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Spinal injuries

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  • 1. By Dr Imran Javed. Associate Professor Surgery. Fiji National University.
  • 2.  Vertebrae  7 cervical (flexion, extension, lateral flexion, rotation)  1st-atlas  2nd-axis  12 thoracic (little movement)  5 lumbar (less flexion than extension, some rotation  5 sacral (fused)  3-4 coccyx (fused)
  • 3.  Each vertebrae has a nerve that exits either below or above it  31 pairs of spinal nerves  8 cervical nerves  12 thoracic nerves  5 lumbar  5 sacral  1 coccygeal
  • 4.  Part of the CNS along with brain  Contained within vertebral canal  Extends from cranium to 1st-2nd lumbar vertebrae  Lumbar roots & sacral nerves for a ―horse-like tail‖ called cauda equina  2 plexuses  Brachial, lumbosacral
  • 5.  L1,2,3-iliopsoas—hip flexion  L2,3,4-Quads—knee extension  L4-tibialis anterior— dorsiflexion/inversion at ankle  L5-Extensor hallicus longus, extensor digitorum longus/brevis, extension/inversion at ankle  S1-peroneus longus/brevis-eversion  S1,2-gastroc/soleus— plantar flexion  C5-deltoid—shoulder abduction  C5-6-biceps—elbow Flexion  C6-wrist extensors— extension  C7-triceps & wrist/finger flexors—elbow extension, wrist/finger flexion  C8-finger flexors—finger flexion  T1-finger Abductors-- abduction
  • 6.  Who’s at risk?  ADULT MEN BETWEEN 15 AND 30 YEARS  Anyone in a risk-taking occupation or lifestyle  SCI in older clients increasing largely due to MVAs  Causes (in order of frequency)  MVA  Gunshot wounds/acts of violence  Falls  Sports injuries
  • 7.  Airway & Cervical Spine.  Breathing.  Circulation.  Disability.  Environment & Exposure.  Fluids.
  • 8.  Below site of injury:  Total lack of function  Decreased or absent reflexes and flaccid paralysis  Lasts from a week to several months after onset.  End of spinal shock signaled by muscular spasticity, reflex bladder emptying, hyperreflexia.
  • 9.  Flexion (bending forward)  Hyperextension (backward)  Rotation (either flexion- or extension- rotation)  Compression (downward motion)
  • 10.  Complete transection  Total paralysis and loss of sensory and motor function although arms or rarely completely paralyzed  Incomplete (partial transection)  Mixed loss of voluntary motor activity and sensation  Four patterns or syndromes
  • 11.  Central cord syndrome More common in older clients  Frequently from hyperextension of spine  Weakness in upper and lower ext, but greater in upper.  Anterior cord syndrome  Posterior cord syndrome  Brown-Sequard syndrome
  • 12.  Compression of the ant. Cord, usually a flexion injury  Sudden, complete motor paralysis at lesion and below; decreased sensation (including pain) and loss of temperature sensation below site.  Touch, position, vibration and motion remain intact.
  • 13.  Assoc with cervical hyperextension injuries  Dorsal area of cord is damaged resulting in loss of proprioception  Pain, temperature sensation and motor function remain intact.
  • 14.  Damage to one half of the cord on either side.  Caused by penetrating trauma or ruptured disk. ischemia (obstruction of a blood vessel), or infectious or inflammatory diseases such as tuberculosis, or multiple sclerosis. BSS may be caused by a spinal cord tumor, trauma (such as a puncture wound to the neck or back),.  a rare SCI syndrome which results in  weakness or paralysis (hemiparaplegia) on one side of the body and  a loss of sensation (hemianesthesia) on the opposite side.
