SPINE  Intubated or obtunded?

 Primary Survey
 Airway
 Breathing
 Circulation
 Disability
 Exposure

 Secondary Survey (Diagnostic, whole body

assessment)
 Not to interfere with ABC’s

PHASES OF SPINE TRAUMA PHYSICAL EXAM

1) Inspection and palpation

 Identify other injuries
 Anterior
 Posterior-log roll (can be part of primary or
secondary survey)

 Inspection-Anterior
 Start with head-to-toe visual inspection
 Remove all clothes
 Head-Racoon Eyes, bleeding from auditory
meatus, etc Basal Skull fracture
 Neck-Cock-robin posture Atlantoaxial
rotatory subluxation, facet dislocation
 Chest Chest contusions
 Flail Chest
 Chest/ Abdomen = Seat belt sign
 Perineum/ Pelvis = Scrotal swelling
 Vaginal bruising
 Extremities = Limb Deformities/ injury ER
position of hip, etc
 Bruising/ Swelling Palpate all large joints
 If intubated, patient may withdraw from pain
 Gross movement/ muscle tone
 Every bruised, swollen or tender extremity
gets an Xray!

2) Neurologic
 Motor
 Sensory
 Reflexes
SPINE TRAUMA EVALUATION AND EXAM
 Neurologic Exam
 Considerations before you step in the  Motor
trauma  Sensory
 High energy?MVC, fall of a ladder, etc..  Reflexes
 Low energy?Ground level fall? Step off a
curb?
 Age?Osteoporosis fracture risk?
 Pathologic fracture risk?
 Awake and Alert?
 Sensory testing –28 dermatomes (light
touch & pin prick), each side
 Motor testing –10 myotomes, each side
 Neurologic level -most distal level with
normal function
 Motor level -most distal muscle group with a
power score of 3 out of 5
 Rectal examination is essential, should be
accompanied by bulbocavernosus reflex
testing to assess for spinal shock
 Classification of
neurologic deficit as
complete or incomplete
cannot be determined
until spinal shock has
resolved
 Sensory Exam-Cervical Spine
 C5-Anterior lateral shoulder
 C6-Dorsal Thumb
 C7-Dorsal MF
 C8-Dorsal 4/5thdigit
 T1-Medial Forearm

 Sensory Exam-Lumbar Spine

 L2-Proximal medial thigh
 L3-Distal medial thigh
 L4-Medial ankle
 L5-1stweb space
 S1-Lateral ankle/ heel

Sensory Exam-Sensory Grading (ASIA)

 0 Absent
 1 Altered (decreased, impaired, or
hypersensitivity)
 2 Normal

Rectal Exam (ASIA)

 Extremely important REFLEXES
 Helps determine cord injury grade
 Dermatome is S4-5  CervicaL
 Exam consists of: SensationLight touch  C5-Bicep
(LT)/ pin prick (PP)  C6-Brachioradialis
 Deep anal pressure (DAP)  C7-Tricep
 Voluntary Anal Contraction (VAC)  Lumbar
 Grading/ ScoringIf sensation (LT/ PP) or  L4-Patella
DAP orVAC are present= Sacral sparing=  S1-Achilles
incomplete cord injury
 Reflexes-Grading
Spinal Shock  0 Absent
 1+Hyporeflexic
 It is a transient state of complete areflexia  2+Normal
after spinal cord injury  3+Hyperreflexic
 Typically resolves 24 hours  4+/ CLAssociated with Clonus
 During spinal shock there is no residual
cord function
 End of spinal shock is heralded by return of RADIOGRAPHIC EVALUATION
anal wink or bulbocavernosus reflex  Adjunct to history and physical examination
 If sacral reflexes do not return –injury is in process of establishing diagnosis of spine
termed complete injury.
 Ascertain as definitively as possible whether
there is a Spine injury
 Define fully the nature of the Spine injury
  MRI-soft tissue definition
 T1 sequences:
o Excellent for surveying anatomy and
caliber of spinal cord

 T2 images with or without fat saturation:

o epidural fluid collection, ligamentous
disruption, edema and herniated
discs

 MRI
 best soft tissues definition
 Clinical suspicion
 Has neural deficit
 Herniated disc
 Cord injury
Incomplete Spinal Cord Injury Syndromes outcomes than patients who were treated
with late decompression or those who were
1. Central Cord Syndrome treated conservatively.

