Spinal injury Dr. sundar karki

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Spinal injury

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  • Hyperflexion - Excessive/abnormal bending forward of the chin toward the chest. This is one mechanism seen when patients are ejected from moving vehicles
  • Hyperotation - Excessive/abnormal rotation. This may produce injuries in any area of the spine.
  • Bulbocavernosus Reflex - Discussion:     - bulbocaverosus reflex refers to anal sphincter contraction in response to squeezing the glans penis or tugging on the Foley;          - reflex involves S-1 , S-2 , and S-3 nerve roots and is spinal cord- mediated reflex arc;     - following spinal cord trauma, presence or absence of this reflex carries prognostic significance;          - in cases of cervical or thoracic cord injury, absence of this reflex documents continuation of spinal shock  or spinal injury at the level of                 the reflex arc itself;                - period of spinal shock usually resolves w/ in 48 hours and return of bulbocavernosus reflex signals termination of spinal shock;          - note that spinal shock does not apply to lesions that occur below the cord, and therefore, low lumbar burst frx should not cause spinal                 shock (and in this situation, the absence of the bulbocaveronsus reflex indicates that there is a cauda equina injury );                 - persistent loss of the bulbocavernosus reflex may be a result of a conus medullaris injury (eg from an L1 burst frx ); - Prognositic Significance:     - complete absence of distal motor or sensory function or perirectal sensation, together with recovery of the bulbocavernosus reflex,            indicates a complete cord injury, and in such cases it is highly unlikely that significant neurologic function will ever return;           - therefore, if no motor or sensory recovery below the level of frx is present, pt has a complete spinal cord injury and no further distal                  recovery of motor function can be expected;          - on other hand, any spared motor or sensory function below level of injury is considered incomplete spinal cord injury ;          - potential for recovery of incomplete lesion is determined by part of the cord most severely injured
  • Etiology: - direct anterior cord compression - flexion of cervical spine - thrombosis of anterior spinal atery Symptoms - complete paralysis of below the lesion with the loss of pain and touch sensation - preservation of propioception and vibratory function Prognosis : bad
  • Etiology - transverse hemisection of spinal cord -unilateral cord compression Symptoms -Ipsilateral spastic paresis, loss of proprioception and vibratory sensation, and contralateral loss of pain and temperature sensation Prognosis: good
  • Etilogy -Hyperextension injuries -Disruption of blood flow to the spinal cord -Cervical spinal stenosis Symptoms -Quadriparesis—greater in the upper extremities than the lower extremities. Some loss of pain and temperature sensation, also greater in the upper extremities Prognosis: good
  • Neurogenic Shock Injury to the spinal cord at the level of the cervical or thoracic vertebrae causes peripheral sympathetic denervation. The loss of sympathetic arterial tone results in decreased systemic vascular resistance and blood pressure. Loss of sympathetic innervation to the heart (T1 through T4 cord levels) leaves the parasympathetic cardiac innervation via the vagus nerve unopposed, resulting in bradycardia, or an absence of reflex tachycardia. In general, patients with neurogenic shock are warm, peripherally vasodilated, and hypotensive with a relative bradycardia . Patients tend to tolerate hypotension relatively well, as peripheral oxygen delivery is presumably normal. Bradycardia is characteristic but not universal. Loss of sympathetic tone and subsequent inability to redirect blood from the periphery to the core may cause excessive heat loss and hypothermia.8 The diagnosis of neurogenic shock should be one of exclusion. Certain clues—such as bradycardia and warm, dry skin—may be evident, but hypotension in the trauma patient can never be presumed to be caused by neurogenic shock until other possible sources of hypotension have been excluded .9 A large percentage of patients will have significant concomitant injuries, with blood loss as the cause of their hypotension.9,10 A search for hemorrhage should be conducted before hypotension can be attributed solely to neurogenic shock. Treatment of Neurogenic Shock Loss of sympathetic innervation during neurogenic shock results in blood pooling in the distal circulation. Infusion of IV crystalloid will correct this relative hypovolemia. Adequate fluid