Spine and Spinal Cord

Injury

TJOKORDA GB MAHADEWA, M.D., M.Med., S.F.N.S. (jpn)

Presented in Block Neuroscience
19th May 2011
Description

 Trauma to bony or ligamentous structurs of

the spine, with or without spinal cord damage
 Whiplash associated disorder (WAD):
damage to the soft tissues of the spine caused
by acceleration/deceleration
TRIAGE:
 Process of management prioritization of multiple
patient casualties
 What factors are considered in the Triage Process?
1. Degree of life threatening (ABCDE)
2. Injury severity
3. Salvageability
4. Resources: Man, Materials, Time, etc.
5. Information may be incomplete.
6. Decisions may differ.
7. Use all cues possible—Frequently requires survey from a
distance
8. Avoid indecision
All patient start with

Initial Assessment
and Management
Primary Survey
 Adult, children, pregnant women
Priorities are the same !
A Airway with C-spine protection
B Breathing with ventilation
C Circulation with hemorrhage
control
D Disability
E Exposure/Environment
Airways + C-spine Protection

Noisy breathing is obstructive breathing:

snorering, gurgling, stridor
Primary Survey

Immediate action
 Spinal cord damage is incurable. If in doubt,
immobilize the spine
Suspect C-Spine Injury
 Spinal protection
 C-spine X-ray when
appropriate
Reevaluation

Proceed to Secondary Survey After :

 Primary survey completed
 ABCDEs are reassessed
 Vital functions are returning to
normal
Spine and Spinal Cord Injury

 ≥ 5% of patients worsen neurologically at

hospital
 Protection — priority;
detection— secondary
 Spinal evaluation complicated by brain
injury
 Remove spine board as soon as possible
Suspect Spine and Spinal Cord
Injury
 High-Speed Crash
 Unconscious patient
 Multiple injuries
 Neurologic deficit
 Spinal pain / tenderness
Screening for Spine and Spinal Cord Injury

Conscious Patient
Presence of
paraplegia/quadriplegia /pentaplegia

Presume spinal instability

Identify bony Early

neurosurgical
fracture subluxation consult
 Screening for Spine and Spinal Cord injury

Alert,sober, neurologically normal patient :

① If no neck or spine ④ If still no pain or

pain or tenderness to tenderness with
palpation or voluntary voluntary
movement
movement
② If no painful ⑤ No further spine
distracting injury evaluation or c-
③ Remove C-colar spine x-ray
necessary
 Screening for Spine and Spinal Cord
Injury

Alert, sober, neurologically normal patient :

 If “ yes” to any question
 Neck or spine pain  Protect c-spine
or tenderness to  Obtain necessary
palpation or x-ray exams
voluntary
movement ?
 After removal of c-
collar ?
Examination

 Exclude other injuries.

 Palpate all spinous processes.
 Ask patient to move spine within the pain
limits.
 Inspect motor and sensory function.
 Look for Horner's syndrome.
 Torticollis.
 Sensory Examination

Cervical Thoracic Lumbosacral

C-5 Deltoid T-4 Nipple L-4 Medial Leg

C-6 Thumb T-8 Xiphoid L-5 1st/2nd toes
C-7 Middle T-10 Umbilicus S-1 Lateral foot
finger T-12 Symphysis S-4 Perianal
C-8 Little finger
Motor Examination
Cervical / Thoracic Lumbosacral
C-5 Shoulder abduction L-2 Hip flexion
C-6 Wrist Extension L-3 Knee extension
C-7 Elbow extension L-4 Ankle
C-8 Middle finger dorsiflexion
flexion L-5 Big toe
T-1 Little finger extension
abduction S-1 Big toe / ankle
plantar flexion
 Neurologic Assessment

Neurogenic Shock
 Hypotension associated with cervical /high

thoracic spine injury

 Bradycardia

 Treatment : Maintenance fluids, atropine

and occasionally vasopressors

Neurologic Assessment

Spinal “Shock”
 Neurologic Not hemodynamic

phenomenon
 Occurs shortly after cord injury

 Flaccidity

 Loss of reflexes
Classification of Injury
Incomplete Complete
 Any sensation
 No motor /

