C-spine injury

CERVICAL SPINE INJURY

Narain Chotirosniramit MD.

Trauma and critical care unit

Department of surgery

Faculty of medicine Chiangmai University

NEUROLOGICAL ASSESSMENT

AIRWAY MANEUVERS ON C-SPINE MOVEMENT

WAY TO ACHIEVE TRACHEAL INTUBATION

BREATHING AND CIRCULATION

CLINICAL CRITERIA FOR CLEARING C-SPINE

CERVICAL SPINE IMMOBILIZATION

C-SPINE CLEARANCE GUIDELINE

CORTICOSTEROIDS WITH SCI

INTRODUCTION

EPIDEMIOLOGY

Incidence : 28-50 cases per million

Male to Female ratio 4:1

The most common cause of spinal injuryMotor vehicle accident 40%-50%

Falls 20%-25%

Gunshot wounds 10-14%

Sport 10%

Level of injury ,commonly

Cervical 55%

Thoracic 30%

Lumbar 15%

95% one spinal region

Two thirds: cervical

EPIDEMIOLOGY

PATHOPHYSIOLOGY

• Primary injury : Most of the damage– Concussion

– Contusion : Hemorrhage and swelling

– Laceration : Tissue Disruption

• Secondary injury – Biologic response processes

– Cause ischemia and hypoxia of the cord

– Lead to secondary tissue degeneration.










• The examination should include :

Sensory

Motor

Proprioception

Perianal sensation

Rectal sphincter tone

Bulbocavernous reflex

Simple & acceptable classification of SCI :

A. Complete absence of motor and sensory function.

B. Sensation present but no motor function

C. Sensation + motor function 2–3/5.

D. Sensation present with motor function of 4/5.

E. Normal sensory and motor functionBrowner BD, Jupiter JB, Levine AM, et al. Skeletal Trauma: Fractures, Dislocations,

Ligamentous Injuries. Philadelphia: WB Saunders, 1998

Frankel classification

• To assess the patient : must be defined:

1. Complete SCI:

No motor or sensory function caudal to the level of injury

The bulbocavernous reflex is present.



2. Spinal shock:

Complete SCI with absent bulbocavernous reflex.

Not neurogenic shock.

Revaluate the neurologic status after the reappearance of the bulbocavernous reflex

3. Incomplete SCI (ICSCI):

Some motor or sensory function below the level of injury.


• Central cord syndrome

Most common ICSCI

Quadriplegia with perianal & sacral sparing.

75% : partial recovery of the motor function.

Formal Types of ICSCI

• Brown-Sequard syndrome Unilateral SCI (usually due

to penetration)

Motor deficit ipsilateral to the injury combined with contralateral sensory deficit.

Most : gain partial recovery with bowel and bladder continence & usually walking ability.


• Anterior cord syndrome

Relatively common

Complete motor & sensory loss

Some remnant of trunk and lower extremity deep sensation & proprioception.

Poor prognosis : only 10% some motor recovery.


• Posterior cord syndrome

Rare ICSCI

Loss of proprioception & deep sensation

Intact motor functioning.

“tabes dorsalis gait”.










AIRWAY MANEUVERS

• Both basic and advanced airway maneuver : cause movement in different segments of the cervical spine.

• Even chin lift and jaw thrust : cause movements cervical spine.

• Advanced airway : Blind NT intubation & direct laryngoscopy & OT intubation (DLOI)

Cause relative segmental cervical spine movement

Atlanto-occipital and atlantoaxial joints : most oftenAprahamian C, et al. Ann Emerg Med 1984; 13: 584–7.

Sawin PD, et al. Anesthesiology 1996; 85: 26–36

AIRWAY MANEUVERS

No significant different in movement was found between curved or straight laryngoscope blades.

Gerling MC, et al. Ann Emerg Med 2000; 36: 293–300.

AIRWAY MANEUVERS

Manual in-line stabilization :

Most common

Most effective in limiting segmental movement to 1–3 mm in various airway maneuvers.

Lennarson PJ, Smith D, Todd MM, et al. J Neurosurg (Spine 2) 2000; 92: 201–6.

Brimacombe J, Keller C, Kunzel KH, et al. Anesth Analg 2000; 91: 1274–8.