resuscitation should be undertaken, with the aim of keeping the mean arterial blood pressure at 85 to 90 mm Hg for the first 7 days after acute spine injury.11 Though a bit arbitrary, it has been determined by collective clinical experience that this level of pressure provides adequate perfusion and minimizes the effects of secondary cord injury.12 The aggressive use of fluids in neurogenic shock should be performed with careful monitoring, as there is danger of excessive fluid replacement, with resultant heart failure and pulmonary edema.13 The placement of a pulmonary artery catheter and its resultant pressure measurements can be of tremendous benefit in helping to prevent excess fluid administration. If IV fluids are not adequate to maintain organ perfusion, positive inotropic pressor agents may be beneficial adjuncts to improve cardiac output and raise perfusion pressure.14 Optimal combinations and doses of these agents are variable and should be titrated to the patient's hemodynamic response. Bradycardia, when present, usually occurs within the first few hours or days after spinal cord injury because of a predominance of vagal tone to the heart. In cases of hemodynamically significant bradycardia, atropine may be needed. In rare instances, patients will have an atrioventricular conduction block, with significant bradycardia requiring a pacemaker
  • BCR: bulbocavernosus reflex Spinal Shock The syndrome neurogenic shock must be differentiated from spinal shock; the two terms have very different meanings and are not interchangeable. Spinal shock refers to the temporary loss or depression of spinal reflex activity that occurs below a complete or incomplete spinal cord injury. The lower the spinal cord injury, the more likely that all distal reflexes will be absent.15 Loss of neurologic function that occurs with spinal shock can cause an incomplete spinal cord injury to mimic a complete cord injury. Therefore, cord lesions cannot be deemed complete until spinal shock has resolved. The bulbocavernosus reflex is among the first to return as spinal shock resolves. The duration of spinal shock is variable; it generally persists for days to weeks.
  • Jefferson Fracture The Jefferson fracture is usually produced when the cervical spine is subjected to an axial load, as would occur from a direct blow to the top of the head. The occipital condyles are forced downward and produce a burst fracture by driving the lateral masses of C1 apart ( Figure 255-2 ). The Jefferson fracture produces outward displacement of the lateral masses on the open-mouth odontoid radiograph. A fracture through one lateral mass will cause unilateral displacement on the open-mouth view ( Figure 255-3 ). Spinal instability from the Jefferson fracture results from disruption of the transverse ligament and is likely if the lateral masses are significantly displaced. If displacement of both lateral masses (measured as offset from the superior corner of the C2 vertebral body on each side) is >7 mm when added together, rupture of the transverse ligament is likely, and the spine is unstable
  • Traumatic Spondylolisthesis of the Axis (Hangman's Fracture) The hangman's fracture describes a fracture of both pedicles of C2. The resulting instability allows the body of C2 to displace anteriorly on C3 ( Figure 255-7 ). This fracture is caused by an extension mechanism and has acquired its colloquial name from its association with judicial hangings, where the noose knot is placed under the subject's chin and snaps the head backward as the rope becomes taut at the end of a fall. Suicidal hangings do not usually cause the extreme hyperextension seen in judicial hangings and are not associated with the hangman's fracture. The same fracture is seen in motor vehicle crashes and diving accidents, where sudden hyperextension forces are applied in deceleration. Owing to the large diameter of the spinal canal at the level of C2, even displacement of C2 on C3 may not cause neurologic injury, and patients may be neurologically intact.
  • Spinal injury Dr. sundar karki

    1. 1. Emergency & GP BPKIHS, Dharan Spinal Injury Dr. Sundar Karki Medical Officer
    2. 2. Outlines • Introduction • Epidemiology • Aetiology and distribution • Normal spinal anatomy • Common mechanism of injury • Prehospital management • Diagnosis of spinal injury • Management and prognosis • Common type of spinal fracture
    3. 3. Introduction • Spinal injuries are devastating • Spinal injury may be defined as injury to the spinal column (bone column)/spinal cord or both • Improper management can have horrible and permanent result • Appropriate use of immobilization can mean difference between a patient who fully recovers and other spent whole life paralyzed.
