Management of spinal trauma


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Management of spinal trauma

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Management of spinal trauma

  1. 1. Management of Spinal Trauma Dr Nola McPherson SCGH Registrar Education April 2014
  2. 2.  Spinal anatomy  Evaluating a patient with suspected spinal injury  Broad management principles of spinal injury  Hypovolaemic vs neurogenic vs spinal shock Overview
  3. 3. Anatomy Location of Spinal Injuries 55% in cervical region (mobile & exposed) 15% in thoracic region (less mobile & protected) 15% in thoracolumbar region (fulcrum) 15% in lumbosacral region
  4. 4. Anatomy  Upper cervical region is wide from foramen magnum to lower part C3 - 1/3 die at scene from apnoea - those that survive are usually neurologically intact when reach hospital
  5. 5. Anatomy  Below C3, diameter of spinal canal is smaller - vertebral column injuries more likely to produce spinal cord injuries
  6. 6. Anatomy  Most thoracic spine fractures are wedge compression fractures without SC injury If fracture-dislocation in thoracic spine region – almost always complete spinal cord injury because narrow thoracic canal
  7. 7. Anatomy  Thoracolumbar junction - inflexible thoracic spine meets strong lumbar spine making it vulnerable to injury
  8. 8. Anatomy  Multiple ascending and descending tracts in the spinal cord (not going to cover all of these today!)  THREE are easily clinically assessable lateral corticospinal tract (descending tract) spinothalamic tract (ascending) dorsal columns (ascending)
  9. 9. Anatomy Corticospinal tract – controls motor power on SAME side Spinothalamic tract – transmits pain & temp sensation from OPPOSITE side Dorsal columns – carries position sense (proprioception), vibration sense and some light touch sensation from SAME side
  10. 10. Anatomy  Sensory Examination  Dermatomes  Motor Examination  Myotomes
  11. 11. Spinal Injury: Classification Spinal cord injury may be categorised as:  Incomplete quadraplegia (incomplete cervical injury)  Complete quadraplegia  Incomplete paraplegia (incomplete thoracic injury)  Complete paraplegia
  12. 12. QUIZ – location of lesions and clinical presentations
  13. 13. COMPLETE Neurology Total flaccid paralysis Total anaesthesia Total analgesia No tendon reflexes MUST WAIT UNTIL SPINAL SHOCK RESOLVED to diagnose
  14. 14. INCOMPLETE Neurology Partial paralysis Altered sensation (light touch or pin prick) Sacral sparing BETTER prognosis, may recover
  15. 15. Spinal Cord Syndromes Different patterns of neurologic injury with the following syndromes: Central Cord Syndrome Anterior Cord Syndrome Posterior Cord Syndrome Inferior Cord Syndrome Transverse Cord Syndrome Brown-Sequard Syndrome Cauda Equina Syndrome Syringomyelia
  16. 16. Spinal Injury: Morphology Spinal injuries can be described as: 1. Fractures 2. Fracture – dislocations 3. Spinal cord injury without radiographic abnormalities 4. Penetrating injuries These injuries can be further categorized as stable or unstable
  17. 17. Spinal Injury: Signs and Symptoms Pain (and bony tenderness on examination) Tingling, numbness and weakness in peripheries Loss of sensation or paralysis below level of injury Impaired breathing – C3/4/5 (diaphragm) Incontinence Priapism
  18. 18. Spinal Trauma: Primary Survey Activate trauma team, triage to trauma bay Move patient off spinal board as soon as clinically safe to do so  Airway maintenance with C spine immobilisation - definitive airway early if respiratory compromise (injury higher than C6 need intubation and ventilation) - maintain hard collar, sandbag/bolsters and tape  Breathing and Ventilation - 15L /min oxygen (NRB) + ventilatory support - monitor RR, respiratory effort, cough
  19. 19.  Circulation with haemorrhage control - if hypotension – hypovolaemic vs neurogenic shock - assume hypovolaemia 1st : search for source blood loss + replace fluids - if SC injury: guide fluid replacement with CVP monitoring (controversial) - inotropes may be required - before IDC – perform rectal examination and assess rectal sphincter tone and sensation Spinal Trauma: Primary Survey
