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Assessment Techniques
-  Suspected spinal injury
-  Neurological assessment
Spinal Injury: Neurological
Assessment
Dr Fauzi Bin Che Hussin
Pakar Perubatan Kecemasan
Hospital Raja Perempuan Zainab II

Spinal Injury Spinal Injury

When should you suspect a spine injury? When should you suspect a spine injury?
●  Mechanism of injury
●  Unconscious pa3ent
●  Neurologic deficit
●  Spine pain / tenderness

Spinal Injury Spinal Injury

How do I protect the spine during evalua9on and How do I protect the spine during evalua9on and
transport? transport?

●  Immobilize pa3ent on long spine board with

proper head immobiliza3onadding
●  Apply semirigid collar.

Protection is priority; detection

is secondary.

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Spinal Injury Screening Spinal Injury Screening

●  Clinical ●  If pa3ent is
●  Conscious
●  Normal neurologic exam and
●  Coopera3ve
●  Absence of spinal pain and tenderness
●  Able to concentrate on c-spine

●  If no neck or spine pain or tenderness

●  If s3ll no pain or tenderness with voluntary
Caution
movement
●  No further evalua3on or x-ray necessary
Drugs, alcohol, and other
injuries can mask spinal injury.

Clear spine and remove cervical collar.

Spinal Injury Screening Spinal Injury Screening

Altered Consciousness or Symptoms How do I confirm a spine injury?

●  Radiographic visualiza3on of en3re spine

●  Plain films
●  CT scan of suspicious or poorly visualized
areas

Spinal Injury Screening Cervical Spine X-rays

How do I confirm a spine injury? ●  Crosstable lateral film excludes 85% of

fractures
●  Clinical signs of neurological deficit
●  Radiological inves3ga3ons ●  Addi3on of AP and odontoid views excludes
●  Plain X-ray / CT / MRI most fractures
●  Iden3fy bony fracture / subluxa3on ●  Also may require
●  Presume spinal instability ●  Swimmer’s view
●  Early spine service consult ●  CT scan for bony detail
●  MRI

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Cervical Spine X-rays Pitfalls

●  10% of pa3ents with a c-spine fracture have a Pitfalls

second, associated noncon3guous vertebral column
●  Spinal evaluation complicated by altered
fracture
sensorium
●  Iden3fy one abnormality? Look for another!
●  Radiographic screening of en3re spine required in ●  Remove spine board as soon as possible
and logroll patient
this situa3on
●  Pressure sores occur early in unconscious
or paralyzed patients

Caution Neurologic Status

How do I assess the pa9ent’s neurologic status?

Caution

At least 5% of patients with

spinal cord injuries worsen
neurologically at the hospital.

Neurologic Status Neurologic Status

How do I assess the pa9ent’s neurologic status?

Complete Injury
●  No motor or sensory func3on below injury
Neurologic level level
●  Most caudal level of motor / sensory func3on
●  Motor and sensory may not be the same

●  Sensory can vary on each side Incomplete Injury
●  Any motor or sensory preserva3on below
Bony level injury level
●  Site of vertebral column damage ●  Sacral sparing may be only residual func3on

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Effects of Spinal Cord Injury Effects of Spinal Cord Injury

●  Neurogenic shock
Neurogenic Shock – Direct Effects
●  Spinal shock ●  Cardiovascular phenomenon due to loss of
●  Other consequences sympathe3c tone
●  Associated with cervical / high thoracic
Fasciculus gracilis spine injury
Dorsal column
Fasciculus cuneatus ●  Hypotension and slow heart rate
Lateral corticospinal tract
●  Treatment includes fluid resuscita3on and
occasional atropine and vasopressors
Spinothalamic

Effects of Spinal Cord Injury Effects of Spinal Cord Injury

Spinal Shock – Direct Effects Other Consequences

●  Neurologic, not hemodynamic phenomenon ●  Inadequate ven3la3on
●  Occurs shortly a[er cord injury ●  Abdominal evalua3on compromised
●  Variable dura3on ●  Occult compartment syndrome
●  Flaccidity and loss of reflexes

Management Management

How do I manage pa9ents with spinal cord injury and How do I manage pa9ents with spinal cord injury and
limit secondary injury? limit secondary injury?

●  Ensure adequate ven3la3on and

oxygena3on
●  Maintain blood pressure
●  Maintain perfusion of spinal cord

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Management Management

Management of Hypotension Whom do I transfer?

●  Assess for associated bleeding ●  Unstable fractures

●  Consider neurogenic shock ●  Neurologic deficit
●  Monitor urinary output

Stop
the Caution

bleeding! Avoid transfer delay!

Management Summary

Management of Pa3ents Requiring Transfer

●  Treat life-threatening injuries first
●  Provide respiratory ●  Properly immobilize en3re pa3ent
support as needed
●  Exclude other life- ●  Obtain appropriate spine films
threatening injury
●  Document examina3on
●  Properly immobilize
en3re pa3ent ●  Obtain neurosurgical / orthopaedic consult
●  Avoid hypothermia
●  Transfer unstable fracture / cord injury

THANK YOU