    4. 4. Epidemiology • 40 cases per million in US • Most common cervical region(55%) • Mortality rate 40-50% • Between the ages 16-30. M:F=4:1 • Most frequent age is 19 • Current estimates are 250,000 - 400,000 individuals living with Spinal Cord Injury or Spinal Dysfunction.
    5. 5. Ateiolgy and Distribution
    6. 6. Normal Spinal Anatomy ▪33 separate irregular bones ▪Vertebral foramen: canal formed for spinal cord
    7. 7. Cervical Vertebrae ▪C1-7,located in the neck ▪Small vetrebral body Extensive joint surface ▪C1: atlas C2: axis
    8. 8. Thoracic Vertebrae ▪Rib bearing vertebrae ▪Designed to remain stiff and straight
    9. 9. Lumbar vertebrae ▪Weight bearing vertebrae ▪Lamina, facets and SPs are major parts
    10. 10. Spinal Ligament
    11. 11. Spinal cord and Nerves ▪31 pairs of nerves ▪motor and sensory both ▪Ligaments provide support ▪Cord is nerve tissue ▪Extend from foramen magnum to the L1 and end in the form of conus medullaris
    12. 12. Common Mechanism • Compression • Flexion • Extension • Rotation • Lateral bending • Distraction • Penetration
    13. 13. Spinal Column Injury Bony spinal injuries may or may not beBony spinal injuries may or may not be associated with spinal cord injuryassociated with spinal cord injury These bony injuries include:These bony injuries include: – Compression fracturesCompression fractures – Comminuted fracturesComminuted fractures – Subluxation (partial dislocation)Subluxation (partial dislocation) Other injuries may include:Other injuries may include: – Sprains- over-stretching or tearing ofSprains- over-stretching or tearing of ligamentsligaments – Strains- over-stretching or tearing ofStrains- over-stretching or tearing of the musclesthe muscles
    14. 14. Hyperflexion Whiplash injury:(C3-7) Traumatic injury to the soft tissue in the cervical region Hyperflexion, hyperextention No fractures or dislocations Most common automobile injury Recover 3-6 months Hyperextension  Atlanto-occipital dislocation:  frequently results in prehospital cardiorespiratory arrest  3 times more common in children than adults  Unstable
    15. 15. Hyper rotation  Atlanto-Axial dislocation:  Transverse ligament injury  more common in children than adults  1/3 of patients have deficit  Unstable
    16. 16. Spinal Cord injury • Cutting compression or stretching of spinal cord • Causing loss of distal function sensation or motion • Caused by: -unstable or sharp bony fragment pushing the cord - Pressure from bone fragments orPressure from bone fragments or swelling that interrupts the blood supply toswelling that interrupts the blood supply to the cord causing ischemiathe cord causing ischemia
    17. 17. Spinal cord injury ▪Primary spinal cord injury - cutting, compression or stretching of spinal cord ▪Secondary spinal cord injury -occurs later due to swelling, ischemia or movement of unstable bony fragments
    18. 18. Spinal Cord injury severity ▪Complete - less common - loss of motor and sensory function below the level of injury ▪Incomplete - some preservation of motor and sensory function
    19. 19. Spinal cord injury without radiological abnormality(SCIWORA) • referred to spinal cord injury without radiographic or CT evidence of fracture or dislocation • With advent of MRI, term has become ambiguous • "Spinal cord injury without neuroimaging abnormality" more correct name • Mostly in pediatric population (range: birth to 16 years old) • Common in cervical and thoracic region
    20. 20. Spinal cord injury without radiological abnormality(SCIWORA) • Following findings on MRI have been recognized as causing primary or secondary spinal cord injury: -Intervertebral disk rupture -Spinal epidural hematoma -Cord contusion -Hematomyelia • Prognosis of SCIWORA is actually better than patients with spinal cord injury and radiologic evidence of traumatic injury