  20. 20.  Disability - GCS /pupils/BSL - look for paralysis/paresis/priapism/ anal sphincter tone/bulbocavernosus reflex  Exposure/Environment – keep warm (blankets, bair hugger, fluid warmer) peripherally vasodilated, unable to regulate temp if injury above T4 Spinal Trauma: Primary Survey
  21. 21. Adjuncts to Primary Survey  Full non invasive monitoring (consider invasive later)  ECG  Trauma Xray series – lateral cervical spine, chest, pelvis  Bedside FAST scan (?sources of bleeding)  NGT  IDC
  22. 22.  Focused AMPLE Hx  Ask mechanism? does your neck or back hurt? can you feel me touching your fingers and toes? can you move your hands and feet? Spinal Trauma: Secondary Survey
  23. 23.  Assess full spine A. Log roll and palpate spine/paraspinal region look for deformity/ crepitus/pain/contusions/ lacs/penetrating wounds B. Assess for pain, paralysis and paraesthesia location neurological level Spinal Trauma: Secondary Survey
  24. 24. Spinal Trauma: Secondary Survey  Test sensation  Test motor function  Test deep tendon reflexes  DOCUMENT carefully and REPEAT  Head to toe examination – assess for associated injuries
  25. 25. Adjuncts to Secondary Survey  Advanced spinal imaging - CT scan (defines bony injury) - MRI scan (defines neurological injury)  Consider CVP monitoring
  26. 26. Disposition  EARLY discussion with spinal specialists - best imaging technique based on suspected injury - management options - ?steriods – give or not give  Transfer to spinal unit
  27. 27. Examination For SC Level  Sensory Examination  Best Motor Examination: TABLE 1: Determining the level of Quadraplegia TABLE 2: Determining the level of Paraplegia
  28. 28. Table 1: Examination For SC Level Action Nerve Root Level Raises elbow to shoulder level Deltoid, C5 Flexes forearm Biceps, C6 Extends forearm Triceps, C7 Flexes wrist and fingers C8 Spreads fingers T1
  29. 29. Table 2: Examination For SC Level Action Nerve Root Level Flexes hip Iliopsoas, L2 Extends knee Quadriceps L3-4 Flexes Knee Hamstrings L4-5, S1 Dorsiflexes big toe Extensor hallucis longus, L5 Plantar flexes ankle Gastrocnemius, S1
  30. 30. Phases of Injury  Primary spinal cord Injury – initial trauma  direct injury to SC due to fractures, dislocations, haematomas, soft tissue swelling  Secondary spinal cord injury (later) – due to ongoing mechanical instability or insults secondary to hypoxia and hypotension
  31. 31. Spinal Trauma: Management Principles 1. Immobiisation 2. Intravenous fluids 3. Medications 4. Early advise, prompt referral/transfer ED acute care priority: avoid secondary spinal injury
  32. 32. Spinal Trauma: Management Principles  Immobilisation: protect from further spinal injury cervical collar long spinal board, bolsters and tape remove from spinal board as soon as possible (ideally < 2hours, BEWARE pressure pts & decubitus ulcers) logroll maintaining neutral alignment of entire spine (four or more helpers required with av 70kg patient)
  33. 33. After arriving at ED, at least 5% with spinal injury experience new symptoms or worsening of preexisting symptoms as a result of – secondary spinal injury (ischaemia & progression of spinal cord oedema) poor immobilisation technique
  34. 34. Spinal Trauma: Management Principles  Fluid resuscitation • Maintenance fluids only unless shock • If shocked – establish if hypovolaemic OR neurogenic  Insert IDC (during primary survey) • Monitor urinary output • Prevent bladder distension  Insert NGT • Prevent gastric distension (+/- paralytic ileus) • Prevent aspiration (sphincter paralysis)
  35. 35. Spinal Trauma: Management Principles  Medications  Corticosteriods - insufficient evidence for routine use Aimed at reducing extent of permanent paralysis Most trials have used high dose methylprednisolone Improved motor neurological outcome up to one year post injury if given within eight hours of injury Given as bolus dose and then IV infusion for 24-48 hours - 24 hour IVI if treatment commenced within 3 hours of injury - 48 hours IVI if treatment commenced within 3-8 hours of injury
  36. 36. Spinal Trauma: Management Principles Early studies (NASCIS I & II)* showed no increased complications or mortality if 24 or 48 hour IVI More recent larger studies have raised concerns about increased risk of sepsis due to immunosuppressive effects CI: heavily contaminated open injuries, other heavily contaminated injuries eg perforated bowel, sepsis Consult with spinal specialist (use or not to use??) More research needed  Analgesia * National Acute Spinal Cord Injury Study I & II
