Managing (Acute) Traumatic Spinal Injuries

Dr. Richard Bwana Ombachi Lecturer and Consultant Spine &

Orthopaedic surgeon

IntroductionSpine -Vertebral Column/Nervous Tissue5% worsen in the hospitalProtection is priority –Diagnosis a secondary

priorityTreat the spine of an alive patient – Identify

live threatening conditionsEffects of spinal injury

Inadequate ventilation Compromised abdominal evaluation Mask compartment syndrome

Patient Referral

Trauma Vertebral Column Trauma and Nervous Tissue Trauma

Somatic Nervous System Spinal Cord tracts Nerve roots / Nerves

Autonomic Nervous System sympathetic

Spinal Injuries Devastating effectProtection primary priorityManagement starts at the scene of the

accident

Spinal Cord InjuryPrimary Injury- physical injury by mechanical

forces ContusionCompressionStretchLaceration –

penetrating foreign bodies, missiles, fragments or displaced bone

Secondary InjuryAdditional neural tissue damage from biologic

response Changes local blood flow Tissue oedema Metabolite concetration lethal to the neural tissues

leading to further injury

StatisticsAetiology

RTA 45% ( motor cycle accidends )Falls 20%Sports 15 %Assault 15%

Gender ratio M: F 4:1Neurologic Injury

Cervical 40%Thoracolumbar 20%

PRINCIPLES OF MANAGEMENT Suspect Spinal Injuries and Protect further

injuryImmobilize the spineAssess the patient (ATLS Protocal)Manage live threatening conditions while

caring for spineImage patient to identify the injuriesManage/Reffer injuries as appropriate

Suspect Spinal Injuries History of transient neurological symptoms Neck pain or back pain Multiply Injured patient An inconsolable child Inability to assess pain because of a secondary distracting injury or

intoxication Head injury or severe facial or scalp lacerations or neck injuries Trauma +Unconscious : assume spinal injury until proven otherwise Abnormal neurological finding Diaphragmatic breathing Physical signs of spinal trauma (e.g., ecchymosis and abrasions, step

deformity, gap deformity. hypotension, hypothermia, and bradycardia- upper thoracic/ cervical

injuries neurogenic shock Penile erection and incontinence of the bowel or bladder suggest a

significant spinal injury

Tale Tell Signs on ExaminationPatient should be log rolled by at least 4 people

for back examinationleakage of CSF or blood behind the tympanic

membrane- a skull fracture. paraplegia/ quadriplegiaPainful spinous process Palpable defects ( gaps or steps) indicate

disruption of the supporting ligamentous complex.Scalp wounds, neck injuries, seat belt marks etc. Diaphragmatic Breathing

Immobilize the SpineProtection PriorityNeck immobilization firm collar + head strapped

to bolsters/ sand bags on either side to the boardImmobilize in neutral position don’t correct

deformities- ? AS, ? RS children, ? SpondylosisChildren - board should have a depression to

accomodate big head – avoid flexing neck.Patients should not be kept on the board longer

than two hours as pressure sores start to develope two hours on the board (Spine board transporting tool)

NEUROLOGICAL EXAMINATIONDone to determine level and severity of injury. Sensation to light touch and pain should be

documented comparing each spinal level and side

Motor examination using MRC grading. Deep tendon reflexes and pathological reflexes

also should be checked. Motor and sensory evaluation of the rectum

and perirectal area is mandatory (complete/incomplete Injuries)

Asia ChartASIA Chart.pdf

Spinal ShockSpinal dysfunction based on physiological

rather than structural disruption.Recognized by return of the reflexes caudal

to the level of injury usually 24 -48 hours (BCR or the anal wink)

Neurogenic ShockInjuries above T6 disrupt the sympathetic

nervous system to the heart and the vascular system – Neurogenic shock

Sympathetic disruption leads to uncounterted vagal action leading to Bradycardia, Hypotension, Vasodilatation

Maintain Mean Preasure above 70mmHgDo not over infuse pt use ionotropic drugs

Vertebral Column ExaminationDone in Secondary SurveyUse log rolling techniqueDetect

Bruises/ LacerationsSwellings / BogginessStep or Gap DeformityTenderness

Remove spine board at this stage if not referring

Radiological Imaging IndicationsNo x-rays if

No neurological deficit Conscious Cooperative Able to concentrate If no neck or back tenderness

Altered sensorium, then X-ray the whole spine

Pain or tenderness, no neurological deficitXray affected areas consider flex-ext

X-raysAABBCCDs

Adequacy, Alignment, Bony

abnormality, Base of Skull, Cartilage, contours, Disc space, Soft tissues- Cross-Table Lateral: 85% sensitive -AP + Lat 92 % sensitivity -excludes most fractures-Swimmer’s for C7-T1- Open mouth view upper cervical-Obliques not necessary in trauma-CXR / Abd Xrays not adequate for evaluation spine

CT SCAN / MRICT Scan

Clearance in patients with questionable or inadequate plain radiographs

Assess occipitocervical and cervicothoracic junctions

MRISpinal cord injury – disruptions, oedema,

haematomasIntervertebral disc disruptionPosterior ligamentous disruptionCanal compromise and neural tissue compression

Summary of Management High Index of Suscipicion Immobilize the spine to protect spine (Protection Priority) Examine for Spinal and none spinal injuries.

Neurological Examination +Vertebral Examination Institute rescuscitation as condition demands giving preference to life threatening

conditions While taking care of the spine. Do not over infuse the patient with neurogenic shock- use ionotropic agents as

indicated Image the spine to identify and confirm suspected injuries. (Maintain Spine Board

untill imaging is complete) Remove Spine Board within two hours to avoid decibitus ulcers Pressure sore management Bladder management Respiratory system management GIT Psychological support Definative stabilization according to the injury

Steroids in some centres