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

2. 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

3. 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

4. Goal of spine trauma care
Maintain or restore spinal alignment
Minimize loss of spinal mobility
Obtain healed & stable spine
Facilitate rehabilitation

5. Suspected Spinal Injury
High speed crash
Unconscious
Multiple injuries
Neurological deficit
Spinal pain/tenderness

6. 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

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

8. Pre-hospital management
Cervical spine immobilization
Transportation of spinal cord-injured patients

9. 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

10. Philadelphia hard collar

11. Transportation of spinal cord-injured patients
Emergency Medical Systems (EMS)
Paramedical staff
Primary trauma center
Spinal injury center

12. 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

13. Physical examination Information Mechanism Direction of Impact
energy, energy
Direction of Impact
Associated Injuries

14. 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!
------

15. “Unexaminable” ≠
“No exam”

16. 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)

17. 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

18. 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

19. 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

20. 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

21. 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

24. Incomplete cord injury
Anterior cord syndrome
Brown-Sequard syndrome
Central cord syndrome

25. Anterior cord syndrome
Loss of motor, pain and temperature
Preserved propioception and deep touch

26. Brown-Sequard syndrome
Loss of ipsilateral motor and propioception
Loss of contralateral pain and temperature

27. Central cord syndrome Weakness : Variable sensory loss Sacral sparing
upper > lower
Variable sensory loss
Sacral sparing

28. 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:

29. 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

30. 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)

31. 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

32. 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

33. 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

34. 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

35. Radiolographic evaluation
X-ray Guidelines (cervical)
AABBCDS
Adequacy, Alignment
Bone abnormality, Base of skull
Cartilage
Disc space
Soft tissue

36. 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

37. Swimmer’s view

38. 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

39. 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

40. Bones

41. Disc Disc Spaces Assess spaces between the spinous processes
Should be uniform
Assess spaces between the spinous processes

42. 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)

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

44. 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

45. 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%

46. MRI
Ideally all patients with abnormal neurological examination should be evaluated with MRI scan

47. 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

48. 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 ~ mmHg

49. 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

50. Principle of treatment
Spinal alignment
deformity/subluxation/dislocation reduction
Spinal column stability
unstable  stabilization
Neurological status
neurological deficit  decompression

51. 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

52. Burst Fracture Fracture of C3-C7 from axial loading
Spinal cord injury is common from posterior displacement of fragments into the spinal canal
Unstable

53. Clay Shoveler’s Fracture
Flexion fracture of spinous process
C7>C6>T1
Stable fracture

54. Flexion Teardrop Fracture
Flexion injury causing a fracture of the anteroinferior portion of the vertebral body
Unstable because usually associated with posterior ligamentous injury

55. 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

56. Hangman’s Fracture Extension injury Bilateral fractures of C2 pedicles
(white arrow)
Anterior dislocation of C2 vertebral body (red arrow)
Unstable

57. 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

58. Odontoid Fracture Type II

59. Odontoid Fracture Type III

60. Thank you for your attention