AIRWAY MANEUVERS

• Summary and recommendations: No Level I clinical data.

Airway management in suspected CSI may cause relative spinal segmental movement.

Manual in-line stabilization : Safely applied & significantly limit the dangerous spine motion

( Recommendation grade: B.)

AIRWAY MANEUVERS









TRACHEAL INTUBATION

12 retrospective series :

395 DLOI in patients with CSI

(most of them unstable)

Only 2 : Neurological deterioration (not attributed to the airway intervention)

Crosby ET. Anesthesiology 2006; 104: 1293–318.

Awake nasotracheal intubation :

Many anesthesiologists prefered for definitive airway control in suspected CSI patients.

Rosenblatt WH, et al. Anesth Analg 1998; 87: 153–7.

TRACHEAL INTUBATION

• Fiber optic endoscope.

Minimal spine movement

Maintaining airway protective reflexes

Disadvantages : Slow learning curve that causes many doctors to be uncomfortable with the procedure

Ezri T, et al. J Clin Anesth 2003; 15: 418–22.Potential for desaturation : might aggravate secondary cord injury.

Fuchs G, et al. J Neurosurg Anesth 1999; 11: 11–16.

TRACHEAL INTUBATION

• Summary and recommendations: Both DLOI and fiber optic awake NT intubation are safe & effective options for securing the airway in a trauma patient with suspected CSI.

(Recommendation grade: B).

DLOI : No special equipment or advanced expertise

Preferred in emergency situations

Fiber optic : elective procedures.

(Recommendation grade: C.)

TRACHEAL INTUBATION










• Cervical spinal cord injury : May have respiratory failure and hemodynamic compromise.

• Hypoxemia & hypotension : increase the chance for secondary cord injury and worsening the neurological outcome.

• Risk for ventilatory failure : based on the level and completeness of injury.

• Ventilatory support : majority of patients > C5 injuries

> C3 injuries. Adequate fluid resuscitation & hemodynamic improvement : correlated to better neurological outcome

Vale FL, Burns J, Jackson AB, et al. J Neurosurg 1997; 87: 239–46.


• High SCI (above T6) :

Disruption of sympathetic chain

Hypotension & bradycardia. (neurogenic shock)

Found to be 19.3% Guly HR, Bouamra O, Lecky FE. Resuscitation 2008; 76: 57–62.


• If SBP < 90 mmHg, MABP < 85 mmHg.

• Early administration of vasoactive drug should be considered.

Hadley MN, et al. Neurosurgery 2002; 50(suppl): 58–62.










CLINICAL CRITERIA

• The NEXUS study : 34,069 patients.

• 5 criteria for the definition a low probability of CSI:

1. No midline cervical tenderness

2. No focal neurological deficit

3. Normal alertness

4. No intoxication

5. No painful, distracting injuryHoffman JR, Mower WR, Wolfson AB, et al. N Engl J Med 2000; 343: 94–9.

• The results were 100% sensitivity

(95% CI, 98–100%)

and 42.5% specificity (95% CI, 40–44%) for identifying clinically important C-spine injuries.

Stiell IG, et al. JAMA 2001; 286: 1841–8.

CLINICAL CRITERIA

The Canadian C-spine rule :

More sensitive than the NEXUS (99.4% versus 90.7%, p < 0.001)

More specific (45.1% versus 36.8%, p < 0.001)

Lower radiography rates.Stiell IG, Clement CM, McKnight RD, et al. N Engl J Med 2003; 349: 2510–18.

CLINICAL CRITERIA









IMMOBILIZATION

Cervical spine injuries : may be impaired by pathological motion of the injured vertebrae.

3 to 25% of SCI : Occur during transit or early in the course of management .

Brunette DD, et al. J Trauma 27:445–447, 1987.

Burney RE, et al. J Trauma 29:1497–1499, 1989.

Geisler WO, et al. Med Serv J Can 22:512–523, 1966.

Hachen HJ. Paraplegia 12:33–37, 1974.

Prasad VS, et al. Spinal Cord 37:560–568, 1999

Totten VY, et al. Prehosp Emerg Care 3:347–352, 1999.

