5 C = Incomplete: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3 D = Incomplete: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more E = Normal: motor and sensory function are normal

SCI General Assessment
ABCs Airway and/or Breathing impairment Inability to maintain airway Apnea Diaphragmatic breathing Cardiovascular impairment Neurogenic Shock Hypotension and bradycardia Patient appears warm and dry Hypoperfusion

Neurologic Status: Level of Consciousness Brain injury also? Cooperative No impairment (drugs, alcohol) Understands & Recalls events surrounding injury No Distracting injuries No difficulty in communication

Assess Function & Sensation Palpate over each spinous process Sensation (Position and Pain) weakness, numbness, paresthesia pain (pinprick), sharp vs dull, symmetry Motor function Shrug shoulders Spread fingers of both hands and keep apart with force “Hitchhike” {T1} Foot plantar flexors (gas pedal) {S1,2} Priapism- Reflexes

Spinal Cord Injuries Primary Injury Secondary Injury
occurs at the time of injury may result in cord compression direct cord injury interruption in cord blood supply Secondary Injury occurs after initial injury may result from swelling/inflammation ischemia movement of body fragments

Spinal Cord Injuries Cord concussion & Cord contusion Cord compression
temporary loss of cord-mediated function Cord compression decompression required to minimize permanent injury (may have permanent injury) Laceration permanent injury dependent on degree of damage Hemorrhage may result in local ischemia

Spinal Cord Injuries Cord transection Complete all tracts disrupted
cord mediated functions below transection are permanently lost determined ~ 24 hours post injury possible results quadriplegia paraplegia

Terminology Paraplegia Quadriplegia
loss of motor and/or sensory function in thoracic, lumbar or sacral segments of SC (arm function is spared) Quadriplegia loss of motor and/or sensory function in the cervical segments of SC

Spinal Cord Injuries Cord transection Incomplete
some tracts and cord mediated functions remain intact potential for recovery of function Possible syndromes Brown-Sequard Syndrome Anterior Cord Syndrome Central Cord Syndrome

Brown Sequard Syndrome
Incomplete Cord Injury Injury to one side of the cord (Hemisection) Often due to penetrating injury or vertebral dislocation Complete damage to all spinal tracts on affected side Prognosis for recovery is variable

Brown Sequard Syndrome
Exam Findings Ipsilateral loss of motor function motion, position, vibration, and light touch Contralateral loss of sensation to pain and temperature Bladder and bowel dysfunction (usually short term)

Anterior Cord Syndrome
Anterior Spinal Artery Syndrome Supplies the anterior 2/3 of the spinal cord to the upper thoracic region caused by bony fragments or pressure on spinal arteries

Anterior Cord Syndrome
Exam Findings Variable loss of motor function and sensitivity to pinprick and temperature loss of motor function and sensation to pain, temperature and light touch Proprioception (position sense) and vibration are preserved

Central Cord Syndrome Usually occurs with a hyperextension of the cervical region Exam Findings weakness or paresthesias in upper extremities but normal strength in lower extremities varying degree of bladder dysfunction

Cauda Equina Syndrome Injury to nerves within the spinal cord as they exit the lumbar and sacral regions Usually fractures below L2 Specific dysfunction depends on level of injury Exam Findings Flaccid-type paralysis of lower body Bladder and bowel impairment

Neurogenic Shock Temporary loss of autonomic function of the cord at the level of injury Usually results from cervical or high thoracic injury Does not always involve permanent primary injury Effects may be temporary and resolve in hours to weeks Goal is to avoid secondary injury

Neurogenic Shock Presentation Flaccid paralysis distal to injury site
Loss of autonomic function hypotension or relative hypotension vasodilation loss of bladder and bowel control priapism loss of thermoregulation warm, pink, dry below injury site relative bradycardia may have class SNS response presentation above injury

Autonomic Hyperreflexia Syndrome
Associated with SCI patients (usually T-6 or above) after initial injury (weeks to months) Vasculature has adapted to loss of sympathetic tone Blood pressure normalized No vasodilation response to increased BP ANA reflexively responds with arteriolar spasm increased BP stimulates PNS results in bradycardia peripheral and visceral vessels unable to dilate

Autonomic Hyperreflexia Syndrome
Presentation Paroxysmal hypertension, possible extreme headache blurred vision sweating and flushed skin above level of injury increased nasal congestion nausea bradycardia distended bladder or rectum

Effect on other Organ Systems
Hypoventilation due to the paralysis: Intercostal muscles Diaphragm The inability to perceive pain may mask a potentially serious injury elsewhere: Abdominal injury – no abdominal tenderness Lower extremity injury – no tenderness

Classifications of Spinal Cord Injuries: level of injury
Determination of the level of injury on both sides is important. Injury above the T-1 level quadriplegia Injury below the T-1 level paraplegia Apart from the initial management to stabilize the bony injury, all subsequent descriptions of the level of injury are based on the neurologic level.

