Management of spinal trauma

1. Management of Spinal Trauma
Dr Nola McPherson
SCGH Registrar Education
April 2014

2.  Spinal anatomy
 Evaluating a patient with suspected spinal injury
 Broad management principles of spinal injury
 Hypovolaemic vs neurogenic vs spinal shock
Overview

3. Anatomy
Location of Spinal Injuries
55% in cervical region
(mobile & exposed)
15% in thoracic region
(less mobile & protected)
15% in thoracolumbar region
(fulcrum)
15% in lumbosacral region

4. Anatomy
 Upper cervical region is wide from foramen magnum to
lower part C3
- 1/3 die at scene from apnoea
- those that survive are usually neurologically intact
when reach hospital

5. Anatomy
 Below C3, diameter of spinal canal is smaller
- vertebral column injuries more likely to produce
spinal cord injuries

6. Anatomy
 Most thoracic spine fractures are wedge compression
fractures without SC injury
If fracture-dislocation in thoracic spine region
– almost always complete spinal cord injury
because narrow thoracic canal

7. Anatomy
 Thoracolumbar junction
- inflexible thoracic spine meets strong lumbar
spine making it vulnerable to injury

8. Anatomy
 Multiple ascending and descending tracts in the spinal
cord (not going to cover all of these today!)
 THREE are easily clinically assessable
lateral corticospinal tract (descending tract)
spinothalamic tract (ascending)
dorsal columns (ascending)

9. Anatomy
Corticospinal tract – controls motor power on SAME side
Spinothalamic tract – transmits pain & temp sensation from
OPPOSITE side
Dorsal columns – carries position sense (proprioception), vibration
sense and some light touch sensation from SAME side

10. Anatomy
 Sensory Examination
 Dermatomes
 Motor Examination
 Myotomes

13. Spinal Injury: Classification
Spinal cord injury may be categorised as:
 Incomplete quadraplegia (incomplete cervical injury)
 Complete quadraplegia
 Incomplete paraplegia (incomplete thoracic injury)
 Complete paraplegia

15. QUIZ
– location of lesions and clinical presentations

16. COMPLETE Neurology
Total flaccid paralysis
Total anaesthesia
Total analgesia
No tendon reflexes
MUST WAIT UNTIL SPINAL SHOCK RESOLVED to diagnose

17. INCOMPLETE Neurology
Partial paralysis
Altered sensation (light touch or pin prick)
Sacral sparing
BETTER prognosis, may recover

18. Spinal Cord Syndromes
Different patterns of neurologic injury with the following syndromes:
Central Cord Syndrome
Anterior Cord Syndrome
Posterior Cord Syndrome
Inferior Cord Syndrome
Transverse Cord Syndrome
Brown-Sequard Syndrome
Cauda Equina Syndrome
Syringomyelia

19. Spinal Injury: Morphology
Spinal injuries can be described as:
1. Fractures
2. Fracture – dislocations
3. Spinal cord injury without radiographic abnormalities
4. Penetrating injuries
These injuries can be further categorized as stable or unstable

20. Spinal Injury: Signs and Symptoms
Pain (and bony tenderness on examination)
Tingling, numbness and weakness in peripheries
Loss of sensation or paralysis below level of injury
Impaired breathing – C3/4/5 (diaphragm)
Incontinence
Priapism

21. Spinal Trauma: Primary Survey
Activate trauma team, triage to trauma bay
Move patient off spinal board as soon as clinically safe to do so
 Airway maintenance with C spine immobilisation
- definitive airway early if respiratory
compromise
(injury higher than C6 need intubation and
ventilation)
- maintain hard collar, sandbag/bolsters and
tape
 Breathing and Ventilation
- 15L /min oxygen (NRB) + ventilatory support
- monitor RR, respiratory effort, cough

22.  Circulation with haemorrhage control
- if hypotension – hypovolaemic vs neurogenic shock
- assume hypovolaemia 1st : search for source
blood loss + replace fluids
- if SC injury: guide fluid replacement with CVP
monitoring (controversial)
- inotropes may be required
- before IDC – perform rectal examination and
assess rectal sphincter tone and sensation
Spinal Trauma: Primary Survey

23.  Disability
- GCS /pupils/BSL
- look for paralysis/paresis/priapism/
anal sphincter tone/bulbocavernosus reflex
 Exposure/Environment
– keep warm (blankets, bair hugger, fluid warmer)
peripherally vasodilated, unable to regulate temp
if injury above T4
Spinal Trauma: Primary Survey