The optimal device has not yet been identified by careful comparative analysis.

American College of Surgeons :

Hard backboard

Rigid cervical collar

Lateral support devices

Tape or straps to secure the patient

IMMOBILIZATION

Occipital padding combined with a rigid backboard : a better neutral position than a flat backboard alone

Schriger DL, et al. Ann Emerg Med 20:878–881, 1991.

Stauffer ES. Clin Orthop 102: 92–99, 1974.

IMMOBILIZATION

Extension Neutral Flexion

• Compare immobilization : Soft collar

Hard collar

Extrication collar

Philadelphia collar

Bilateral sandbags with 3-inch cloth tape across forehead

Combination of sandbags, tape, and a Philadelphia collar.Podolsky S, et al.J Trauma 23:461–465, 1983.

IMMOBILIZATION

• Hard foam & hard plastic collars were better at limiting cervical spine motion than soft foam collars

• Neither collars alone nor sandbags and tape in combination provided satisfactory restriction of cervical spine motion

• Sandbags and tape combined with a rigid cervical collar were the best

Podolsky S, et al.J Trauma 23:461–465, 1983.

IMMOBILIZATION

• Spine immobilization increases the risk of pressure sores.

• Pressure sores were associated with immobilization (patients who were not turned during the first 2 hours after injury).

Linares HA, et al. Orthopedics 10:571–573, 1987

IMMOBILIZATION

• Summary :

Immobilization of the entire spinal column is necessary until a spinal column injury has been excluded, or until appropriate treatment has been initiated

IMMOBILIZATION

• Summary :

It seems that a combination of rigid cervical collar with supportive blocks on a rigid backboard with straps is effective at achieving safe, effective spine immobilization for transport.

IMMOBILIZATION









Practice management guidelines for

identification of cervical spine injuries

following trauma

2009

update from the Eastern Association for the Surgery of Trauma

Practice

Management Guidelines Committee

C-spine clearance

• Search from PubMed

• Articles regarding the identification of CS injury from 1998-2007

78 articles were identified.

52 articles were selected

C-spine clearance

• The questions posed were:

1. Who needs CS imaging

2. What imaging should be obtained;

3. When should CT, MRI, or F/E radiographs be used.

4. How is significant ligamentous injury excluded in the comatose patient?

RECOMMENDATIONS

A. Removal of cervical collars:

Cervical collars should be removed as soon as feasible after trauma (level 3)

C-spine clearance

A. Removal of cervical collars

• Early removal of cervical collars may decrease :

Collar-related decubitus ulceration

Incidence of increase Intracranial pressure (ICP)

Ventilator days

Intensive care unit (ICU) and hospital days

The incidence of delirium and pneumonia.


• Chendrasekhar and colleagues

38% : Collar-related decubitus ulceration in head-injured patients who survived greater than 24 hours.

• A significantly longer duration of cervical collar use than those who did not

Chendrasekhar A, Moorman DW, Timberlake GA.

An evaluation of the effects of semirigid cervical collars in patients with severe closed head injury.

Am Surg 1998; 64:604-606


• Powers et al

Skin breakdown in 6.8% of ICU patients (with a cervical collar >24 hours).

Most significant predictor of breakdown was time in a cervical collar.

Powers J, Daniels D, McGuire C, et al.

The incidence of skin breakdown associated with the use of cervical collars.

J Trauma Nurs 2006; 13:198-200


Hunt and co-workers applied cervical collars to patients with traumatic brain injury and found a significant rise from the baseline ICP when the collars were applied

Hunt K, Hallworth S, Smith M. Anaesthesia 2001; 56:511-513

B. In the patient with penetrating trauma to the brain:

Immobilization in a cervical collar is not necessary unless the trajectory suggests direct injury to the cervical spine (CS) (level 3)

C-spine clearance

B. Penetrating trauma to the brain

• Retrospective studies

105 patients with GSW to the cranium : no CS injury

Kennedy FR, Gonzalez P, Beitler A, et al. South Med J 1994; 87:621-623.

B. Penetrating trauma to the brain

• Kaups and co-workers :

Reviewed 215 patients with a GSW to the head : no patient sustained indirect (blast or fall-related) spinal column injury

J Trauma 1998; 44:865-867.

