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INJURY
Normal Anatomy
Normal Anatomy
SPINAL CORD
DERMATOM
Normal Anatomy
Functionally, the cervical spine is divided
into:
The upper cervical spine [occiput (C0)C1
C2]
The lower (sub-axial) cervical spine (C3C7).
Normal Anatomy
Upper Cervical Spine:
The atlas-occiput
junction primarily allows
flexion/extension and
limited rotation.
Axial rotation at the
craniocervical junction
is restricted by osseous
as well as ligamentous
structures.
Normal Anatomy
Lower (Subaxial) Cervical Spine:
The vertebrae of the lower cervical spine have a
superior cortical surface which is concave in the
coronal plane and convex in the sagittal plane.
This configuration allows flexion, extension, and
lateral tilt by gliding motion of the facets.
Biomechanics of Cervical Spine
Trauma
The conditions under which neck injury
occurs include several key variables such
as:
impact magnitude.
impact direction.
point of application.
rate of application.
Suspected Spinal Injury
High speed crash
Unconscious
Multiple injuries
Neurological deficit
Spinal pain/tenderness
Spinal Cord Injury
It is now well accepted that acute spinal cord
injury (SCI) involves both:
Primary injury mechanisms.
Secondary injury mechanisms.
History
The cardinal symptoms of an acute cervical
injury are:
pain
loss of function (inability to move the head)
numbness and weakness
bowel and bladder dysfunction.
Initial Management
Primary survey
A full general and neurological assessment
must be undertaken in accordance with the
principles of advanced trauma life support
(ATLS).
As always, the patients airway, breathing
and circulation (ABCin that order) are the
first priorities in resuscitation from trauma.
Initial Management
Secondary survey
specific signs of injury including:
local bruising
deformity of the spine (e.g. a gibbus or an increased
interspinous gap)
vertebral tenderness.
The whole length of the spine must be palpated,
another spinal injury at a different level.
Diaphragmatic breathing invariably indicate a high
spinal cord lesion.
Hypotensive patient should always raise the
possibility of neurogenic shock attributable to spinal
cord injury in the differential diagnosis.
Initial Management
Secondary survey
At the end of the secondary survey,
examination of the peripheral nervous
system must not be neglected.
Physical examination
Inspection and palpation
Occiput to Coccyx
Soft tissue swelling and bruising
Point of spinal tenderness
Gap or Step-off
Spasm of associated muscles
Neurological assessment
Motor, sensation and reflexes
Cervical spine immobilization
Safe assumptions
Head injury and unconscious
Multiple trauma
Fall
Severely injured worker
Unstable spinal column
Neutral position
Philadelphia hard collar
Transportation of spinal cord-injured
patients
Emergency Medical Systems (EMS)
Paramedical staff
Primary trauma center
Spinal injury center
Cervical Spine Imaging Options
Plain films
AP, lateral and open mouth view
Optional: Oblique and Swimmers
CT
Better for occult fractures
MRI
Very good for spinal cord, soft tissue and
ligamentous injuries
Management of SCI
Spinal motion restriction: immobilization devices
ABCs
Increase FiO2
Assist ventilations as needed with c-spine control
Indications for intubation :
Acute respiratory failure
GCS <9
Increased RR with hypoxia
PCO2 > 50
VC < 10 mL/kg
IV Access & fluids titrated to BP ~ 90-100 mmHg
Principle of treatment
Spinal alignment
deformity/subluxation/dislocation reduction
Neurological status
neurological deficit decompression
Jefferson Fracture
Burst fracture of C1 ring
Unstable fracture
Need CT scan
Hangmans Fracture
Extension injury
Bilateral fractures of
C2 pedicles
(white arrow)
Anterior dislocation of
C2 vertebral body
(red arrow)
Unstable
Burst Fracture
Unstable
Clay Shovelers Fracture
Flexion fracture of
spinous process
C7>C6>T1
Stable fracture
Flexion Teardrop Fracture
Unstable because
usually associated with
posterior ligamentous
injury
Bilateral Facet Dislocation
Flexion injury
Subluxation of dislocated
vertebra of greater than
the AP diameter of the
vertebral body below it
High incidence of spinal
cord injury
Extremely unstable
TERIMAKASIH