Severity of the Neurologic Deficit
Incomplete paraplegia Complete paraplegia Incomplete quadriplegia Complete quadriplegia Signs of incomplete injury may include: Any sensation ( including position sense) or voluntary movement in the lower extremities. Sacral sparing

Morphology Spinal injuries can be described as, Fractures
Fracture dislocations SCIWORA Penetrating injuries Injuries can be stable or unstable All patients with x-ray evidence of injury and all those with neurologic deficits should be considered to have an unstable spinal injury until proven otherwise.

imaging Who needs a cervical spine x-ray ?
Two papers have attempted to address this question NEXUS -The National Emergency X- Radiograph Utilization Study Canadian C-Spine rules

Imaging: NEXUS 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

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 Any patient who fulfilled all 5 of the criteria were considered low risk for C-spine injury and as such did not need C-spine radiography For patients who had any of the 5 criteria, radiographic imaging was indicated in the form of AP, lateral, and odontoid C-spine views

Results of NEXUS study 34,069 patients were enrolled
818 had significant C-spine injury 810 were identified by the decision rule 8 patients were identified as low risk but in fact had radiographic injury

NEXUS Sensitivity 99% Negative predictive value 99.8%
Specificity 12.9% Positive predictive value 2.7% Study was well received But…..some felt criteria to be too ambiguous and open to interpretation

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:

Rules were as follows….. 1. Was there any high risk factor that mandates radiography? Age>65 Dangerous mechanism of injury Presence of paresthesias IF YES -> X-RAY

Rules were as follows….. 2. Were there any low risk factors that allow some assessment of range of motion? Simple rear end MVC Sitting position in ER Ambulatory at any time Delayed onset of neck pain Absence of midline c-spine tenderness IF NONE -> X-RAY

Rules were as follows….. 3. Was the patient actively able to move their neck? IF YES -> NO X-RAY

Results of Canadian C-Spine Study
8,924 patients enrolled 100 % sensitivity for identifying 151 clinically important C-spine injuries 42.5 % specificity Deemed a highly sensitive decision rule for use of C-spine radiography in alert and stable trauma patients

Able to actively rotate neck? • 45 degrees left and right
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 Paresthesias in extremities NO YES Any low-risk factor that allows safe assessment of range of motion? • Simple rear-end MVC, or • Sitting position in ED, or • Ambulatory at any time, or • Delayed onset of neck pain, or • Absence of midline C-spine tenderness NO Radiography UNABLE YES Able to actively rotate neck? • 45 degrees left and right ABLE No Radiography From Stiell I et al JAMA Oct 2001

National Emergency X Radiography Utilization Study (NEXUS)
Vs The Canadian C-spine rule? Both have: Excellent negative predictive value for excluding patients identified as low risk Poor positive predictive value as most “no-low risk” patients do not have a fracture

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
Initial Screening Options: Plain films– Lateral, AP, and Odontoid, Optional: Oblique and Swimmer’s (if necessary) CT- much better than plain films for bony fractures/dislocations. Poor evaluation of ligamentous injuries. Other cervical spine imaging options MRI- Very good for soft tissue/ligamentous injuries. Flexion-Extension Plain Films- to determine stability (may replace MRI if unavailable or contraindicated)

Plain Film Radiology The standard 3 view plain film series is the lateral, antero-posterior, and open-mouth view The lateral cervical spine film must include the base of the occiput and the top of the first thoracic vertebra The lateral view alone is inadequate and will miss up to 15% of cervical spine injuries

Plain Film Radiology If lower cervical spine difficult to see, caudal traction on the arms may be used to improve visualization Swimmer’s views Repeated attempts at plain radiography are usually unsuccessful If the lower cervical spine is not visible, a CT scan of the region is then indicated

