Author(s): Patrick Carter, Daniel Wachter, Rockefeller Oteng, Carl … · 2016-10-10 · Brown...

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Advanced Emergency Trauma Course

GhanaEmergencyMedicineCollaborativePatrickCarter,MD∙DanielWachter,MD∙RockefellerOteng,MD∙CarlSeger,MD

C-SpineandSpinalCordTrauma

Presenter:CarlSeger,MD

Epidemiology

  Spinal Trauma- 10,000 new cases eachyear, with over 200,000 spinal injuryvictimslivinginUS

  55%ofspinalinjuriesoccurintheC-spine  15% in the thoracic, lumbar, and sacralregions

  10% of pts with c-spine injury haveanothervertebralfracture

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Spinal Trauma

  Spinaltraumahasahugeimpactphysically,financially,andemotionallyonsociety

  Propertreatmentcanminimizefurtherdamage

  Immobilizationequipmentiseasytouse,inexpensive,andreadilyavailable

  OurdutyasEMphysiciansistoprovidepropercareand“DoNoHarm”


Can we make an impact?

  “3-25%ofcasesofpermanentneurologicimpairmentafterspinaltraumahavebeenattributedtoinjudiciousmanipulationbyparamedicalpersonnel,examiningphysicians,orradiologytechnicians.”

FranciscodeAssissAquinoGondim,MD,e-medicine-SpinalCordTrauma


Prevention is key!

 Withproperapplicationofspinalprecautions,wecanpositivelyimpactpatientoutcomes


Evolution of Spine

  PrehistoricMan•  Hunchedshoulders•  Strongposteriorneckmuscles

  ModernMan•  Shouldersdropaway,headelevates•  Atrophyparaspinalmuscles•  Sacrificeprotectionforincreasedrangeofmotion

http://commons.wikimedia.org/wiki/File:Human_evolution.svg


Modern Man   IncreasedIntellect,sameaggression  Horsedrawncarriagesreplacedbymachine-poweredvehicles

  Fistsandclubsgavewaytoknivesandguns  Newandinventivewaystoinflictinjurytospine


Basic Anatomy   7Cervical  12Thoracic  5Lumbar  5Sacral  4Fused  Coccygeal

  LordoticCurves  KyphyoticCurves

Gray’sAnatomy(Wikipedia)


Functional Anatomy Review   VertebralColumn•  33Vertebrae

  Vertebrae=Body+Arch•  VertebralArch

  Pedicles  Laminae  Processes




  Ligaments•  Anterior/PosteriorLongitudinal•  VertebralArchLigaments

  LigamentumFlavum  SupraspinatousLigament  InterspinousLigament  IntertransverseLigament  CapsularLigament

  IntervertebralDisks•  NucleusPropulsus•  AnnulusFibrosus

Functional Anatomy Review


UweGille(Wikipedia)GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Spinal Stability   CervicalSpine•  AnteriorColumn•  PosteriorColumn•  Disruptbothcolumnstobeunstable

  ThoracolumbarSpine•  DenisClassification•  AnteriorColumn•  MiddleColumn•  PosteriorColumn•  Disrupt2columnstobeunstable


https://commons.wikimedia.org/wiki/File:Cervical_vertebra_english.png


Normal Cervical Spine

http://www.trauma.org/archive/spine/images/cspinealign.jpg

http://www.trauma.org/archive/spine/images/cspineLAT.jpg


Injury Patterns   Acutespinalinjuriescanbemosteasilyclassifiedaccordingtothemechanismoftrauma

  CategoriesincludeFLEXION,FLEXION-ROTATION,EXTENSIONandVERTICALCOMPRESSIONinjuries

  CanalsoincludeinclassificationwhetherornotaparticularinjuryisSTABLEvs.UNSTABLE


Cervical Spine Injuries   FlexionInjuries•  Wedgecompressionfracture•  Flexionteardropfracture•  ClayShoveler’sFracture•  BilateralFacetDislocation

  FlexionRotation•  Unilateralfacetdislocation

  VerticalCompression•  JeffersonBurstFracture•  BurstFracturesofLowerCervicalSpine

  HyperextensionInjuries•  Avulsionfractureofanteriorarchofatlas•  Extensionteardropfracture•  Posteriorarchofatlasfracture•  Laminarfracture•  Hangman’sFracture

  LateralFlexion•  UncinateProcessFracture

  UpperC-spineInjuries•  Occipitoatlantaldissociation


Flexion Injuries   FlexioninjuriesinvolvingC1-C2cancauseatlantooccipitaloratlantoaxialdislocation,withorwithoutfractureoftheodontoid