  37. 37. Spinal Trauma: Management Principles  Transfer  Promptly after consultation with spinal specialist If injury above C6 (can result in partial or complete loss of respiratory function) – intubate before transfer
  38. 38. Secondary Complications  Consider DVT/PE Pressure sores Respiratory complications eg pneumonia UTIs Muscle length changes Psychological problems
  39. 39. Hypovolaemic vs Neurogenic Shock Hypovolaemic Shock Neurogenic Shock Increase HR Decreased HR Decreased BP Decreased BP Cool extremities Warm extremities
  40. 40. American Spinal Injury Association (ASIA) Classification  Allows classification of spinal cord injury (standardizing terminology worldwide)  Based on - severity of neurological deficit A=complete to E=normal - neurological level most caudal segment with normal function
  41. 41. Neurogenic Shock  Neurogenic Shock Mechanism impairment of descending sympathetic pathways in the cervical or upper thoracic spinal cord (usually above T6)  Loss of sympathetic vasomotor tone - peripheral vasodilation (visceral and lower extremity b/v)  pooling of blood  HYPOTENSION
  42. 42. Neurogenic Shock  Loss of sympathetic innervation to heart (usually lesion above T1)  bradycardia (or at least failure of tachycardic response to hypovolaemia)
  43. 43. Neurogenic Shock Management: 1. Hypotension 1. crystalloid (250mL boluses) and IVI – may not improve BP despite massive infusion (beware fluid overload and pulmonary oedema) 2. vasopressors eg noradrenaline, dopamine - after trial of volume replacement Maintain organ perfusion: mentation, UO>0.5mL/kg/hr, MAP >65mmHg, warm peripheries Consider CVP monitoring
  44. 44. Neurogenic Shock 2. Bradycardia 1. atropine (0.6mg IV boluses, up to max 3mg) 2. avoid overzealous vagal stimulation with suction/NGT and ETT placement
  45. 45. Spinal Shock  Spinal Shock = transient loss of muscle tone and loss of reflexes (flaccid areflexia) below the level of spinal cord injury Not true shock Spinal cord (temporarily) nonfunctional but not destroyed No ANS or somatic reflexes First to return is bulbocavernosus and Babinski reflexes Duration variable (hours to weeks) Resolves with improvement in soft tissue swelling
  46. 46. Take Home Messages  Over half of spinal cord injuries occur in the cervical spine region (most vulnerable and mobile region)  C spine immobilisation in trauma = spinal board (initially), hard collar, sandbags/bolster and tape  Consider early intubation and ventilation with injuries higher than C6 (altered LOC, regurgitation, cervical haematomas) – hypoxaemia is late sign of deterioration  Follow ATLS ‘A B C D E’ algorithm in spinal trauma – aim is to limit secondary spinal cord injury
  47. 47. Take Home Messages  Neurogenic shock is a triad of hypotension, bradycardia and peripheral vasodilation  In trauma patients, neurogenic shock is a diagnosis of exclusion  Watch over zealous fluid treatment – if hypotension not improving with fluid resuscitation, consider neurogenic shock  EARLY discussion with spinal specialist the use of noradrenaline (for hypotension) and steroids (remains controversial) in spinal trauma
  48. 48. Question and discussion time Thank you
  49. 49. References  Fildes J, et al. Advanced Trauma Life Support Student Course Manual (9th edition), American College of Surgeons 2012.  Image of Vertebral Column taken from: Gray_111_-_Vertebral_column-coloured.png  Image of Major Tracts in Spinal Cord taken from: 222-spinal.html
  50. 50. References  Image of Dermatomes taken from: _cutaneous_nerves_-_anterior.svg  Image of Myotomes taken from:  Image of Tetraplegia/paraplegia spinal levels taken from: exam-2-flash-cards/
  51. 51. References  Trauma Spinal Injury taken from:  ASIA Impairment Scale taken from: ISNCSCI_ASIA_ISCOS_low.pdf  BrackenMB.Steroidsforacutespinalcordinjury.CochraneDatabas eofSystematicReviews2012,Issue1.Art.No.:CD001046. DOI: 10.1002/14651858.CD001046.pub2.
  52. 52. References  Cameron P, Jelinek G, Kelly AM, Murray L, Brown A. Textbook of Adult Emergency Medicine. 3rd Edition. Churchill Livingston Elsevier 2009.