Assessment of Spinal Assessment of Spinal InjuryInjury

Stephen Schutts, Master Sergeant, WA ANG

National Registry Emergency Medical Technician - Paramedic

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ObjectivesObjectives

Identify the anatomical levels of the Identify the anatomical levels of the spine.spine.

Understand the function of the spinal Understand the function of the spinal cord/column.cord/column.

View Types and Mechanisms of injury View Types and Mechanisms of injury that can cause spine injury. that can cause spine injury.

Discuss the difference between Spinal Discuss the difference between Spinal Column Injury vs Spinal Cord Injury.Column Injury vs Spinal Cord Injury.

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ObjectivesObjectives

Overview of Spinal Regions and InjuriesOverview of Spinal Regions and Injuries Step by step view of the Step by step view of the EMS Spinal EMS Spinal

Immobilization Assessment Immobilization Assessment ProtocolProtocol

Discuss Common Discuss Common Treatment/Management MistakesTreatment/Management Mistakes

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IntroductionIntroduction

Spinal injuries are devastatingSpinal injuries are devastating Improper management can have Improper management can have

horrible and permanent resultshorrible and permanent results Appropriate use of spinal Appropriate use of spinal

immobilization can mean the immobilization can mean the difference between a patient who fully difference between a patient who fully recovers and one who must spent the recovers and one who must spent the rest of his/her life paralyzedrest of his/her life paralyzed

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Mechanism based Mechanism based assessment (the current assessment (the current

method)method) Low-speed fender Low-speed fender

benderbender An elderly man trips over An elderly man trips over

a lamp cord and fallsa lamp cord and falls

When in doubt back When in doubt back board ‘emboard ‘em

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Are all 8 patients Are all 8 patients assumed to have assumed to have spinal injuries?spinal injuries?

Does this man have a Does this man have a spinal injury? Do all spinal injury? Do all such falls cause such falls cause spinal injuries?spinal injuries?

Not necessarily, apply Not necessarily, apply EMS Spinal EMS Spinal Immobilization.Immobilization.

Anatomy & Physiology- Anatomy & Physiology- General Structure & General Structure &

FunctionFunctionSpinal ColumnSpinal Column Made up of 26 Made up of 26

vertebrae stacked vertebrae stacked on top of one on top of one anotheranother

Divided into 5 Divided into 5 areas; cervical, areas; cervical, thoracic, lumbar, thoracic, lumbar, sacral, and coccyxsacral, and coccyx

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Anatomy & Anatomy & Physiology-“Long Physiology-“Long

Bone”Bone” Think of the Spinal Think of the Spinal

Column as on “Long Column as on “Long Bone” with “Joints” Bone” with “Joints” at each endat each end– The Cervical spine The Cervical spine

makes up one “joint”makes up one “joint”– The Hip makes up The Hip makes up

the otherthe other

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Anatomy & Physiology- Anatomy & Physiology- Cervical Spine (7)Cervical Spine (7)

““Joint” at the superior Joint” at the superior end of the spinal “Long end of the spinal “Long Bone”Bone”

Very flexibleVery flexible– Allows flexion, extension, Allows flexion, extension,

and rotation of the headand rotation of the head The head acts as a weighted The head acts as a weighted

lever during acceleration/ lever during acceleration/ decelerationdeceleration

Common site of spinal Common site of spinal injuriesinjuries

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C-1 “Atlas”C-1 “Atlas” C-2 “Axis”C-2 “Axis”

•C-1 supports the full weight of the headC-1 supports the full weight of the head

•C-1 and C-2 allow head rotation and fine flexion C-1 and C-2 allow head rotation and fine flexion and extensionand extension

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Anatomy & Physiology- Anatomy & Physiology- Thoracic Spine (12)Thoracic Spine (12)

Much less flexible than C-SpineMuch less flexible than C-Spine– Stabilized by rib cage (especially down to T-10)Stabilized by rib cage (especially down to T-10)

Spinal canal narrow through T-SpineSpinal canal narrow through T-Spine– Spinal cord tightly fitted into narrow spaceSpinal cord tightly fitted into narrow space– Spinal cord ends about T-12 or L-1Spinal cord ends about T-12 or L-1

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Anatomy & Physiology- Anatomy & Physiology- Lumbosacral SpineLumbosacral Spine

5 Lumbar vertebrae plus sacrum and coccyx5 Lumbar vertebrae plus sacrum and coccyx More flexible than T-spineMore flexible than T-spine More room in spinal canalMore room in spinal canal Spinal cord ends about T-12 or L-1Spinal cord ends about T-12 or L-1