 Position sense sensory function

 Voluntary  No sacral sparing

movement in  May have reflexes

lower extremity
 Sacral sparing
Classifications of Injury

Spinal Cord Syndromes

 Central cord

 Posterior cord

 Anterior cord

 Brown – Sequard

 Complete transection
 Classification of Injury

Morphology
 Fracture or fracture / dislocation
 Spinal cord injury without radiographic
abnormality (SCIWORA)
 Spinal Cord Injury without radiographic
evidence of Trauma (SCIWORET)
 Penetrating
Classification of Injury

Morphology
 Consider unstable if :

• X-ray evidence of injury

• Neurologic deficit
• Severe pain on spine movement or
palpation
C Spine X-ray Guidelines

 Adequacy
 Alignment
 Bony abnormality
 Base of skull
 Cartilage , Contours
 Disc space
 Soft tissue
C – Spine X-rays

 10% of patients with a C-spine fracture have a

2nd, associated noncontiguous vertebral
column fracture
 Indentify one abnormality ? Look for
another!
 Radiographic screening of entire spine
required in this instance
C-spine x-rays

 Crosstable lateral film exludes 85% of

fracture
 Additional 2 views exludes most fractures
 Also may require
• Swimmers view
• Ct scan for bony detail
• Flexion extension views
• MRI/CT myelogram
Cervical Trauma MRI
Other spine X –ray Guidelines

 Adequacy
 Alignment
 Bony abnormality
 Cartilage, Contours
 Disc Space
 Soft tissue
Summary of tests

 Plain spine X-rays if indicated.

 Flexion extension views (by specialist).
 MRI (by specialist): this is considered the 'gold
standard' in detecting soft-tissue injury.
 Cervical spine fractures are often best
demonstrated on a high-resolution CT scan
Management
Immobilization  MANAGEMENT
 Entire Patient  Treat life threatening
 Proper padding injuries first
 Maintain until spine
 Immobilize
injury excluded
 Appropriate spine
 Avoid prolonged
imaging
use of backboard!
 Document examination
 Definitive treatment
Hyperflexion injuries

 Posterior ligamentous injuries

 Unilateral facet dislocation

 Bilateral facet dislocation

Unilateral facet dislocation
Unilateral facet dislocation
 Extension injuries

Central cord syndrome

 due to congenital or degenerative
stenosis/OPLL
 usually not associated with instability

 if spinal cord compression, decompression

later
Flexion-compression fracture
Burst fracture
Fracture-dislocation
 Medical Management

 Ensure adequate ventilation especially for high level (c-4)

quadriplegic
 Maintain blood pressure
 Atropine as needed
 Methylprednisolone (NASCIS III)
Steroids
 IV Methylprednisolone
 Proven spinal cord injury
 Starts within 1st 8 hours from injury only
 30 mg/kg over 15 minutes
 5.4 mg/kg over next 23 hours
Proven in blunt trauma only
Nonoperative treatment
closed reduction and immobilization

 Postural reduction with pillow

 Hyper-extension position
Spinal Shock
Transfer
Transfer
 Unstable fractures

 Neurologic deficit

Avoid delay
 Properly Immobilized

 Respiratory support as needed

Never

 Never remove the helmet from an injured motorcyclist

in the field unless there are airway problems
 Never ask patient with suspected cervical spine injury to
move until spine stability is assured
 Never force passive movement of spine
 Never force a patient with ankylosing spondylitis to lie
down flat
 Never refer for manipulation therapy unless serious
cervical spine injury has been excluded
Questions?
 Conclusion
1.Rapid development of fixation devices.
 selection of proper instrument.
 instrument availability.
 instrument price.
2. Exact understanding of injury mechanism
and surgery indications.
3. Financial status
4. Patient education
Further Reading
Terimakasih
Thank You