  • 15.  Depend on the LEVEL and DEGREE of the injury!  Quadriplegia occurs with C-1 through  C-8 injuries.  Paraplegia occurs with T-1 thru L-4.  Respiratory  C1 – C3: Absence of ability to breathe independently.  C4 – poor cough, diaphragmatic breathing, hypoventilation  C5 – T6: decreased respiratory reserve  T6 or T7 – L4: functional respiratory system with adequate reserve.  Cardiovascular:  C1 – T5 shows decreased or absent SNS influence.  BRADYCARDIA AND HYPOTENSION (due to vasodilation)
  • 16.  The phrenic nerve stimulates the diaphragm to contract.  Two phrenic nerves (right and left) - injury to one or the other paralyzes contraction of only one half of the diaphragm but even hemi- (half) paralysis can significantly interfere with breathing for patients with lung disease.  The nerve arises from branches of the C3,4, and 5 nerve roots.  The phrenic nerve can be damaged by procedures exploring the neck & upper back  Loss of the phrenic nerve on either side results in paralysis of the diaphragm on that side.  Paralysis of the diaphragm on one side results in less inflation of the lung on that side.  Whether this is physiologically significant (producing respiratory distress, hypoventilation/hypercapnia) depends on other aspects of a patient's pulmonary physiology (namely underlying chronic obstructive pulmonary disease [emphysema, bronchitis], pneumonia, etc.).
  • 17.  The longest of the cranial nerves- exits out of the medulla and ends in the abdomen  It supplies sensory and motor function to the pharynx  Supplies motor function to the muscles of the abdominal organs  Provides parasympathetic activity to the heart, lungs, and most of the digestive system
  • 18.  Atonic bladder with RETENTION in spinal shock.  Post acute phase – irritability causing dribbling or frequent urination.  Urinary infection and calculi from retention and distention.  INTERMITTENT CATHETERIZATION!
  • 19.  Decreased motility  Paralytic ileus  Gastric distention – intermittent NG suctioning  Increased H2 – administer H2 inhibitors such as Zantac or Pepcid in initial stages  Carafate and antacids later as prophylaxis  Intra-abdominal bleeding! Remember, no pain or tenderness to warn you.  Watch for impactions.
  • 20.  Pressure ulcers!  Muscle atrophy in flaccid paralysis  Contractures in spastic paralysis  Poikilothermism – the adjustment of body temp to room temperature  Decreased ability to sweat below lesion
  • 21.  DVT common but not detected easily  Pulmonary embolism a significant cause of death.  Doppler studies, measurement of extremity girth, impedance plethysmography (what the heck is this?)
  • 22.  Goals are to  Sustain life  Prevent further cord damage  Assessment of muscle groups; motor status  Against gravity  Against resistance  Both sides of the body  Ask to move legs, hands, fingers, wrists, then shrug shoulders Thorough motor examination including position sense and vibration.  Sensory examination  Pinprick starting at toes and working upward  ALWAYS HAVE CLIENT CLOSE EYES OR LOOK AWAY! If he can see what you’re doing, he will answer accordingly.  Assess for head injury and ICP  X-ray, CT scan, EMG
  • 23.  MRI provides Better Evaluation of Spinal cord.  CT Scan is good for Bony Injury but radiation exposure is involved.  X-Ray is still good for initial evaluation & Screening purposes with multiple views.  Myelogram is outdated but still may be used where MRI is not available.  Tomograms may be of little value.  Continuous Imaging (Fluoroscopy) may be used during surgery & Manipulation of Spine.
  • 24.  Surgical Therapy:  Reduces injury and stabilizes the SC  Done for Compression, Bony fragments in the cord, Compound fracture, Penetrating trauma  Vasopressors: to keep mean arterial pressure greater than 80mm to 900mm/Hg so that PERFUSION TO CORD is improved.  MethylPrednisolone: Increases the recovery of function. IV bolus then continuous IV over a 23 hour period. Improves blood flow and reduces edema in the SC.  GI problems - zantac, tagamet, pepcid  Bradycardia - atropine  bladder spasticity - anticholinergics  autonomic dysreflexia – blood pressure reduction