Radiological evaluation
X-ray Guidelines (cervical) Mnemonic AABBCCDS Adequacy, Alignment Bone abnormality, Base of skull Cartilage, Contours Disc space Soft tissue

How to read the Lateral Cervical Spine X-Ray adequacy
Lateral cervical spine x ray must visualize entire cervical spine . A film that does not show the upper border of T1 is inadequate Caudal traction on the arms may help If 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 Less than 50% of the width of a vertebral body implies unifacet dislocation Greater than 50% implies bilateral facet dislocation This is usually accompanied by widening of the interspinous and interlaminar spaces

Cartilage Predental Space should be no more than 3 mm in adults and 5 mm in children Increased distance may indicate fracture of odontoid or transverse ligament injury

Shift of > 3.5mm implies injury to transverse ligament, and > 5mm indicates complete rupture and instability C1-C2 interspinous space should not be >10mm wide

Cartilage Disc Spaces Assess spaces between the spinous processes
Should be uniform Assess spaces between the spinous processes

Disc space Vertebral body and intervertebral disc examination reveal compression and burst type injuries Bodies normally regular cuboids similar in size and shape to the vertebrae immediately above and below (not C1/C2) Anterior wedging of vertebral body or teardrop fractures of antero-inferior portion of body implies compression fracture

Disc space Anterior compression of greater than 40% of normal vertebral body height indicates a burst fracture with retropulsion of fragments of the vertebral body into the spinal canal

Disc space , soft tissue Loss of height of an intervertebral disc space may indicate disc herniation Analysis of prevertebral soft tissues may allow the diagnosis of cervical injuries Soft tissue shadow is created by pharyngeal and prevertebral tissues

Soft tissue Nasopharyngeal space (C1) - 10 mm (adult)
Retropharyngeal space (C2-C4) mm Retrotracheal space (C5-C7) - 14 mm (children), 22 mm (adults) Extremely variable and nonspecific

Atlanto–Occipital dissociation
Atlanto-occipital dissociation can be very difficult to diagnose and is easily missed The distance from the occiput to the atlas should not exceed 5mm anywhere on the film

Anterior/Posterior C-spine Films
Spinous processes should line up. Disc space should be uniform Vertebral body height should be uniform. Check for oblique fractures.

Odontoid 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

Mechanisms of Injury Hyperflexion i.e. diving in shallow water
Axial compression i.e. landing directly on head Hyperextension i.e. hitting dashboard in MVC Rotation

Where is the fracture?

Where is the fracture? 94

Jefferson Fracture Compression fracture of C1 ring
Most common C1 fracture Unstable Commonly see increase in predental space on lateral if transverse ligament is damaged and displacement of C1 lateral masses on odontoid. Obtain CT

Burst Fracture Fracture of C3-C7 from axial loading
Spinal cord injury is common from posterior displacement of fragments into the spinal canal Stable if ligaments intact

Clay Shoveler’s Fracture
Flexion fracture of spinous process C7>C6>T1 stable

Flexion Teardrop Fracture
Flexion injury causing a fracture of the anteroinferior portion of the vertebral body Unstable because usually associated with ligamentous injury (posterior ligaments torn)

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 secondary to Anterior longitudal ligament tear (red arrow) Unstable

Dens Fracture

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

Odontoid Fracture

Stable vs Unstable Fractures
Stability of cervical spine is provided by two functional vertical columns Anterior column: vertebral bodies, the disc spaces, the anterior and posterior longitudinal ligaments and annulus fibrosus Posterior column: pedicles, facets and apophyseal joints, laminar spinous processes and the posterior ligament complex As long as one column is intact the injury is stable.

“Jefferson Bit Off A Hangman’s Thumb”
Jefferson: C2 Burst Fx Bifacet Dislocation or Fracture Odontoid: II-body or III-Lateral masses Any Fx with dislocation/subluxation Hangman’s: posterior C2 secondary to hyperextension Teardrop: anterior chip of any vertebrae

X-Ray evaluation Thoracic and lumbar spine A.P film
Thoracic Spine Fractured ( T-1 Through T-10) Thoracolumbar Junction Fractures ( T-11 through L-1) Lumbar Fractures Penetrating Injuries

CT Scanning Thin cut CT scanning should be used to evaluate abnormal, suspicious or poorly visualized areas on plain radiology The combination of plain radiology and directed CT scanning provides a false negative rate of less than 0.1%