– flexible nerve roots (Cauda equina) flow through flexible nerve roots (Cauda equina) flow through LS spineLS spine

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Anatomy & Physiology- Anatomy & Physiology- Spinal CordSpinal Cord

Bundles of nerve fibers originating in the Bundles of nerve fibers originating in the brainbrain

Bundles or tracts travel in right and left Bundles or tracts travel in right and left pairspairs

Spinal Tract pairs crossover midline at Spinal Tract pairs crossover midline at various specific levelsvarious specific levels– always in specific anatomical areasalways in specific anatomical areas– understanding of the structure of these tracts understanding of the structure of these tracts

helps in assessing spinal cord injurieshelps in assessing spinal cord injuries16

Mechanism of InjuryMechanism of Injury

Physical manner and forces involved in Physical manner and forces involved in producing injuries or potential injuriesproducing injuries or potential injuries

Valuable tool in determining if the a Valuable tool in determining if the a particular set of circumstances could have particular set of circumstances could have caused a spinal injurycaused a spinal injury

Mechanisms likely to produce spinal Mechanisms likely to produce spinal injuries occur in MVAs, falls, violence, and injuries occur in MVAs, falls, violence, and sports (including diving accidents)sports (including diving accidents)

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HyperflexionHyperflexion

HyperextensionHyperextension

HyperotationHyperotation

Axial LoadingAxial Loading

Axial DistractionAxial Distraction

Sudden/Extreme Sudden/Extreme Lateral BendingLateral Bending

Excessive/abnormal lateral movement of Excessive/abnormal lateral movement of the spinethe spine

Can affect any portion of the spineCan affect any portion of the spine Example: T-bone MVAsExample: T-bone MVAs

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Spinal Column InjurySpinal Column Injury

Bony spinal injuries may or may not be associated Bony spinal injuries may or may not be associated with spinal cord injurywith spinal cord injury

These bony injuries include:These bony injuries include:– Compression fractures of the vertebraeCompression fractures of the vertebrae– Comminuted fractures of the vertebraeComminuted fractures of the vertebrae– Subluxation (partial dislocation) of the vertebraeSubluxation (partial dislocation) of the vertebrae

Other injuries may include:Other injuries may include:– Sprains- over-stretching or tearing of ligamentsSprains- over-stretching or tearing of ligaments– Strains- over-stretching or tearing of the musclesStrains- over-stretching or tearing of the muscles

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Spinal Cord InjurySpinal Cord Injury

Cutting, compression, or stretching of the spinal Cutting, compression, or stretching of the spinal cordcord

Causing loss of distal function, sensation, or Causing loss of distal function, sensation, or motionmotion

Caused by:Caused by:– Unstable or sharp bony fragments pushing on the cord, Unstable or sharp bony fragments pushing on the cord,

oror– Pressure from bone fragments or swelling that interrupts Pressure from bone fragments or swelling that interrupts

the blood supply to the cord causing ischemiathe blood supply to the cord causing ischemia

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Primary Spinal Cord Primary Spinal Cord InjuryInjury

Immediate and irreversible loss of Immediate and irreversible loss of sensation and motionsensation and motion

Cutting, compression, or stretching of the Cutting, compression, or stretching of the spinal cordspinal cord

Occurs at the time of impact/injuryOccurs at the time of impact/injury

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Secondary Spinal Cord Secondary Spinal Cord InjuryInjury

Injury DelayedInjury Delayed Occurs later due to swelling, ischemia, or Occurs later due to swelling, ischemia, or

movement of sharp or unstable bone movement of sharp or unstable bone fragmentsfragments

May be avoided if spine immobilized May be avoided if spine immobilized during extrication, packaging, treatment, during extrication, packaging, treatment, and transportand transport

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Incomplete Spinal Cord Incomplete Spinal Cord InjuryInjury

Complete injury to specific spinal tracts Complete injury to specific spinal tracts with reduced function distallywith reduced function distally

Other tracts continue to function normally Other tracts continue to function normally with distal function intactwith distal function intact

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Spinal Region OverviewSpinal Region Overview

Cervical Spine InjuriesCervical Spine Injuries Thoracic Spine InjuriesThoracic Spine Injuries Lumbosacral Spine InjuriesLumbosacral Spine Injuries Spinal Injury SummarySpinal Injury Summary

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Cervical Spine InjuriesCervical Spine Injuries

C-spine very flexibleC-spine very flexible Most frequently injured area of spineMost frequently injured area of spine Most injuries at C-5/C-6 levelMost injuries at C-5/C-6 level

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Thoracic Spine InjuriesThoracic Spine Injuries