C. In awake, alert trauma patients without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion of the CS:

CS imaging is not necessary and the cervical collar may be removed

C-spine clearance

C. Awake, alert trauma patients • National Emergency X-Radiography Utilization Study (NEXUS)

Required patients to have

1) No midline cervical tenderness

2) No focal neurologic deficit,

3) Normal alertness

4) No intoxication

5) No painful distracting injury.Hoffman JR, Mower WR, Wolfson AB, et al.

Validation of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000; 343:94-99.

D. All other patients in whom CS injury is suspected must have radiographic evaluation

1. The primary screening modality is axial computed tomography (CT) from the occiput to T1 with sagittal and coronal reconstructions

2. Plain radiographs contribute no additional information and should not be obtained

C-spine clearance

D. CS injury is suspected

• In the past : initial radiographic screening test was

A 3-view ( lateral, AP & odontoid views)

CS series supplemented by swimmer’s views and CT CS for poorly-visualized areas.


• A prospective study of 58 blunt trauma patients with CS imaging and a CT of another body region.

• Both plain radiography and CT CS.

20 patients (34.4%) : CS injuries.

Plain radiography : missed 8 injuries (3 unstable)

CT CS : missed only 2 injuries (stable).

• The sensitivity for plain CS : 60%, CT CS : 90% Berne JD, Velmahos GC, El-Tawil Q, et al. J Trauma 1999; 47:896-903


• Cohort of 1,199 blunt trauma patients with posterior neck tenderness, altered mental status, or neurologic deficit that underwent both plain films and CT CS for CS evaluation.

• 116 patients : CS injury.

Detected by both plain films & CT CS : 75 patients.

Detected by CT CS but missed by plain radiography : 41 patients�

• CT CS missed no injuries.

• There was no apparent role for screening with plain CS radiography.Griffen MM, Frykberg ER, Kerwin AJ, et al.

J Trauma 2003; 55:222-227.


• A prospective study of 1,006 hemodynamically stable patients with either altered mental status or distracting injury who underwent 5-view plain films and CT CS.

• Plain films of the CS missed 90 of 172 (52.3%) injuries.

Also missed 5 of 29 (17.2%) of patients with unstable injuries.

• CT CS missed 3 injuries, none of which were unstable.

• CT CS outperformed plain films in this group of patientsDiaz JJ, Gillman C, Morris JA Jr., et al. J Trauma 2003; 55:658-664


• 2005 : Holmes and Akkinepalli published a meta-analysis comparing plain films to CT CS.

• The pooled sensitivity

Plain radiography was 52%

CT CS it was 98%.Holmes JF, Akkinepalli R.

Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis.

J Trauma 2005; 58:902-905


CT CS must :

Include axial images from the occiput to T1

Sagittal and coronal reconstructions.

CT CS :

More accurate than plain radiography

Time, effective, cost effective

Does not require additional plain films

All other patients in whom CS injury is suspected must

have radiographic evaluation

iii. If CT of the CS demonstrates injury:

1. Obtain spine consultation.

iv. If there is neurologic deficit attributable to a CS injury:

1. Obtain spine consultation.

2. Obtain magnetic resonance imaging (MR)

C-spine clearance

• v. For the neurologically-intact awake and alert patient complaining of neck pain with a negative CT:

1. Options

A. Continue cervical collar.

B. Cervical collar may be removed after negative MR (ideally within 72 hrs)

C. Cervical collar may be removed after negative and adequate flexion/extension films

C-spine clearance

• Vi. Obtunded patient with a negative CT and gross motor function of extremities:

1. Flexion / extension radiography should not be performed

2. The risk / benefit ratio of obtaining MR in addition to CT is not clear, and its use must be individualized in each institution options are:

A. Continue cervical collar immobilization until a clinical exam can be performed.

B. Remove the cervical collar on the basis of CT alone.

C. Obtain MR.

3. If MR is negative, the cervical collar may be safely removed

C-spine clearance

1. F/E radiography should not be performed

• The incidence of ligamentous injury identified by dynamic fluoroscopy in patients with altered mental status was 0.7%.

Davis JW, Kaups KL, Cunningham MA, et al.

Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal.

