Spinal injury

1. Emergency & GP
BPKIHS, Dharan
Spinal Injury
Dr. Sundar Karki
Medical Officer

2. Outlines
• Introduction
• Epidemiology
• Aetiology and distribution
• Normal spinal anatomy
• Common mechanism of injury
• Prehospital management
• Diagnosis of spinal injury
• Management and prognosis
• Common type of spinal fracture

3. Introduction
• Spinal injuries are devastating
• Spinal injury may be defined as injury to
the spinal column (bone column)/spinal
cord or both
• Improper management can have horrible
and permanent result
• Appropriate use of immobilization can
mean difference between a patient who
fully recovers and other spent whole life
paralyzed.

4. Epidemiology
• 40 cases per million in US
• Most common cervical region(55%)
• Mortality rate 40-50%
• Between the ages 16-30. M:F=4:1
• Most frequent age is 19
• Current estimates are 250,000 - 400,000
individuals living with Spinal Cord Injury
or Spinal Dysfunction.

5. Ateiolgy and Distribution

6. Normal Spinal Anatomy
▪33 separate irregular
bones
▪Vertebral foramen: canal
formed for spinal cord

7. Cervical Vertebrae
▪C1-7,located in the
neck
▪Small vetrebral body
Extensive joint surface
▪C1: atlas C2: axis

8. Thoracic Vertebrae
▪Rib bearing vertebrae
▪Designed to remain
stiff and straight

9. Lumbar vertebrae
▪Weight bearing vertebrae
▪Lamina, facets and SPs
are major parts

10. Spinal Ligament

11. Spinal cord and Nerves
▪31 pairs of nerves
▪motor and sensory
both
▪Ligaments provide
support
▪Cord is nerve tissue
▪Extend from foramen
magnum to the L1 and
end in the form of
conus medullaris

12. Common Mechanism
• Compression
• Flexion
• Extension
• Rotation
• Lateral bending
• Distraction
• Penetration

13. Spinal Column Injury
Bony spinal injuries may or may not beBony spinal injuries may or may not be
associated with spinal cord injuryassociated with spinal cord injury
These bony injuries include:These bony injuries include:
– Compression fracturesCompression fractures
– Comminuted fracturesComminuted fractures
– Subluxation (partial dislocation)Subluxation (partial dislocation)
Other injuries may include:Other injuries may include:
– Sprains- over-stretching or tearing ofSprains- over-stretching or tearing of
ligamentsligaments
– Strains- over-stretching or tearing ofStrains- over-stretching or tearing of
the musclesthe muscles

14. Hyperflexion
Whiplash injury:(C3-7)
Traumatic injury to the soft tissue in the cervical region
Hyperflexion, hyperextention
No fractures or dislocations
Most common automobile injury
Recover 3-6 months
Hyperextension
 Atlanto-occipital dislocation:
 frequently results in prehospital cardiorespiratory arrest
 3 times more common in children than adults
 Unstable

15. Hyper rotation
 Atlanto-Axial dislocation:
 Transverse ligament injury
 more common in children than
adults
 1/3 of patients have deficit
 Unstable

16. Spinal Cord injury
• Cutting compression or stretching of spinal
cord
• Causing loss of distal function sensation or
motion
• Caused by:
-unstable or sharp bony fragment
pushing the cord
- Pressure from bone fragments orPressure from bone fragments or
swelling that interrupts the blood supply toswelling that interrupts the blood supply to
the cord causing ischemiathe cord causing ischemia

17. Spinal cord injury
▪Primary spinal cord injury
- cutting, compression or stretching of
spinal cord
▪Secondary spinal cord injury
-occurs later due to swelling, ischemia or
movement of unstable bony fragments

18. Spinal Cord injury severity
▪Complete
- less common
- loss of motor and sensory function
below the level of injury
▪Incomplete
- some preservation of motor and sensory
function

19. Spinal cord injury without radiological
abnormality(SCIWORA)
• referred to spinal cord injury without
radiographic or CT evidence of fracture or
dislocation
• With advent of MRI, term has become
ambiguous
• "Spinal cord injury without neuroimaging
abnormality" more correct name
• Mostly in pediatric population (range: birth to 16
years old)
• Common in cervical and thoracic region

20. Spinal cord injury without radiological
abnormality(SCIWORA)
• Following findings on MRI have been recognized
as causing primary or secondary spinal cord
injury:
-Intervertebral disk rupture
-Spinal epidural hematoma
-Cord contusion
-Hematomyelia
• Prognosis of SCIWORA is actually better than
patients with spinal cord injury and radiologic
evidence of traumatic injury

21. Suspected Spinal Injury
• High speed crash
• Compression injury (diving, fall on buttock)
• Significant blunt trauma
• Very violent mechanism
• Unconscious
• Neurological deficit
• Spinal pain/tenderness

22. Pre-hospital management
• Protect spine at all times during the
management of patients with multiple
injuries
• Up to 5% 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

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

24. 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)

25. Philadelphia hard collar

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

27. • PROTECTION  PRIORITY
• Detection  Secondary
• Rigid cervical collar
• “Log rolling”
• Rigid transportation board remove
• Rigid transfer slide
Immobilization at hospital

