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ACS

Spine and Spinal Cord

Trauma
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ACS

Objectives
Describe basic spinal anatomy and
physiology.
Evaluate for suspected spine injury.

Identify types of spinal injuries and x-ray

features.
Appropriately manage spinal injury.

Determine appropriate patient

disposition.
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ACS

Suspect Spinal Injury

High-Speed Crash
Unconscious patient
Multiple injuries
Neurologic deficit
Spinal pain / tenderness
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ACS

Spinal Injury
5% of patients worsen neurologically at
hospital
Protection priority;

detection secondary
Spinal evaluation complicated by brain

injury
Remove spine board as soon as possible
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ACS

Cord injury Severity

Complete : No motor or sensory
function below injury level
Incomplete :
Any motor or sensory preservation
injury level
Sacral sparing may be only residual
function
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ACS

Sensory Examination

Cervical Thoracic Lumbosacral

C-5 Deltoid T-4 Nipple L-4 Medial Leg
C-6 Thumb T-8 Xiphoid L-5 1st/2nd toes
C-7 Middle T-10 Umbilicus S-1 Lateral foot
finger T-12 Symphysis S-4 Perianal
C-8 Little finger
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ACS

Motor Examination

Cervical / Thoracic Lumbosacral

C-5 Shoulder abduction L-2 Hip flexion
C-6 Wrist Extension L-3 Knee extension
C-7 Elbow extension L-4 Ankle dorsiflexion
C-8 Middle finger flexion L-5 Big toe extension
T-1 Little finger abduction S-1 Big toe / ankle
plantar flexion
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ACS

Neurologic Assessment

Neurogenic Shock
Hypotension associated with cervical /
high thoracic spine injury
Bradycardia
Treatment : Maintenance fluids, atropine
and occasionally vasopressors
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ACS

Neurologic Assessment
Spinal Shock
Neurologic Not hemodynamic
phenomenon
Occurs shortly after cord injury
Flaccidity
Loss of reflexes
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ACS

Neurologic Assessment

Effect on Other Organ Systems

Inadequate ventilation
Abdominal evaluation compromised
Occult compartment syndrome
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ACS

Classifications of injury
Levels of injury
Clinical exam
Most caudal
Normal bilaterally
Motor / sensory function
Bony : Site of vertebral column damage
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ACS

Classification of Injury

Incomplete Complete
Any sensation No motor / sensory
Position sense function
Voluntary No sacral sparing
movement in May have reflexes
lower extremity
Sacral sparing
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ACS

Classifications of Injury
Spinal Cord Syndromes
Central cord
Anterior cord
Brown - Sequard
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ACS

Classification of Injury

Morphology
Fracture or fracture / dislocation
Spinal cord injury without radiographic
abnormality
Penetrating
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ACS

Classification of Injury

Morphology
Consider unstable if :
X-ray evidence of injury
Neurologic deficit
Severe pain on spine movement or
palpation
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ACS

X-ray Guidelines
Adequacy
Alignment
Bony abnormality
Base of skull
Cartilage , Contours
Disc space
Soft tissue
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ACS

C-spine x-rays
Crosstable lateral film exludes 85% of
fracture
Additional 2 views exludes most fractures
Also may require
Swimmers view
Ct scan for bony detail
Flexion extension views
MRI / CT myelogram
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ACS

C Spine X-rays
10% of patients with a c-spine fracture
have a 2nd, associated noncontiguous
vertebral column fracture
Identify one abnormality? Look for
another!
Radiographic screening of entire spine
required in this instance
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ACS

X ray Guidelines
Adequacy
Alignment
Bony abnormality
Cartilage, Contours
Disc Space
Soft tissue
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ACS

Screening for Spinal Injury

Conscious Patient
Presence of
Paraplegia / quadriplegia

Presume spinal instability

Identify bony Early neurosurgical

fracture subluxation / orthopedic consult
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ACS

Screening for spinal injury

Alert, sober, neurologically normal patient :

If no neck or spine If still no pain or

pain or tenderness to tenderness with
palpation or voluntary voluntary
movement movement
If no painful No further spine
distracting injury evaluation or c-
Remove c-collar spine x-ray
necessary
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ACS

Screening for Spinal Injury

Alert, sober, neurologically normal patient :

Neck or spine pain If yes to any

or tenderness to question
palpation or Protect c-spine
voluntary Obtain
necessary
movement ?
x-ray exams
After removal of c-
collar ?
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ACS

Screening for Spinal Injury

Altered LOC
Radiographic visualization of entire spine
Plain films
CT scan of suspicious areas
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ACS

Screening for Spinal Injury

Radiographic : Normal x-rays
Clinical :
Normal neurologic exam and
Absence of spinal pain / tenderness

Drugs,alcohol,
distracting injuries
may mask an injury
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ACS

Management
Immobilization
Entire Patient
Proper padding
Maintain until spine
injury excluded
Avoid prolonged
use of backboard!
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ACS

Medical Management

Ensure adequate ventilation especially

for high level (c-4) quadriplegic
Maintain blood pressure
Atropine as needed for bradycardia
Methylprednisolone
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ACS

Medical Management

Intravenous Fluids
Treat hypovolemia first
Consider neurogenic shock
Insert urinary catheter
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ACS

Medical Management
Steroids
IV Methylprednisolone
Proven spinal cord injury
Starts within 1st 8 hours from injury only
30 mg/kg over 15 minutes
5.4 mg/kg over next 23 hours
Proven in blunt trauma only
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ACS

Medical Management
Transfer
Unstable fractures
Neurologic deficit
Avoid delay
Properly Immobilized
Respiratory support as needed
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ACS

Questions
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ACS

Summary
Treat life-threatening injuries first
Immobilize
Appropriate spine films
Document examination
Neurosurgical / orthopedic consult
Transfer unstable fracture / cord injury