MRI Ideally (ie. US) all patients with an abnormal neurological examination should be evaluated with an MRI scan Patients who report transient neurological symptoms but who have a normal exam should also undergo an MRI assessment of their spinal cord

Management of SCI Primary Goal
Prevent secondary injury Stabilization 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 Dr. Robert’s Rule: All or None Immobilization vs Motion Restriction

Management of SCI Neutral positioning of head and neck if at all possible allows for the most space for cord most stable position for spinal column don’t force it

Management of SCI Cervical Motion Restriction Manual method
Rigid collar comes later Interim device (KED) Move to long board or full body vacuum splint Manual continues until trunk and head secured “CID” Don’t use sand bags or IV fluid bags as head blocks Tape works wonders! Improvise with blanket rolls

Management of SCI Don’t forget the Padding
Maintains anatomical position Limits movement on board especially during transport on board or in vehicle fill all the voids curvature of the lower back is normal - fill it pillows, blankets, towels Tape along (even duct tape) is not enough

Management of SCI Securing to the Board Straps, Tape, Cravats
Torso first then legs and feet and head Even patients extricated with a KED are secured to the board

Management of SCI Pediatric Patient Considerations
Elevate the entire torso if large occiput Pad underneath Short board underneath Vacuum mattress Lots of voids to fill Difficult to find a correctly sized rigid collar Improvise with horse collar blanket or towel rolls

Management of SCI Helmeted Patients
Removal should be limited to emergent need for access to airway and ventilation Leave in place if good fit with little or no head movement within no impending airway or breathing problems can perform spinal motion restriction with helmet on no interference in airway assessment or management no cardiac arrest

Management of SCI General Manual Spinal Motion Restriction ABCs
Increase FiO2 Assist ventilations as needed IV Access & fluids titrated to BP ~ mm Hg Look for other injuries: “Life over Limb” Transport to appropriate SCI center once stabilized

Management of SCI Consider High Dose methylprednisolone [SoluMedrol]:
30 mg/kg bolus over 15 mins After bolus: infusion 5.4mg/kg IV for 23 hours Controversial as recent evidence questions benefit Must be started < 8 hours of injury Harmful if started > 8 hours after injury Most spine surgeons do not use for penetrating trauma 120

Clearing Protocols Spinal Clearance Current Practice
First initiated in Maine with a state-wide protocol Now much more common in US Current Practice Assess scene and MOI Assess neuro status Immobilize Most MOIs Prevent further injury No 100% method to rule out in the field fear of litigation devastating consequences possible

What’s Wrong with Immobilizing Nearly Everyone?
Concern for secondary injuries resulting from immobilization Increases scene time Increased pain to patient Impaired ventilatory ability Increases safety risk to providers Increased risk of soft tissue injury Difficulties in ED exam Several published studies support the conclusion that many persons are immobilized when it is clearly not necessary patients do experience adverse effects from immobilization field screening tools can be developed and have been proven effective

When should the screening tool be used?
One of three paths is chosen: Positive or Obvious Severe Mechanism Violent impact High likelihood of spinal injury Negative or Obviously Minimal Mechanism No reasonable probability of spinal injury Uncertain Mechanism (Very Common) Injury may or may not be possible Difficult to determine Then, use screening tool or algorithm

“Clearing” Protocols - Dr. Roberts
No significant MOI or evidence of spine injury No neck or back pain (Palpate all) Normal Neuro Exam (no motor/sensory losses) Normal Level of Consciousness Adult, Reliable Patient w/o anxiety reaction or “normally” abnormal mental status No ETOH or drugs No language barriers No distracting injuries or penetrating injury near spine

“Clearing” Protocols – General Consensus
Absence of pain or tenderness of the spine Lack of neurologic deficits Normal level of consciousness Includes ability to understand cause & effect Able to make own healthcare decisions No evidence of alcohol or drug use No distracting injuries

Points to Remember: Maintain cervical spine immobilization until spine properly evaluated Either clinical or radiographic clearance Criteria exist (NEXUS and Canadian C-spine Rule) that identify the need for cervical spine imaging Patients negative for either criteria may have their spine clinically cleared Screen patients with plain radiograph or CT CT better than plain radiographs 126

Spinal cord injury HOANG TRONG AI QUOC, MD EMERGENCY DEPARTMENT

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