28. Diagnosis of Spinal injury: clinical
evaluation
• Inspection and palpation: occiput to coccyx
- tenderness
- gap or step
- edema and bruising
- spasm of associated muscle

29. Diagnosis of Spinal injury: clinical
evaluation
• Neurological Examination
- sensation
- motor function
- reflexes
- rectal examination

30. Neurological: Sensory

31. Neurological: Motor

32. Neurological Examination: Rectal
• Tone: the presence of rectal tone in itself
does not indicate incomplete injury
• Sensation
• Voilition: a voluntary contraction of
sphincter or the presence of rectal
sensation supports the presence of a
communication between the lower spinal
cord and supraspinal centers

33. Neurological examination: Rectal
• Bulbocavernosus reflex
-refers to anal sphincter contraction in response to
squeezing the glans penis or tugging on the
Foley;
-reflex involves S-1, S-2, and S-3 nerve roots and
is spinal cord- mediated reflex arc
-absence of this reflex documents continuation of
spinal shock or spinal injury at the level of the
reflex arc itself.

34. 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!
------

35. Neurologic assessment and grading
• 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

36. American Spinal Injury association grade

38. Incomplete Cord Injury:
Anterior cord syndrome
• Loss of motor, pain
and temperature
• Preserved
propioception and
deep touch

39. Incomplete cord injury:
Brown-Sequard syndrome
• Loss of ipsilateral
motor and
propioception
• Loss of
contralateral pain
and temperature

40. Incomplete cord injury:
Central cord syndrome
• Weakness :
– upper > lower
• Variable sensory
loss
• Sacral sparing

41. 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

42. 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

43. 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 sort of any of the 5
criteria
 radiographic imaging was indicated
( AP, lateral and open mouth views)

44. The Canadian C-spine Rule for alert and stable trauma patients where cervical
spine injury is a concern.
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
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
Able to actively rotate neck?
• 45 degrees left and right
No Radiography
Radiography
NO
YES
ABLE
YES
NO
UNABLE

45. National Emergency X
Radiography Utilization Study
(NEXUS)
National Emergency X
Radiography Utilization Study
(NEXUS)
Both have:
• Excellent negative predictive value for
excluding patients identified as low risk
The Canadian C-spine rule
&

46. 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

47. 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

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

49. 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

50. Swimmer’s view

51. 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

52. 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

53. Bones

54. Disc
• Disc Spaces
– Should be
uniform
• Assess spaces
between the
spinous processes

55. 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)

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

57. Open mouth view
• Adequacy: all of the: all of the
dens and lateraldens and lateral
borders of C1 & C2borders of C1 & C2
• Alignment: lateral: lateral
masses of C1 and C2masses of C1 and C2
• Bone: Inspect dens
for lucent fracture
lines

58. 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%

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

60. 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

61. 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

62. Management of SCI
• Clinical assessment and neurological
examination
• Spinal Imaging and send laboratory
investigation
• GI intervention: put nasogastric tube to
prevent aspiration
• Pain Management
- Opiates and NSAIDs

63. Management of SCI
• 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
– Bolus followed by a 45-min pause
– Then infusion 5.4mg/kg IV for 23 hours

64. 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

65. Spinal and Neurogenic shock

66. Hemodynamic state in neurogenic
shock
• Unopposed parasympathetic outflow can lead to
dysrythmias and hypotension(most common
within 14 hours)
• Loss of sympathetic innervation to the heart (T1
through T4 cord levels) leaves the
parasympathetic cardiac innervation via the
vagus nerve unopposed, resulting in bradycardia,
or an absence of reflex tachycardia.
• Most common dysrythmia is bradycardia

67. Hemodynamic instability: intervention
• First line
volume resusciation ( 1-2 liter)
• Second line:
vasopressor (dopamine/norepinephrine) to
counter loss of sympathetic tone and
provide chronotropic support to the heart

68. Hemodynamics and cord perfusion
• Avoid hypotension
• Maintain MAP 85-90mmHg for first 7
days if possible

69. Bradycardia: intervention
• Prevention
-avoid vagal stimulation
- hyperventilate and hyperoxygenate
before suctioning
- premedicate patient with known
hypersensitivity to vagal stimuli
▪Symptomatic bradycardia
atropine 0.5- 1.0 mg IV

70. Indication for Surgery
• Decompression of neural elements( spinal
cord and nerves)
• Stabilization of bony element( spine)
• Deformity correction
• Thoracolumbar spine fracture/dislocation

71. Prognosis of recovery
• Patient with complete cervical spine injuries that
remain within the first 24 hours of admission are
unlikely to regain significant ambulatory function
• Cervical injuries have a higher potential for
recovery than do thoracic or thoracolumbar
injuries
• Younger patient fare much better than older
• Intermedullary hemorrhage signifies a worse
neurological outcome

72. Jefferson Fracture
• Burst fracture of C1 ring
• cervical spine is subjected to an
axial load, as would occur from
a direct blow to the top of the
head
• Unstable fracture
• Need CT scan

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

74. 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

75. Odontoid Fracture Type II

76. Odontoid Fracture Type III

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

78. Clay Shoveler’s Fracture
• Avulsion off the end of one
of the lower cervical spinous
processes
• C7>C6>T1
• Stable fracture

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

80. 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