24. Adjuncts to Primary Survey
 Full non invasive monitoring (consider invasive later)
 ECG
 Trauma Xray series – lateral cervical spine, chest, pelvis
 Bedside FAST scan (?sources of bleeding)
 NGT
 IDC

25.  Focused AMPLE Hx
 Ask
mechanism?
does your neck or back hurt?
can you feel me touching your fingers and toes?
can you move your hands and feet?
Spinal Trauma: Secondary
Survey

26.  Assess full spine
A. Log roll and palpate spine/paraspinal region
look for deformity/ crepitus/pain/contusions/
lacs/penetrating wounds
B. Assess for pain, paralysis and paraesthesia
location
neurological level
Spinal Trauma: Secondary
Survey

27. Spinal Trauma: Secondary
Survey
 Test sensation
 Test motor function
 Test deep tendon reflexes
 DOCUMENT carefully and REPEAT
 Head to toe examination – assess for associated injuries

28. Adjuncts to Secondary Survey
 Advanced spinal imaging
- CT scan (defines bony injury)
- MRI scan (defines neurological injury)
 Consider CVP monitoring

29. Disposition
 EARLY discussion with spinal specialists
- best imaging technique based on suspected injury
- management options - ?steriods – give or not give
 Transfer to spinal unit

30. Examination For SC Level
 Sensory Examination
 Best Motor Examination:
TABLE 1: Determining the level of Quadraplegia
TABLE 2: Determining the level of Paraplegia

31. Table 1: Examination For SC
Level
Action Nerve Root Level
Raises elbow to shoulder level Deltoid, C5
Flexes forearm Biceps, C6
Extends forearm Triceps, C7
Flexes wrist and fingers C8
Spreads fingers T1

32. Table 2: Examination For SC
Level
Action Nerve Root Level
Flexes hip Iliopsoas, L2
Extends knee Quadriceps L3-4
Flexes Knee Hamstrings L4-5, S1
Dorsiflexes big toe Extensor hallucis longus, L5
Plantar flexes ankle Gastrocnemius, S1

33. Phases of Injury
 Primary spinal cord Injury
– initial trauma  direct injury to SC due to fractures,
dislocations, haematomas, soft tissue swelling
 Secondary spinal cord injury (later)
– due to ongoing mechanical instability or insults secondary
to hypoxia and hypotension

34. Spinal Trauma:
Management Principles
1. Immobiisation
2. Intravenous fluids
3. Medications
4. Early advise, prompt referral/transfer
ED acute care priority: avoid secondary spinal injury

35. Spinal Trauma:
Management Principles
 Immobilisation: protect from further spinal injury
cervical collar
long spinal board, bolsters and tape
remove from spinal board as soon as possible
(ideally < 2hours, BEWARE pressure pts & decubitus
ulcers)
logroll maintaining neutral alignment of entire spine
(four or more helpers required with av 70kg patient)

36. After arriving at ED, at least 5% with spinal injury experience
new symptoms or worsening of preexisting symptoms as a
result of –
secondary spinal injury
(ischaemia & progression of spinal cord
oedema)
poor immobilisation technique

37. Spinal Trauma:
Management Principles
 Fluid resuscitation
• Maintenance fluids only unless shock
• If shocked – establish if hypovolaemic OR neurogenic
 Insert IDC (during primary survey)
• Monitor urinary output
• Prevent bladder distension
 Insert NGT
• Prevent gastric distension (+/- paralytic ileus)
• Prevent aspiration (sphincter paralysis)

38. Spinal Trauma:
Management Principles
 Medications
 Corticosteriods - insufficient evidence for routine use
Aimed at reducing extent of permanent paralysis
Most trials have used high dose methylprednisolone
Improved motor neurological outcome up to one year post
injury if given within eight hours of injury
Given as bolus dose and then IV infusion for 24-48 hours
- 24 hour IVI if treatment commenced within 3 hours of injury
- 48 hours IVI if treatment commenced within 3-8 hours of injury

39. Spinal Trauma:
Management Principles
Early studies (NASCIS I & II)* showed no increased complications
or mortality if 24 or 48 hour IVI
More recent larger studies have raised concerns about
increased risk of sepsis due to immunosuppressive effects
CI: heavily contaminated open injuries, other heavily
contaminated injuries eg perforated bowel, sepsis
Consult with spinal specialist (use or not to use??)
More research needed
 Analgesia
* National Acute Spinal Cord Injury Study I & II

40. Spinal Trauma:
Management Principles
 Transfer
 Promptly after consultation with spinal specialist
If injury above C6 (can result in partial or complete loss of
respiratory function) – intubate before transfer