2. Anterior Cord Syndrome

 Most common
 Extension injury in elderly with spondylotic
 Direct compression of anterior spinal cord-
spine -cord gets “pinched” between anterior
disc herniation of osteophyte
osteophytes and posterior infolded
 Direct trauma to anterior cord
ligamentum flavum
 Ischemia due to anterior spinal artery
 Contusion of the central area of the cord
involvement from trauma or infection
(hematomyelia) affects the lateral
corticospinal tracts  Loss of motor function and pain and
temperature sensation
 More centrally located motor fibers from the
hand and upper extremity are  Preservation of vibration and position sense
disproportionately affected  Worst prognosis of all incomplete cord
 Most patients present as quadriparetic with injuries
or without bladder involvement
3. Posterior Cord Syndrome
 Recovery is typically caudal to cranial with
return of sacral motor elements followed by
lumbar
 Recovery of upper extremity function is
minimal and depends on degree of grey
matter destruction
 Functional recovery is moderate with 75
percent achieving independent ambulatory
status
 Surgical Management of Central Cord
Syndrome
o In patients with ongoing cord compression,  Least common
the effect of surgical timing on functional  Caused by injury to dorsal column from
recovery has not been established trauma, tumors or posterior
conclusively leading to significant osteophytes/calcified ligamentum flavum
controversy about the optimal timing of
 Loss of vibration and joint position sense
surgical treatment.
 Touch, pain and motor function is preserved
o Surgical Treatment for Acute Spinal Cord
 Functional recovery is fair
Injury Study (STASCIS)Only level I study
o Patients who had surgery within 24 hours
had greater improvement.
o In a meta-analysis which included 1687
patients, La Rosa et alconcluded that
patients with any traumatic SCI who had
surgery within 24 hours had better
4. Brown-Sequard Syndrome
 Hemitransection of the spinal cord
 Usually with penetrating injury
 Corticospinal tract involvement
o Flaccid paralysis at the level of the
lesion (lower motor neuron)
o Spastic paralysis below the lesion
 Posterior column (uncrossed fibers)
involvement
o Ipsilateral loss of proprioception and
vibration as well as fine touch
 Spinothalamic tract involvement (fibers
cross one or two levels after entering the
cord)
o Contralateral loss of pain,
temperature and crude touch
 Fairly good prognosis
Management of Spinal Cord Injury
 Goals of Management: Optimize neurologic
outcome
 Allow for early mobilization by stabilizing the
associated spinal injury
 Facilitate rehabilitation
 Spinal cord injury is a devastating injury with
a significant social impact
 Treatment modalities are geared towards
decreasing the damage done to the spinal
cord during the “second hit”
 Early decompression and stabilization is
encouraged for better chances at functional
recovery
 A multimodal team approach –surgeon,
anaesthesiologist, intensivists, nursings,
physical and occupational therapy, speech
therapist all play a vital role in improvement
in patient outcomes
 Ongoing research on various pharmacologic
agents is the key
SCOLIOSIS
 a spinal deformity that affects the curvature
of the spine.
 While the spine naturally curves in the
cervical, thoracic, and lumbar regions,
scoliosis causes abnormal curves and
changes.
 Scoliosis is actually a “3D” problem.
 The body is divided into three planes: the
coronal, sagittal, and axial
 Scoliosis affects 2-3 percent of the
population, or an estimated six to nine
million people in the United States.
 Scoliosis can develop in infancy or early
childhood.
 However, the primary age of onset for
scoliosis is 10-15 years old, occurring
equally among both genders.
 Females are eight times more likely to
progress to a curve magnitude that requires
treatment.
 Every year, scoliosis patients make more
than 600,000 visits to private physician
offices, an estimated 30,000 children are
fitted with a brace and 38,000 patients
undergo spinal fusion surgery.
 Causes
 Congenital
o Congenital scoliosis results from
embryological malformation of one or
more vertebrae and may occur in any
location of the spine.
o The vertebral abnormalities cause
curvature and other deformities of the
spine because one area of the spinal
column lengthens at a slower rate than
the rest.
o The geometry and location of the
abnormalities determine the rate at
which the scoliosis progresses in
magnitude as the child grows. Because
these abnormalities are present at birth,
congenital scoliosis is usually detected
at a younger age than idiopathic
scoliosis.
 Idiopathic
o Idiopathic scoliosis is the diagnosis
when all other causes are excluded and
comprises about 80 percent of all cases.
o Adolescent idiopathic scoliosis is the
most common type of scoliosis and is
usually diagnosed during puberty.
  Concussion
 Neuromuscular
o Neuromuscular scoliosis encompasses  Management
scoliosis that is secondary to  R.I.C.E
neurological or muscular diseases. o Rest
o This includes scoliosis associated with o Ice
cerebral palsy, spinal cord trauma, o Compress
muscular dystrophy, spinal muscular
o Elevate
atrophy and spina bifida.
o This type of scoliosis generally  No H.A.R.M
progresses more rapidly than idiopathic o Heat
scoliosis and often requires surgical o Alcohol
treatment. o Running
o Massage
 SIGNS AND SYMPTOMS
 Shoulders are uneven
 Head is not centered directly above the
pelvis
 One or both hips are raised or unusually
high
 Rib cages are at different heights
 Waist is uneven
 The appearance or texture of the skin
overlying the spine changes (dimples, hairy
patches, color abnormalities)
 The entire body leans to one side

 DIAGNOSIS
 XRAY
 CT-SCAN
 MRI

 TREAMENT
 Spinal maturity – is the patient's spine still
growing and changing?
 Degree and extent of curvature – how
severe is the curve and how does it affect
the patient's lifestyle?
 Location of curve – according to some
experts, thoracic curves are more likely to
progress than curves in other regions of the
spine.
 Possibility of curve progression – patients
who have large curves prior to their
adolescent growth spurts are more likely to
experience curve progression.

SPORTS INJURIES
 Strains
 Sprains
 Knee Injuries
 Fractures/Dislocation
 Tennis elbow
 Plantar fasciitis
 Back injuries