Spinal Trauma. Dr T G Kruger

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1 Spinal Trauma Dr T G Kruger

2 Epidemiology Spine injury in 6% of trauma patients Multiple levels involved in 20% of cases 80% of spinal cord injury patients have concurrent other system injuries 41% have head injuries South Africa high incidence of gunshot injuries to the spine

3 Location Most commonly cervical - 60% 6% of all blunt trauma injuries have associated cervical injuries Lumbar up to 25% of spinal injuries 50% of patients have complete fallout

4 Neural injury primary injury - tissue disruption by mechanical forces secondary injury - biologic response initiated by the trauma

5 Primary injury Concussion - physiologic disruption without anatomic changes Contusion - tissue haemorrhage and swelling Laceration - loss of continuity of structural elements Most cord injuries are crushing injuries

6 Biological response

7 Secondary injury Ischemia contributes to delayed secondary injury Severity of neurological injury is proportional to the duration of cord deformation Reversible injury may become irreversible from local ischemia and inflammation.

8 Goal of treatment Restoration of the patient to maximal possible function Protect all patients until a spinal injury is definitively excluded or identified Identify associated injuries Protecting uninjured neural tissues Maximize recovery of injured neural tissues Optimize musculoskeletal portions of the spinal column

Initial management All trauma patients are at risk for spinal injury ABC ATLS maximize O 2 to the cord Securing the airway In line stabilization Head and neck - aligned with the long axis of the

9 Initial management All trauma patients are at risk for spinal injury ABC ATLS maximize O 2 to the cord Securing the airway In line stabilization Head and neck - aligned with the long axis of the trunk Immobilized in this position Cervical collar, sandbags, tape, and spine board Remember the anatomic differences of children Steroid should be administered as soon as Dx of cord pathology is made Transport as soon as stable time is NB

10 Casualty Continue resuscitation Urinary catheter Peripheral lines Nasogastric tube Spine evaluation(primary): Neurological evaluation (Gross) Diagnosis of severely unstable injuries Analysis of hemodynamic parameters Hemodinamic shock Neurogenic shock

11 Casualty Complete spine examination follows resuscitation Inspection and palpation Log Roll 4 assistants necessary Haemorrhage, abrasion, laceration, malalignment, or palpable gap Perineal reflex and rectal examination

12 Casualty Complete neurological examination Complete Frankel scale A Total loss of function B Sensation sparing C Motor sparing not useful D Motor sparing useful E Normal Neurological level is the most caudal level with intact motor and sensory function

13 Neurological assessment Power is graded from 1 to 5 Incomplete lesions Sentral Cord Brown Sequard Anterior Cord syndrome Posterior Cord syndrome Sacral sparing

15 Unresponsive patient Spontaneous extremity motion Response to noxious stimuli Reflexes Rectal tone Spontaneous respiration Elevation and separation of the costal margins

16 NO FINAL NEUROLOGICAL LEVEL UNTIL SPINAL SHOCK IS OVER

17 Spinal shock Over when primitive reflexes return Bulbocavernosis reflex Anal wink Absence of the bulbocavernosus reflex and the anal wink Spinal shock, damage to the sacral segments of the cord, or injury to the sacral roots.

18 Radiographic evaluation Cervical X-rays See C7 T1 junction If not possible do swimmers view

19 Cervical XR

20 Radiographic evaluation Cervical XR Soft tissue injury flexion extension views Dangerous in acute setting Thoracolumbar X-rays Often difficult to interpret Have to make accurate diagnosis Ct scan MRI Determine the mechanism of injury Compression versus distraction

21 Immobilization Cervical injuries Distraction injuries Halo thoracic jacket Sandbags and tape Watch out for pressure sores All other injuries Gardner Well s skull tongs A neck collar alone is not sufficient immobilization for a cervical injury

22 C spine injury Incomplete and complete neurology Immediate closed reduction Up to 70% of body weight is safe MRI should not delay reduction Post reduction MRI Awake patient!!!!! Intact/obtunded patients MRI before reduction Surgery

23 Traction Technique Arbitrary starting weight of 3 pounds per injury level Caveat fracture dislocation C2 Levine + Edwards Type IIA Ankylosing spondilitis Added every min Monitoring No upper weight limit

24 Traction Technique Stop adding weights: Reduction Intractable pain Worsening neurology Over distraction on XR Impractical to add weight Pt sliding up in the bed Decision that reduction has failed

25 Thoracolumbar Positional immobilization Reduction and decompression can not be performed closed Surgery usually necessary in cases of neurological compromise Instability is already implied

26 Special cases Significant spinal cord injury trauma without any fractures or ligamentous ruptures SCIWORA Commonly children <10 years of age Patients > 50yrs Bulging of ligamentum flavum Gunshot Injuries Rarely cause spine instability Decompression does not improve recovery Traversed the oropharynx or colon intravenous antibiotics 3 days for infection prophylaxis

