spine and spinal trauma

Spine and Spinal TraumaSpine and Spinal Trauma

Rebecca Burton-MacLeodR1, 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 #


Wedge #

teardrop #


Clay shoveller # (lat)

clay shoveller # (AP)


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 teardrop #


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


Burst #


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


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 injuriesAnterior 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)


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

RadiographyRadiographyStandard 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.

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