  Atlas=C1,Axis=C2  Unstableduetothelocationandrelativelackofmuscleandligamentoussupport


Flexion injury

  OdontoidFxwithanteriordislocationSourceUndetermined SourceUndetermined


Flexion Injury   InpureflexioninjurybelowC2,forceisexpendedonthevertebralbodyanteriorly,resultinginasimplewedgefracture

  Simplewedgefracturesarestable  Evengreaterflexionforcesawedgeshapedfragmentoffanterior-inferiorportionofvertebralbody,calledaflexionteardropinjury

  Usuallyincludesligamentousinjuryandisunstable


Wedge Fracture

http://faculty.washington.edu/alexbert/MEDEX/Winter/EM1DisordersSpine.htmhttp://emedicine.medscape.com/article/94234-media


Flexion Teardrop Fracture

SourceUndetermined SourceUndetermined


Flexion Injury   InAustraliaduringthe1930’s,certainclayminerssustainedauniqueinjury

  Whilestrainingwithheavyshovelfulofclay,theabruptflexionofheadinoppositiontothestrongsupraspinousligament,resultedinavulsionfractureofspinousprocess

  ClayShoveler’sfractureismoreoftenseentodayduetodirectblow,i.e.poolcueorbaseballbat,orfromsuddendecelerationinMVC

  Stableinjury,noneurologicinvolvement

Clay Shoveler’s

http://faculty.washington.edu/alexbert/MEDEX/Winter/EM1DisordersSpine.htmhttp://emedicine.medscape.com/article/94234-media


Extension Injury   MostwellknownistheHangman’sfracture  Popularexecutionstyleinpreviouseras  “ShortDropwithSuddenstop”.Thedropwaspreferredtothedangle

  Theskullisthrownintoextremehyperextensionresultinginbilateralpediclefracturesofaxis

  Unstable,butneurologicalinvolvementisminimal,thereforedeathusuallyduetostrangulation,notcorddamage


Hangman’s Fracture

http://commons.wikimedia.org/wiki/File:Hangman%27s_fracture.JPG


Vertical Compression Injury   Example=JeffersonFracture  Forceistransmitteddownthroughskullandoccipitalcondylestosuperiorarticularsurfacesoflateralmassesofatlas

  Sinceatlasisaring,thisforcepushesthemassesoutwardresultinginfracturesofanteriorandposteriorarches,anddisruptionoftransverseligament

  ExtremelyUNSTABLEGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Jefferson Fracture

SourceUndetermined


Jefferson Fracture

SourceUndetermined

SourceUndetermined


Injuries of Thoracic and Lumbar Spine

 CompressionFractures BurstFractures FlexionDistractionFractures



  CompressionFractures

http://emedicine.medscape.com/article/397896-media



  BurstFractures

http://emedicine.medscape.com/article/248236-media


Injuries of Thoracic and Lumbar Spine   FlexionDistractionFractures–ChanceFx

http://radiopaedia.org/images/143729


Pathophysiology of Acute Fractures

  Directcompressionofneuralelementsbybonefragments,discmaterial,andligamentsleadstodamageofthecentralandperipheralnervoussystem

  Bloodvesselcompressionanddisruptioncausesischemia

  Massivecordswellinghappenswithinminutesatthelevelofinjuryandleadstosecondaryischemia


Spinal Cord Lesions   Overview•  CompleteSCI=Nomotororsensoryfunctionbelowinjurylevel•  IncompleteSCI=AnySensory/motorfunctionbelowlevelofinjury

  SpinalCordTracts•  Corticospinaltract=Descendingmotorpathway•  Spinothalamictract(anterior)=Pain/Temperature•  DorsalColumnPathway=Vibratory/Proprioception

  Incompletespinalcordlesions•  Anteriorspinalcordsyndrome•  Posteriorspinalcordsyndrome•  CentralCordsyndrome•  BrownSequardSyndrome

SourceUndeterminedGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Pathophysiology   PrimaryInjury•  MechanicalInjury

  SecondaryInjury•  VascularAbnormalities•  FreeRadicals/LipidPeroxidation•  Excitotoxicity

  Electrolytedisturbances•  Inflammation

  Edema

SourceUndetermined

SourceUndetermined


Cord Syndromes   CentralCordSyndrome  AnteriorCordSyndrome  PosteriorSpinalCordSyndrome  BrownSequardSyndrome


Incomplete Spinal Cord Syndromes   AnteriorSpinalCordSyndrome•  Corticospinalandspinothalamictractsinjured•  Preservationofposteriorcolumnpathway•  Etiology

