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Spine and Spinal TraumaSpine and Spinal Trauma
Rebecca Burton-MacLeod
R1, Emergency Medicine
Aug 21, 2003
NumbersNumbers
~10,000 new cases each year in USover 1 million pts with blunt trauma
and potential c-spine injury seen in US EDs
of these pts, <1% have acute # or spinal injury
SIGNIFICANT CONSEQUENCES!
Who?Who?
Age >65malewhite or “other” ethnicity
How?How?
MVA 50% falls 20% sporting accidents
15% remainder from acts
of human violence predisposing
factors--arthritic disease, OP, Ca
Anatomy….[oh no!]Anatomy….[oh no!]
33 vertebrae--7cervical, 12thoracic, 5lumbar, 5sacral (fused), 4coccyx (fused)
intervertebral discs separate them, and ligaments support
spinal cord goes from midbrain to L2 level anterior column (vertebral bodies, discs,
ant/post longitudinal ligs) and posterior column (pedicles, transverse processes, facets, laminae, spinous processes, spinal canal, nuchal/capsular ligs, ligamentum flavum)
Spinal columnSpinal column
Million $ question...Million $ question...
Stable--disruption of only one of ant/post columns
vsunstable--disruption of both columns
at same level OR c1/2 #
Classification of spinal column Classification of spinal column injuriesinjuriesFlexionextensionflexion-rotationvertical compression
Flexion injuriesFlexion injuries
Stable UnstableWedge # Flexioin teardrop #Clay shovelers # Subluxation (potentially)Transverse process # Bilateral facet disloc
Atlantoocipital dislocAnt atlantoaxial disloc +/- #Odontoid # with lat displacement #
Flexion injuriesFlexion injuries
Wedge #
teardrop #
Flexion injuriesFlexion injuries
Clay shoveller # (lat)
clay shoveller # (AP)
Flexion injuriesFlexion injuries
Bilateral facet dislocation
Extension injuriesExtension injuries
Stable Unstable
Extension teardrop #(neck in flexion)
Extension teardrop #(neck in extension)Post neural arch #
Hangmans #
Post atlantoaxialdisloc +/- #
Extension injuriesExtension injuries
Extension teardrop #
Extension injuriesExtension injuries
Hangmans #
Flexion-rotation injuriesFlexion-rotation injuries
Stable Unstable
Unilateral facet disloc Rotary atlantoaxialdisloc
Flexion-rotation injuriesFlexion-rotation injuries
Unilateral facet disloc
Vertical compression injuriesVertical compression injuries
Stable Unstable
Burst # Jefferson #
Isolated # of articularpillar and vert body
Vertical compression injuriesVertical compression injuries
Burst #
Vertical compression injuriesVertical compression injuries
Jefferson #
Spinal cord injuriesSpinal cord injuries
Primary--mechanical disruption of axons as result of stretch, laceration, or vascular injury
vssecondary--progressive injury;
caused by free radical formation, uncontrolled calcium influx, ischemia, lipid peroxidation
Secondary spinal cord injuriesSecondary spinal cord injuries
Reversible/preventable factors:– hypogylcemia– hypoxia– hypotension– hyperthermia–mishandling by medical personnel
Spinal cord injuriesSpinal cord injuries
Complete--total loss of motor power and sensation distal to lesion
vsincomplete--3 syndromes (central
cord, anterior cord, Brown-Sequard), SCIWORA
Complete spinal cord injuriesComplete spinal cord injuries
If lasts >24hrs, 99% will have no functional recovery
must look for any evidence of cord function
sacral sparing is key!Ddx: spinal shockcannot diagnose complete injury until
bulbocavernosus reflex is elicited
Incomplete spinal cord injuriesIncomplete spinal cord injuries
Incomplete spinal cord injuriesIncomplete spinal cord injuries
Central cord syndrome:– affect upper extremities>lower
extremities– 50+% of patients with a severe central
cord syndrome have a return of bowel and bladder control, become ambulatory, and regain some hand function
–may mimic complete cord injury
Incomplete spinal cord injuriesIncomplete spinal cord injuries
Anterior cord syndromecaused by:– cervical flexion injuries causing cord contusion– protrusion of a bony fragment or herniated
intervertebral disk into the spinal canal– laceration or thrombosis of the anterior spinal
artery– systemic embolization or prolonged cross-
clamping of the aorta
Anterior cord s/o cont’dAnterior cord s/o cont’d
paralysis below level of injuryhypalgesia below the level of injury preservation of posterior column
functions (position, touch, and vibratory sensations)
Incomplete spinal cord injuriesIncomplete spinal cord injuries
Brown-Sequard syndrome:– hemisection of spinal cord– often due to penetrating trauma, or may
be due to # of lat mass of c-spine– ipsilateral paralysis and contralateral
sensory hypesthesia below level of injury
–most retain bladder/bowel control
SCIWORASCIWORAUsually <8yrs of age following c-spine
injury; no injury seen on complete plain radiographic series
possibly due to immature anatomy and increased ligamentous elasticity
causes transient spinal column subluxation, stretching of the spinal cord, and variable degrees of vascular compromise
SCIWORA cont’dSCIWORA cont’d
brief episode of upper extremity weakness or paresthesias, followed by the development of neurologic deficits that appear hours to days later
on examon exam
Vitals, GCSinspection--facial contusions, head
injuries, trunk contusions, obvious deformities/penetrating injuries
palpation--spine for step-off deformity, widened interspinous space
neuro exam
Motor examMotor exam
level Loss of fxn Level Loss of fxn
C4 Spontaneousbreathing
L1/2 Flex hip
C5 Shrugshoulders
L3 Adduct hip
C6 Flex elbow L4 Abduct hip
C7 Extendelbow
L5 Dorsiflexfoot
C8/t1 Flex fingers S1/2 Plantar flexfoot
T1-12 Intercostal/abdo muscles
S2-4 Rectalsphinctertone
Deep tendon reflexesDeep tendon reflexes
UMN--present reflexes (but may be absent acutely during spinal shock)
LMN--absent reflexes
Sensory functionSensory function
Light touch--posterior column function
painful touch--anterior spinothalamic function
InvestigationsInvestigations
Plain radiographyCTMRI
RadiographyRadiography
NEXUS:– 34,069 pts with blunt trauma– 818 pts with c-spine injuries– sensitivity 98.0-99.6%, specificity 12.9%– 23 pts (3 potentially unstable) had
injuries not visualized on radiography (2.81% of all pts with radiography performed)
RadiographyRadiography
NEXUS criteria for c-spine xrays:all 5 criteria must be met, or else xray:– absence of midline tenderness– normal alertness– no evidence of intoxication**– no focal neurological deficit– no painful distracting injuries**
** poorly reproducible
RadiographyRadiographyCanadian C-spine rules:– 8924 pts enrolled with trauma to head/neck, stable
vitals, GCS=15– excluded pts--<16yrs, penetrating trauma, known
vertebral disease– 151 clinically important c-spine injuries (1.7%)– sensitivity 100%, specificity 42.5%– identified 27 of 28 unimportant c-spine injuries
(missed c3 avulsion #)– potential radiography rate 58.2% (down from
68.9%!!)