    21. 21. Suspected Spinal Injury • High speed crash • Compression injury (diving, fall on buttock) • Significant blunt trauma • Very violent mechanism • Unconscious • Neurological deficit • Spinal pain/tenderness
    22. 22. Pre-hospital management • Protect spine at all times during the management of patients with multiple injuries • Up to 5% of spinal injuries have a second (possibly non adjacent) fracture elsewhere in the spine ▪ Ideally, whole spine should be immobilized in neutral position on a firm surface
    23. 23. Pre-hospital management • Cervical spine immobilization • Transportation of spinal cord-injured patients
    24. 24. Cervical spine immobilization • “Safe assumptions” – Head injury and unconscious – Multiple trauma – Fall – Severely injured worker – Unstable spinal column • Hard backboard, rigid cervical collar and lateral support (sand bag)
    25. 25. Philadelphia hard collar
    26. 26. Transportation of spinal cord-injured patients • Emergency Medical Systems (EMS) • Paramedical staff • Primary trauma center • Spinal injury center
    27. 27. • PROTECTION  PRIORITY • Detection  Secondary • Rigid cervical collar • “Log rolling” • Rigid transportation board remove • Rigid transfer slide Immobilization at hospital
    28. 28. Diagnosis of Spinal injury: clinical evaluation • Inspection and palpation: occiput to coccyx - tenderness - gap or step - edema and bruising - spasm of associated muscle
    29. 29. Diagnosis of Spinal injury: clinical evaluation • Neurological Examination - sensation - motor function - reflexes - rectal examination
    30. 30. Neurological: Sensory
    31. 31. Neurological: Motor
    32. 32. Neurological Examination: Rectal • Tone: the presence of rectal tone in itself does not indicate incomplete injury • Sensation • Voilition: a voluntary contraction of sphincter or the presence of rectal sensation supports the presence of a communication between the lower spinal cord and supraspinal centers
    33. 33. Neurological examination: Rectal • Bulbocavernosus reflex -refers to anal sphincter contraction in response to squeezing the glans penis or tugging on the Foley; -reflex involves S-1, S-2, and S-3 nerve roots and is spinal cord- mediated reflex arc -absence of this reflex documents continuation of spinal shock or spinal injury at the level of the reflex arc itself.
    34. 34. Is the patient awake or “unexaminable”? • What’s the difference ? – Awake • ask/answer question • pain/tenderness • motor/sensory exam – Not awake • you can ask (but they won’t answer) • can’t assess tenderness • no motor/sensory exam OW! ------
    35. 35. Neurologic assessment and grading • American Spinal Injury Association grade – Grade A – E • American Spinal Injury Association score – Motor score (total = 100 points) • Key muscles : 10 muscles – Sensory score (total = 112 points) • Key sensory points : 28 dermatomes
    36. 36. American Spinal Injury association grade
    37. 37. Incomplete Cord Injury: Anterior cord syndrome • Loss of motor, pain and temperature • Preserved propioception and deep touch
    38. 38. Incomplete cord injury: Brown-Sequard syndrome • Loss of ipsilateral motor and propioception • Loss of contralateral pain and temperature
    39. 39. Incomplete cord injury: Central cord syndrome • Weakness : – upper > lower • Variable sensory loss • Sacral sparing