  Anteriorspinalcordtrauma  Flexionofcervicalspinecausingcordcontusion

  Thrombosisofanteriorspinalartery

SourceUndetermined


Incomplete Spinal Cord Syndromes

  PosteriorSpinalCordSyndrome•  Rarecondition•  Injurytodorsalcolumn•  Preservationofcorticospinalandspinothalamicpathways•  Etiology

  Penetratingtraumatoposterioraspectofcord  Hyperextensioninjurywithvertebralarchfracture


SourceUndetermined

  CentralCordSyndrome•  Injurypreferentiallyaffectscentralportionofcord•  Lossoffunctionofcentralfibersofcorticospinalandspinothalamictracts•  Decreasedstrengthandpain/temperatureofupperextremitiescomparedwithlowerextremities•  Etiology

  Hyperextensioninjuries  Centralspinalstenosis  Disruptionofnormalbloodflow

Incomplete Spinal Cord Syndromes

SourceUndetermined


Incomplete Spinal Cord Syndromes   BrownSequardSyndrome•  Transversehemisectionofspinalcord•  Ipsilaterallossofmotorfunction,proprioceptive/vibratorysensation•  Contralaterallossofpain/temperaturesensation•  Etiology=PenetratinginjuryorLateralcordcompression

SourceUndetermined


Spinal vs. Neurogenic Shock   SpinalShock•  Temporaryphenomenoncharacterizedbylossofallspinalcordfunctioncaudaltolevelofinjury•  Symptoms=Flaccidparalysis,Hypotonia,Areflexia,Priapism•  Typicalduration=24-72hours•  Resolution=ReturnofBulbocavernosusreflex•  Outcome=Spasticparesis,hyper-reflexia

  NeurogenicShock•  Typeofdistributiveshockcharacterizedbylossofadrenergictoneduetosympatheticdenervation•  ClassicTriad=Hypotension,Bradycardia,Hypothermia•  Management=IVF,Vasopressorsupport,Atropine


Spinal Shock vs. Neurogenic Shock

  SpinalShock-theflaccidityandlossofreflexesseenafterspinalcordinjury.Thecordmayappeardestroyedbutactuallymayregainfunctionlatter

  NeurogenicShock-destructionofthedescendingsympatheticpathwaysofthespinalcord.Resultsishypotensionandbradycardia.Ptswillrequirevasopressorsandatropineaswellasfluid.


Management   Immobilization  ClinicalC-spineClearance•  Whentogetimages

  ThoracicandLumbarSpinalImmobilizationandClearance

  ManagementofCervicalandThoracolumbarfractureswithoutspinalcordinjury


Aims of Immobilization   Preventfurtherdamage-ProtecttheCord  Holdthespineinacomfortable,anatomicallycorrectway

  Preventmovementofthespine  Allowforsafeconcurrentmanagementofotherinjuries


Options for Immobilization  AnatomicalRegions• Head• Neck• Body


Head Immobilization  Manual-Hands,Legs  SimpleAssistDevices-Sandbags,Towels,FoamPads

  AdditionalDevices-Straps  Head/Neckimmobilizer


Head Immobilization

Cdang(Wikipedia)


Head Immobilization   Studycompared3methodsduringsimulatedvehiclemotion,(Spine1999;24)•  Sandbags•  Headband•  Styrofoamwedges

  Wedgesslightlybetter  Keyisbodyimmobilization


Neck Immobilization  Collars• Philadelphia• Stiffneck• Otheroptions


Neck Immobilization

Emrgmgmtca(Wikipedia)


Neck Immobilization   AnnEmergMed1992;21:1185-1188•  ComparedCcollarwithAmmermanHaloorthosis,withandwithoutspineboard•  Photographiccomparisonduringtransport•  Conclusion:

  Arigidcervicalcollarandaspineboardprovidesignificantlybetterimmobilizationthanthecollaralone.FurtherimmobilizationisprovidedbyanAmmermanhaloorthosis


Body Immobilization

 Backboards•  Importantfortransportingpatientsandkeepingthemfrompossiblyinjuringthemselvesfurther


Back Boards

Cdang(Wikipedia) Ryan.mco(Wikipedia)


Complications associated with Spinal Immobilization

  Pain  Increasedriskofpressuresores  Aspirationandlimitedrespiratoryfunction•  Increasedriskofaspiratingemesiswhilestrappedonbackboard•  Markedpulmonaryrestrictiveeffectofappropriatelyappliedentirebodyspinalimmobilizationdevices