T-spine less flexibleT-spine less flexible Narrow spinal canalNarrow spinal canal Cord injury occurs with minimal Cord injury occurs with minimal

displacementdisplacement Common mechanismsCommon mechanisms Any cord damage usually complete at this Any cord damage usually complete at this

levellevel Most T-spine injuries occur at T-9/T-10Most T-spine injuries occur at T-9/T-10

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Lumbosacral Spine Lumbosacral Spine InjuriesInjuries

LS spine flexible nerve roots in roomy LS spine flexible nerve roots in roomy spinal canalspinal canal

May have bony injury w/o cord or nerve May have bony injury w/o cord or nerve root damageroot damage

Secondary injury still possibleSecondary injury still possible Neurological injury rare w/ isolated sacral Neurological injury rare w/ isolated sacral

injuriesinjuries

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Assessment OverviewAssessment Overview

Decision to apply spinal immobilization in Decision to apply spinal immobilization in past based was solely on mechanism of past based was solely on mechanism of injuryinjury

Utilize Utilize EMS Spinal Immobilization EMS Spinal Immobilization AlgorithmAlgorithm to determine when spinal to determine when spinal immobilization is immobilization is NOT NOT neededneeded

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Spinal Immobilization Spinal Immobilization AlgorithmAlgorithm

Patient MentationPatient Mentation::Decreased Level of Consciousness?Decreased Level of Consciousness?

NoNo Yes ----------------------------ImmobilizeYes ----------------------------Immobilize

ETOH/Drug Impairment?ETOH/Drug Impairment?NoNo Yes ----------------------------ImmobilizeYes ----------------------------Immobilize

Subjective AssessmentSubjective Assessment::Cervical/Thoracic/Lumbar Spinal pain?Cervical/Thoracic/Lumbar Spinal pain?

No No Yes ----------------------------Yes ----------------------------ImmobilizeImmobilize

Numbness/Tingling/Burning/Weakness?Numbness/Tingling/Burning/Weakness?NoNo Yes -----------------------------ImmobilizeYes -----------------------------Immobilize

Objective Assessment:Objective Assessment:Cervical/Thoracic/Lumbar Deformity or Tenderness?Cervical/Thoracic/Lumbar Deformity or Tenderness?

NoNo Yes -----------------------------ImmobilizeYes -----------------------------Immobilize

Other Severe Injury?Other Severe Injury?NoNo Yes -----------------------------ImmobilizeYes -----------------------------Immobilize

Other Severe Injury?Other Severe Injury?NoNo Yes -----------------------------ImmobilizeYes -----------------------------Immobilize

Pain w/Cervical Range of Motion?Pain w/Cervical Range of Motion?NoNo Yes -----------------------------ImmobilizeYes -----------------------------Immobilize

MAY TREAT/TRANSPORT WITHOUT SPINAL PRECAUTIONSMAY TREAT/TRANSPORT WITHOUT SPINAL PRECAUTIONS35

Principles of TreatmentPrinciples of Treatment

Protect spinal cord from secondary injuryProtect spinal cord from secondary injury We have little or no effect on primary injuryWe have little or no effect on primary injury Focus on prevention of secondary injuryFocus on prevention of secondary injury

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Complete Spinal Complete Spinal ImmobilizationImmobilization

Must act as if whole spine unstableMust act as if whole spine unstable Immobilize entire spineImmobilize entire spine To do this we must immobilize the head, To do this we must immobilize the head,

neck, shoulders/chest, and pelvis /hipsneck, shoulders/chest, and pelvis /hips

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Common Common Treatment/ManagemenTreatment/Managemen

t Mistakest Mistakes Improperly sized C-CollarImproperly sized C-Collar Spine not supported due to improper positioning on Spine not supported due to improper positioning on

backboardbackboard Inadequate strapping allows excessive movementInadequate strapping allows excessive movement Movement possible due to little or no padding to shim Movement possible due to little or no padding to shim

the bodythe body C-spine movement by inadequate or improperly C-spine movement by inadequate or improperly

applied head immobilization deviceapplied head immobilization device C-spine hyperextension due to improperly applied C-C-spine hyperextension due to improperly applied C-

collar or head immobilization devicecollar or head immobilization device

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Common Common Treatment/ManagemenTreatment/Managemen

t Mistakes (cont.)t Mistakes (cont.) Readjusting torso straps after immobilization of the Readjusting torso straps after immobilization of the

head, causing misalignment of the spinehead, causing misalignment of the spine Securing head to backboard prior to securing Securing head to backboard prior to securing

shoulders, torso, hips, and legsshoulders, torso, hips, and legs

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Any Questions???Any Questions???