    40. 40. Radiographic imaging • Who needs an x- ray of the spine ?  NEXUS -The National Emergency X- Radiograph Utilization Study – Prospective study to validate a rule for the decision to obtain cervical spine x- ray in trauma patients – Hoffman, N Engl J Med 2000; 343:94-99  Canadian C-Spine rules – Prospective study whereby patients were evaluated for 20 standardized clinical findings as a basis for formulating a decision as to the need for subsequent cervical spine radiography – Stiell I. JAMA. 2001; 286:1841-1846
    41. 41. NEXUS • NEXUS Criteria: 1. Absence of tenderness in the posterior midline 2. Absence of a neurological deficit 3. Normal level of alertness (GCS score = 15) 4. No evidence of intoxication (drugs or alcohol) 5. No distracting injury/pain
    42. 42. NEXUS • Patient who fulfilled all 5 of the criteria were considered low risk for C-spine injury  No need C-spine X-ray • For patients who sort of any of the 5 criteria  radiographic imaging was indicated ( AP, lateral and open mouth views)
    43. 43. The Canadian C-spine Rule for alert and stable trauma patients where cervical spine injury is a concern. The Canadian C-spine Rule for alert and stable trauma patients where cervical spine injury is a concern. • Any high-risk factor that mandates radiography? • Age>65yrs or • Dangerous mechanism or • Paresthesia in extremities Any low-risk factor that allows safe assessment of range of motion? • Simple rear-end MVC, or • Sitting position in ER, or • Ambulatory at any time, or • Delayed onset of neck pain, or • Absence of midline C-spine tenderness Able to actively rotate neck? • 45 degrees left and right No Radiography Radiography NO YES ABLE YES NO UNABLE
    44. 44. National Emergency X Radiography Utilization Study (NEXUS) National Emergency X Radiography Utilization Study (NEXUS) Both have: • Excellent negative predictive value for excluding patients identified as low risk The Canadian C-spine rule &
    45. 45. Clearance of Cervical Spine Injury in Conscious, Symptomatic Patients 1. Radiological evaluation of the cervical spine is indicated for all patients who do not meet the criteria for clinical clearance as described above 2. Imaging studies should be technically adequate and interpreted by experienced clinicians
    46. 46. Cervical Spine Imaging Options – Plain films • AP, lateral and open mouth view – Optional: Oblique and Swimmer’s – CT • Better for occult fractures – MRI • Very good for spinal cord, soft tissue and ligamentous injuries – Flexion-Extension Plain Films • to determine stability
    47. 47. Radiolographic evaluation X-ray Guidelines (cervical) AABBCDS • Adequacy, Alignment • Bone abnormality, Base of skull • Cartilage • Disc space • Soft tissue
    48. 48. Adequacy • Must visualize entire C-spine • A film that does not show the upper border of T1 is inadequate • Caudal traction on the arms may help • If can not, get swimmer’s view or CT
    49. 49. Swimmer’s view
    50. 50. Alignment • The anterior vertebral line, posterior vertebral line, and spinolaminar line should have a smooth curve with no steps or discontinuities • Malalignment of the posterior vertebral bodies is more significant than that anteriorly, which may be due to rotation • A step-off of >3.5mm is significant anywhere
    51. 51. Lateral Cervical Spine X-Ray • Anterior subluxation of one vertebra on another indicates facet dislocation – < 50% of the width of a vertebral body  unilateral facet dislocation – > 50%  bilateral facet dislocation
    52. 52. Bones
    53. 53. Disc • Disc Spaces – Should be uniform • Assess spaces between the spinous processes
    54. 54. Soft tissue • Nasopharyngeal space (C1) – 10 mm (adult) • Retropharyngeal space (C2-C4) – 5-7 mm • Retrotracheal space (C5-C7) – 14 mm (children) – 22 mm (adults)
    55. 55. AP C-spine Films • Spinous processes should line up • Disc space should be uniform • Vertebral body height should be uniform. Check for oblique fractures.