RadiographyRadiographyCanadian c-spine rules for radiography:– high risk factors? (>=65yrs, dangerous
mechanism, paresthesias)– **must have radiography
– low risk factors? (simple rear-end MVC, sitting in ED, ambulatory since injury, delayed onset pain, absence midline c-spine tenderness)
– **then may assess range of motion
– rotate neck to left and right? (45degrees both directions)
– **do not require radiography
RadiographyRadiography
Standard trauma series (Caroline’s excellent review!!):– lateral– AP– open-mouth odontoid
oblique view--posterior laminar fracture, a unilateral facet dislocation, or a real subluxation
flexion-extension views--if severe pain but normal 3views
CTCTIndications:– inadequate radiography (as high as 25% for
visualization of c7-t1)– suspicious radiography findings– fracture/displacement demonstrated by
standard radiography
– high clinical suspicion of injury, despite normal radiography
– pts undergoing CT of head/abdomen may be considered
CTCT
Pros– evaluate spinal
canal– evaulates
paravertebral soft tissues
– limited movement required
Cons– limited views of
vert body displacement
– poor visualization of horizontal #
– **overcome by spiral CT
*May eventually replace radiography, but not current standard of care as initial investigation*
CTCT
# right lateral mass
MRIMRI
Excellent for evaluation of neurological injury
useful for: ligamentous injury, bony compression, epidural and subdural hemorrhage, and vertebral artery occlusion
MRIMRI
C-spinal cord hemorrhage
Management GoalsManagement Goals
Preservation of pts lifeoptimizing potential for recovery of
neurologic function
ManagementManagement
Prehospital:– high index of suspicion– spinal immobilization--c-collar and
backboard with sandbags and tape
ED ManagementED Management
ABC’s:– above level of c3 often loss of resp drive– avoid hyperextension of neck if
intubation necessary– above level of t6 often “functional
sympathectomy”--systemic hypotension– treat with Trendelenburg position and
crystalloid infusion
ED ManagementED ManagementPharm: (NASCIS II and III):– 487 pts--overall analysis negative– 193 pts--positive effect post hoc analysis– modest improvement in functional recovery at 1yr – loading dose 30mg/kg IV within 8hrs of injury– if loading dose started within 3hrs, then 5.4mg/kg/h IV drip
for 24hrs**– if loading dose started 3-8hrs post-injury, then 5.4mg/kg/h
IV drip for 48hrs**
– no benefit if given >8hrs after injury, or for penetrating injuries
– **Class II evidence (guideline)
ED ManagementED Management
Other pharmacological agents suggested:
lazaroid (lipid peroxidation inhibitor)ganglioside**no clear benefit, if any
Complications of spinal cord Complications of spinal cord injuriesinjuriesPulmonary edemaGI tract and bladder atoniapressure necrosis on skinDVT/PE
DispositionDisposition
Referral to spine injury centreminor ligamentous injuries--outpt
pain mgmtminor #--hospitalization for
appropriate work-up and pain mgmt
??
ReferencesReferences
Berlin. 2003. CT versus radiography for initial evaluation of c-spine trauma: What is the standard of care? AJR 180:911-5.
Fehlings, MG. 2001. Editorial: Recommendations regarding the use of methylprednisolone in acute spinal cord injury: Making sense out of the controversy. Spine 26(24S):S56-7.
Lowery DW et al. 2001. Epidemiology of cervical spine injury victims. Ann Emerg Med jul;38(1):12-6.
Marx. 2002. Rosen’s Emergency Medicine: Concepts and clinical practice, 5th ed. Mosby, Inc.
Mower WR et al. 2001. Use of plain radiography to screen for cervical spine injuries. Ann Emerg Med Jul;38(1):1-7.
Nockels, RP. 2001. Nonoperative management of acute spinal cord injury. Spine 26(24S):S31-7.
Stiell IG et al. The Canadian c-spine rule for radiography in alert and stable trauma patients. JAMA 286(15):1841-8.