27 Checklist spinal cord injury IV line Nasogastric tube Bladder catherization CVP O2 DVT Prevention of gastric ulcers

28 Complications Skin and pressure sores Bladder and bowel Muscle and joints Hyper-reflexia syndrome Heterotopic ossification Physiological set-up

29 Prognosis Initial management Age Severity of spinal injury General condition of patient Associated injuries Definitive management Rehabilitation

30 Spinal Trauma Dr T G Kruger

32 Cervical fractures

33 Cervical spine injuries Whiplash C1 (Jefferson fracture) C1 / C2 rotatory subluxation C2 odontoid fracture or dislocation Hangmans C2 fracture C3 to C7 fracture and dislocations Facet dislocations

34 Whiplash

35 Whiplash

36 Whiplash

37 Whiplash Purely soft tissue injury Can lead to neurological compromise in severe cases Most cases need only conservative treatment Important to exclude serious injury with flexion extension views Before discharge 85% of fatalities associated with blunt trauma to the craniocervical spine are purely ligamentous injuries

38 Mechanism of injury Mechanism of Injury Axial Force: Distraction Force

39 Cervical Trauma Mechanism of Injury Flexion: Extension:

40 Cervical Trauma Mechanism of Injury Shear: A force parallel to the surface on which it acts Rotational A torsional force that rotates tissue fibers

43 Functional units Cervical vertebrae divided into 2 functional units Upper cervical region C1 C2 Lower cervical region C3 T1

44 Upper cervical spine Neurological symptoms vary Locked in syndrome Brown Sequart syndrome Most used to be incompatible with life No neurology due to large empty space Clinical - look for haematoma and swelling

45 Radiology Lateral C-spine not enough for upper cervical injuries Open mouth view is essential If still uncertain do tomograms

47 Open mouth view Normal AP cannot see upper cervical area

48 Fractures of the Atlas Usually due to axial compression Can be stable or unstable Combined overhang >6.9mm = unstable All depends on the integrity of the transverse ligament Can be diagnosed with MRI Stable = conservative treatment

49 Fractures of the Atlas A + B > 6.9mm A B Jefferson Fracture

50 Atlantoaxial Rotary subluxation

$common C2 fracture Usually$ $on type of fracture and$ displacement Treatment

51 Odontoid Fractures Most common C2 fracture Usually unstable Treatment depends on type of fracture and displacement Treatment either Halo-thoracic jacket or surgery

$fracture$ Traumatic

52 Hangman s fracture Traumatic Spondylolisthesis of the Axis

53 Lower cervical spine Stability easiest to gage using the 3 column model Anterior column anterior half of the vertebral body and the anterior ligamentous complex Middle column dorsal half of the vertebral body and the middle ligamentous complex Posterior column everything posterior to the middle column

54 COMPRESSION FLEXION Allen and Fergusson

57 Vertical compression

59 Distraction-flexion Perched facets<25% Unifacet

60 Distraction flexion Reduction ASAP

61 Distraction flexion Reduction ASAP

62 Compression extension Unilateral lamina Bilateral lamina Bilateral Arch Partially displaced

63 Distraction extension

64 Lateral flexion

65 Thoracolumbar fractures

66 Physical Examination Log-rolled to the side + cervical spine immobilized Entire length of the spine should be inspected Abrasions, ecchymoses, deformity Spinous processes should be palpated for step-offs or interspinous widening Backboard in lateral turning is recommended

67 Classification No ideal system available Denis 3 column system

$Fractures Compression fractures$ junction Middle column remains

68 Fractures Compression fractures Most common Usually throracolumbar junction Middle column remains intact Usually stable Treated conservatively

$fractures$ Failure of

69 Burst fractures Failure of anterior and middle columns Often retropulsion of fragments into canal

70 Burst fractures Radiological signs More than 50% compression Retropulsion of fagments Widening of interpendicular distance on AP view Usually unstable Brace or operative treatment

$injuries Chance fractures Can be$ only ligamentous injury Can be

71 Flexion-distraction Seat Belt injuries Chance fractures Can be only ligamentous injury Can be missed Rarely neurological compromize High incidence (50% to 67%) of intraabdominal damage Unstable fractures

72 Fracture-Dislocations Failure of all 3 columns Very unstable High incidence of neurological damage Usually needs surgery

73 Sacral fractures Difficult to diagnose Frequently associated with pelvis fractures Treatment difficult Associated with damage to sacral nerve plexus Retro peritoneal bleeding can be a problem Usually treated conservatively

Spinal Cord Injuries: The Basics. Kadre Sneddon POS Rounds October 1, 2003

Spinal Cord Injuries: The Basics Kadre Sneddon POS Rounds October 1, 2003 Anatomy Dorsal columntouch, vibration Corticospinal tract- UMN Anterior horn-lmn Spinothalamic tractpain, temperature (contralateral)