    56. 56. Open mouth view • Adequacy: all of the: all of the dens and lateraldens and lateral borders of C1 & C2borders of C1 & C2 • Alignment: lateral: lateral masses of C1 and C2masses of C1 and C2 • Bone: Inspect dens for lucent fracture lines
    57. 57. CT Scan • Thin cut CT scan should be used to evaluate abnormal, suspicious or poorly visualized areas on plain film • The combination of plain film and directed CT scan provides a false negative rate of less than 0.1%
    58. 58. MRI • Ideally all patients with abnormal neurological examination should be evaluated with MRI scan
    59. 59. Management of SCI • Primary Goal – Prevent secondary injury • Immobilization of the spine begins in the initial assessment – Treat the spine as a long bone • Secure joint above and below – Caution with “partial” spine splinting
    60. 60. Management of SCI • Spinal motion restriction: immobilization devices • ABCs – Increase FiO2 – Assist ventilations as needed with c-spine control – Indications for intubation : • Acute respiratory failure • GCS <9 • Increased RR with hypoxia • PCO2 > 50 • VC < 10 mL/kg – IV Access & fluids titrated to BP ~ 90-100 mmHg
    61. 61. Management of SCI • Clinical assessment and neurological examination • Spinal Imaging and send laboratory investigation • GI intervention: put nasogastric tube to prevent aspiration • Pain Management - Opiates and NSAIDs
    62. 62. Management of SCI • Consider high dose methylprednisolone – Controversial as recent evidence questions benefit – Must be started < 8 hours of injury – Do not use for penetrating trauma – 30 mg/kg bolus over 15 minute – Bolus followed by a 45-min pause – Then infusion 5.4mg/kg IV for 23 hours
    63. 63. Neurogenic Shock • Temporary loss of autonomic function of the cord at the level of injury – results from cervical or high thoracic injury • Presentation – Flaccid paralysis distal to injury site – Loss of autonomic function • hypotension • vasodilatation • loss of bladder and bowel control • loss of thermoregulation • warm, pink, dry below injury site • bradycardia
    64. 64. Spinal and Neurogenic shock
    65. 65. Hemodynamic state in neurogenic shock • Unopposed parasympathetic outflow can lead to dysrythmias and hypotension(most common within 14 hours) • Loss of sympathetic innervation to the heart (T1 through T4 cord levels) leaves the parasympathetic cardiac innervation via the vagus nerve unopposed, resulting in bradycardia, or an absence of reflex tachycardia. • Most common dysrythmia is bradycardia
    66. 66. Hemodynamic instability: intervention • First line volume resusciation ( 1-2 liter) • Second line: vasopressor (dopamine/norepinephrine) to counter loss of sympathetic tone and provide chronotropic support to the heart
    67. 67. Hemodynamics and cord perfusion • Avoid hypotension • Maintain MAP 85-90mmHg for first 7 days if possible
    68. 68. Bradycardia: intervention • Prevention -avoid vagal stimulation - hyperventilate and hyperoxygenate before suctioning - premedicate patient with known hypersensitivity to vagal stimuli ▪Symptomatic bradycardia atropine 0.5- 1.0 mg IV
    69. 69. Indication for Surgery • Decompression of neural elements( spinal cord and nerves) • Stabilization of bony element( spine) • Deformity correction • Thoracolumbar spine fracture/dislocation
    70. 70. Prognosis of recovery • Patient with complete cervical spine injuries that remain within the first 24 hours of admission are unlikely to regain significant ambulatory function • Cervical injuries have a higher potential for recovery than do thoracic or thoracolumbar injuries • Younger patient fare much better than older • Intermedullary hemorrhage signifies a worse neurological outcome
    71. 71. Jefferson Fracture • Burst fracture of C1 ring • cervical spine is subjected to an axial load, as would occur from a direct blow to the top of the head • Unstable fracture • Need CT scan
    72. 72. Hangman’s Fracture • Hyperextension injury • Bilateral fractures of C2 pedicles (white arrow) • Anterior dislocation of C2 vertebral body (red arrow) • Unstable
    73. 73. Odontoid Fractures • Complex mechanism of injury • Generally unstable • Type 1 fracture through the tip – Rare • Type 2 fracture through the base – Most common • Type 3 fracture through the base and body of axis – Best prognosis
    74. 74. Odontoid Fracture Type II
    75. 75. Odontoid Fracture Type III
    76. 76. Burst Fracture • Fracture of C3-C7 from axial loading • Spinal cord injury is common from posterior displacement of fragments into the spinal canal • Unstable
    77. 77. Clay Shoveler’s Fracture • Avulsion off the end of one of the lower cervical spinous processes • C7>C6>T1 • Stable fracture
    78. 78. Flexion Teardrop Fracture • Flexion injury causing a fracture of the anteroinferior portion of the vertebral body • Unstable because usually associated with posterior ligamentous injury
    79. 79. Bilateral Facet Dislocation • Flexion injury • Subluxation of dislocated vertebra of greater than ½ the AP diameter of the vertebral body below it • High incidence of spinal cord injury • Extremely unstable

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