When to get an X-ray  Patientsinvolvedinatraumaticevent• withmidlinetenderness• Withneurologicdeficits• Alteredlevelofconsciousness• Patientswhoareintoxicated


C-spine X-ray   LateralView• MustseetothetopofT1forfilmtobeadequate• Mayneedswimmersview• Willsee90%ofcervicalspinefractures

 Odontoidview• Mustincludeentireprocessandrightandleftc1andc2articulations


Flexion and Extension Films  ObtainedininjuredptswithoutanAMS,andptswhohaveneckpainwithoutfractureonAP,Lateralandodontoidviews

  Lookingfor•  Instability•  Ligamentousspineinjury


CT Scan  MoreSensitive  Ifhighsuspicionforinjuryandhaveinadequatex-ray,CTiswarranted


How do you clear a C-spine Injury?

  Twostudies-NEXUSvs.CanadianCspine• Nexus

 Patientsrequiredtomeet5criteria• Nomid-linetenderness• Nofocalneurologicaldeficit• Normalalertness• Nointoxication• Nopainful,distractinginjury


NEXUS study   PatientswhounderwentC-spineX-rayforblunttrauma

  34,069patientsincludedinstudy  818patientshadaC-spineinjury  8ofthesepatientsmetall5criteria  4209non-injuredpatientsmetall5criteria


NEXUS Study   Problems• Managementstressors•  Failuretodiscriminatewhatpainissignificant• Whatisadistractinginjury?• Howdrunkisintoxicated?


Canadian C Spine Rule

SourceUndetermined


Canadian C Spine Rule   TheauthorsconcludethattheCCRdecisionruleismoresensitivethanNEXUSforidentificationofclinicallyimportantC-spineinjuriesandalsoismorespecific,therebydecreasingthenumberofunnecessaryC-spineradiographs

  Problemsinclude•  Requiresactiveneckrotation(10%excluded)•  Whatisa“DangerousMechanism”?


Methylprednisolone   Controversialtreatmentmodalityforbluntspinalcordtrauma

  NationalAcuteSpinalCordInjuryStudies(NASCIS)  Subsequentstudies•  Pointillart(2000)•  Matsumoto(2001)

  MechanismofAction•  Inhibitionoffreeradicalinducedlipidperoxidation

  Currentrecommendedregimen•  Methylprednisoloneprescribedasabolusintravenousinfusionof30mg/kgofbodyweightover15minwithin8hoursofacuteclosedspinalcordinjury

•  Followed45minlaterbyaninfusionof5.4mg/kgofbodyweightperhourfor23hours


Summary   Spinalimmobilizationcanreducethelikelihoodofneurologicaldeteriorationinpatientswithunstablec-spineinjuriesfollowingtrauma

  Immobilizationoftheentirespinalcolumnisnecessaryinpatientsuntilaspinalcord/columninjuryhasbeenexcludedoruntiltheappropriatetreatmenthasbeeninitiated


Summary   Acombinationofrigidcervicalcollarwithsupportiveblocksonarigidbackboardwithstrapsiseffectiveatachievingsafe,effectivespinalimmobilizationfortransport

  Spinalimmobilizationdevicesareeffectivebutcanresultinpatientmorbidity.Theyshouldbeusedforsafeextricationandtransport,butshouldberemovedassoonasdefinitiveevaluationisaccomplishedortreatmentinitiated


Summary   Methylprednisolonetherapyforacutespinalcordinjuryiscontroversialwithonlybenefitwhenadministeredwithin8hoursofinjury

  CurrentMethyprednisoloneregimen:•  Methylprednisolonebolusintravenousinfusionof30mg/kgofbodyweightover15minwithin8hoursofacuteclosedspinalcordinjury•  Followed45minlaterbyaninfusionof5.4mg/kgofbodyweightperhourfor23hours

  AppropriateclassificationofSCIpatientswithinEDtoensurepromptevaluationandtreatment

  CommunicationbetweenEDstaffandresidentsiskeytolimitingerrorsandprovidingappropriatecare



Questions?

ErinSilversmith(Wikipedia)


References   Baron,B.,Thomas,S.SpinalCordInjuries,inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.1569-1583.

  AmericanCollegeofSurgeons.SpineandSpinalCordTrauma,inAdvancedTraumaLifeSupportforDoctors7thedition.2004.p.177-204.

  Lin,M.,Mahadevan,S.SpineTraumaandSpinalCordInjuries,inEmergencyMedicine.Adams,Editor.2008,SaundersElsevier.P.765-783

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