spinal injury Goal of spine trauma care Pre-hospital management Clinical and neurologic assessment Acute spinal cord injury Term, type and clinical characteristic Common cervical spine fracture and dislocation

1. SPINAL CORD INJURY
MRS.D.LALITHAMANI
M.SC NURSING
LECTURER
GANGA COLLEGE OF NURSING
COIMBATORE

3. Outline
• Goal of spine trauma care
• Pre-hospital management
• Clinical and neurologic assessment
• Acute spinal cord injury
– Term, type and clinical characteristic
• Common cervical spine fracture and
dislocation

4. Goal of spine trauma care
• Protect further injury during evaluation and
management
• Identify spine injury or document absence of
spine injury
• Optimize conditions for maximal neurologic
recovery

5. Goal of spine trauma care
• Maintain or restore spinal alignment
• Minimize loss of spinal mobility
• Obtain healed & stable spine
• Facilitate rehabilitation

6. Suspected Spinal Injury
• High speed crash
• Unconscious
• Multiple injuries
• Neurological deficit
• Spinal pain/tenderness

7. Pre-hospital management
• Protect spine at all times during the
management of patients with multiple
injuries
• Up to 15% 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

8. • PROTECTION  PRIORITY
• Detection  Secondary
“Log-rolling”

9. Pre-hospital management
• Cervical spine immobilization
• Transportation of spinal cord-injured
patients

10. 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)
• Neutral position

11. Philadelphia hard collar

12. Transportation of spinal cord-injured
patients
• Emergency Medical Systems (EMS)
• Paramedical staff
• Primary trauma center
• Spinal injury center

13. Clinical assessment
• Advance Trauma Life Support (ATLS)
guidelines
• Primary and secondary surveys
• Adequate airway and ventilation are the most
important factors
• Supplemental oxygenation
• Early intubation is critical to limit secondary
injury from hypoxia

14. Physical examination
• Information
• Mechanism
– ↑energy, ↓energy
• Direction of Impact
• Associated Injuries

15. 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

16. Physical examination
• Inspection and palpation
– Occiput to Coccyx
– Soft tissue swelling and bruising
– Point of spinal tenderness
– Gap or Step-off
– Spasm of associated muscles
• Neurological assessment
– Motor, sensation and reflexes
– PR
• Do not forget the cranial nerve (C0-C1 injury)

17. 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

18. 18
Neurogenic Hypovolemic
Etiology Loss of sympathetic
outflow
Loss of blood volume
Blood
pressure
Hypotension Hypotension
Heart rate Bradycardia Tachycardia
Skin
temperature
Warm Cold
Urine
output
Normal Low
Comparison of neurogenic and hypovolemic shock

19. Definitions of terms
• Neurologic level
– Most caudal segment with normal sensory and motor
function both sides
• Skeletal level
– Radiographic level of greatest vertebral damage
• Complete injury
– Absence of sensory and motor function in the lowest
sacral segment
• Incomplete injury
– Partial preservation of sensory and/or motor function
below the neurologic level

20. Neurologic assessment
• Spinal shock
– Bulbocavernosus reflex
• Complete VS incomplete cord injury
– spinal shock
– Sacral sparing
• Voluntary anal sphincter control
• Toe flexor
• Perianal sensation
• Anal wink reflex

21. Neurologic assessment
• 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

24. Incomplete cord injury
• Anterior cord syndrome
• Brown-Sequard syndrome
• Central cord syndrome

25. Anterior cord syndrome
• Loss of motor, pain and
temperature
• Preserved
propioception and deep
touch

26. Brown-Sequard syndrome
• Loss of ipsilateral motor
and propioception
• Loss of contralateral
pain and temperature

27. Central cord syndrome
• Weakness :
– upper > lower
• Variable sensory loss
• Sacral sparing

28. 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

29. 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

30. Radiolographic evaluation
X-ray Guidelines (cervical)
AABBCDS
• Adequacy, Alignment
• Bone abnormality, Base of skull
• Cartilage
• Disc space
• Soft tissue

31. 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

32. 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

33. 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

34. Bones

35. Disc
• Disc Spaces
– Should be uniform
• Assess spaces
between the
spinous processes

36. 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)

37. AP C-spine Films
• Spinous processes
should line up
• Disc space should be
uniform
• Vertebral body height
should be uniform.
Check for oblique
fractures.

38. 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 andmasses of C1 and
C2C2
• Bone: Inspect dens
for lucent fracture
lines

39. 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%

40. MRI
• Ideally all patients
with abnormal
neurological
examination should
be evaluated with
MRI scan

41. 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

42. 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

43. Management of SCI
• Look for other injuries: “Life over Limb”
• Transport to appropriate SCI center once
stabilized
• 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
– After bolus: infusion 5.4mg/kg IV for 23 hours

44. Principle of treatment
• Spinal alignment
– deformity/subluxation/dislocation reduction
• Spinal column stability
– unstable  stabilization
• Neurological status
– neurological deficit  decompression

45. THANK YOU