41. Secondary Complications
 Consider
DVT/PE
Pressure sores
Respiratory complications eg pneumonia
UTIs
Muscle length changes
Psychological problems

42. Hypovolaemic vs Neurogenic Shock
Hypovolaemic Shock Neurogenic Shock
Increase HR Decreased HR
Decreased BP Decreased BP
Cool extremities Warm extremities

43. American Spinal Injury Association
(ASIA) Classification
 Allows classification of spinal cord injury (standardizing
terminology worldwide)
 Based on
- severity of neurological deficit
A=complete to E=normal
- neurological level
most caudal segment with normal function

45. Neurogenic Shock
 Neurogenic Shock
Mechanism
impairment of descending sympathetic pathways in the
cervical or upper thoracic spinal cord (usually above T6)
 Loss of sympathetic vasomotor tone
- peripheral vasodilation (visceral and lower extremity
b/v)  pooling of blood
 HYPOTENSION

46. Neurogenic Shock
 Loss of sympathetic innervation to heart (usually lesion
above T1)
 bradycardia (or at least failure of tachycardic
response to hypovolaemia)

47. Neurogenic Shock
Management:
1. Hypotension
1. crystalloid (250mL boluses) and IVI
– may not improve BP despite massive infusion
(beware fluid overload and pulmonary oedema)
2. vasopressors eg noradrenaline, dopamine
- after trial of volume replacement
Maintain organ perfusion: mentation, UO>0.5mL/kg/hr,
MAP >65mmHg, warm peripheries
Consider CVP monitoring

48. Neurogenic Shock
2. Bradycardia
1. atropine (0.6mg IV boluses, up to max 3mg)
2. avoid overzealous vagal stimulation with suction/NGT
and ETT placement

49. Spinal Shock
 Spinal Shock
= transient loss of muscle tone and loss of reflexes
(flaccid areflexia) below the level of spinal cord injury
Not true shock
Spinal cord (temporarily) nonfunctional but not destroyed
No ANS or somatic reflexes
First to return is bulbocavernosus and Babinski reflexes
Duration variable (hours to weeks)
Resolves with improvement in soft tissue swelling

50. Take Home Messages
 Over half of spinal cord injuries occur in the cervical spine
region (most vulnerable and mobile region)
 C spine immobilisation in trauma = spinal board (initially),
hard collar, sandbags/bolster and tape
 Consider early intubation and ventilation with injuries
higher than C6 (altered LOC, regurgitation, cervical
haematomas) – hypoxaemia is late sign of deterioration
 Follow ATLS ‘A B C D E’ algorithm in spinal trauma – aim is
to limit secondary spinal cord injury

51. Take Home Messages
 Neurogenic shock is a triad of hypotension, bradycardia
and peripheral vasodilation
 In trauma patients, neurogenic shock is a diagnosis of
exclusion
 Watch over zealous fluid treatment – if hypotension not
improving with fluid resuscitation, consider neurogenic
shock
 EARLY discussion with spinal specialist the use of
noradrenaline (for hypotension) and steroids (remains
controversial) in spinal trauma

52. Question and discussion time
Thank you

53. References
 Fildes J, et al. Advanced Trauma Life Support Student Course
Manual (9th edition), American College of Surgeons 2012.
 Image of Vertebral Column taken from:
http://upload.wikimedia.org/wikipedia/commons/5/54/
Gray_111_-_Vertebral_column-coloured.png
 Image of Major Tracts in Spinal Cord taken
from:http://www.dontbeasalmon.net/archives/2012/01/week-
222-spinal.html

54. References
 Image of Dermatomes taken
from:http://commons.wikimedia.org/wiki/File:Dermatomes_and
_cutaneous_nerves_-_anterior.svg
 Image of Myotomes taken from:
https://www.pinterest.com/pin/174162710563226309/
 Image of Tetraplegia/paraplegia spinal levels taken from:
http://quizlet.com/23549824/spinal-cord-injury-med-surg-
exam-2-flash-cards/

55. References
 Trauma Spinal Injury taken from:
https://www.lifeinthefastlane.com/trauma-tribulation-016/
 ASIA Impairment Scale taken from:
http://www.asia-spinalinjury.org/elearning/
ISNCSCI_ASIA_ISCOS_low.pdf
 BrackenMB.Steroidsforacutespinalcordinjury.CochraneDatabas
eofSystematicReviews2012,Issue1.Art.No.:CD001046. DOI:
10.1002/14651858.CD001046.pub2.

56. References
 Cameron P, Jelinek G, Kelly AM, Murray L, Brown A. Textbook of
Adult Emergency Medicine. 3rd Edition. Churchill Livingston
Elsevier 2009.