J Trauma 2001; 50:1044- 1047

CT vs MR

• Negative CT : The incidence of ligamentous injury is very low (<5%)

• The incidence of clinically-significant injury is : much less than 1%.

• MR is very expensive, and obtaining MR may put the obtunded ICU patient at significant risk.

CT vs MR

• Retrospective 51 obtunded patients who had received both CT CS and MR CS

10 of 46 patients (22%) with a normal CT CS had an abnormal MR CS.

4 disk herniations

2 ligamentous injuries

A meningeal tear : potentially unstableGhanta MK, Smith LM, Polin RS, et al.

An analysis of Eastern Association for the Surgery of Trauma practice guidelines for cervical spine evaluation in a series of patients with multiple imaging techniques. Am Surg 2002; 68:563-568.

CT vs MR

• 46 obtunded patients with a normal CT CS : All had MR CS.

• An injury was detected by MR CS in 5 patients (11%).

4 : ligamentous injuries

1 : a herniated disk.

None of these injuries required surgery.Sarani B, Waring S, Sonnad S, et al. Magnetic resonance imaging is a useful adjunct in the evaluation

of the cervical spine of injured patients. J Trauma 2007; 63:637-640.

CT vs MR

• MR CS is not reliable for identifying osseous injury. It missed 45% of fractures.

Holmes JF, Mirvis SE, Panacek EA, et al.

Variability in computed tomography and magnetic resonance imaging in patients with cervical spine injuries.

J Trauma 2002; 53:524-530.

CT vs MR• MR CS should only be used to clear the CS in the

obtunded patient after a CT CS has cleared the CS of any bony abnormality.

• MR CS should be obtained within 72 hours of injury

Ability to detect soft-tissue injury may diminish after this time.

D’Alise MD, Benzel EC, Hart BL.

Magnetic resonance imaging evaluation of the cervical spine in the comatose or obtunded trauma patient.

J Neurosurg 1999; 91:54-59.

• Vi. Obtunded patient with a negative CT and gross motor function of extremities:

1. Flexion / extension radiography should not be performed

2. The risk / benefit ratio of obtaining MR in addition to CT is not clear, and its use must be individualized in each institution options are:

A. Continue cervical collar immobilization until a clinical exam can be performed.

B. Remove the cervical collar on the basis of CT alone.

C. Obtain MR.

3. If MR is negative, the cervical collar may be safely removed

C-spine clearance

• Adjunct to primary survey film

CXR

Pelvis AP

(No lateral C-spine film : Just splint)

C-spine clearance









CORTICOSTEROIDS

• A survey of 60 Canadian neurosurgeons and orthopedic spine surgeons :

75% : Routinely prescribe steroids for acute SCI

70% : Fear from litigation or peer criticism.

17% : Believe that steroids actually improve their patient’s neurological outcome.

Hurlbert RJ, Moulton R. Can J Neurol Sci 2002; 29: 236–9.

• Moderate vs low-dose methylprednisolone, 10-day regi-men

1 trial (Bracken 1984/85).

No difference in the neurologic outcome scores at 6 weeks, 6 months

Only wound infection was elevated in the high dose regimen (RR = 3.50, 95% CI 1.18 to 10.41)

CORTICOSTEROIDS

• High-dose methylprednisolone vs placebo or none, 24-hr regimen

3 trials (Bracken 1990/93, Otani 1994, Petitjean 1998).

Analysis restricted to patients treated within 8 hour

High-does methylprednisolone : Greater motor function recovery at 6 wks, 6 mths and the final outcome (WMD= 4.06, 95% CI 0.58 to 7.55).

Pinprick sensation : Significantly improved at 6 mths (WMD = 3.37, 95% CI 0.74 to 6.00) but not at one year

CORTICOSTEROIDS

• High-dose methylprednisolone for 48 versus 24 hours1 trial (Bracken 1997/98).

Patients treated within 3 hours : did not differ in their recovery from 24 or 48-hour methylprednisolone (Bracken 1997/98).

Patients treated within 3 - 8 hours :

Improved motor function if treated with 48-hr

No differences for pinprick or touch sensation

Severe pneumonia & severe sepsis tended to be elevated in the 48-hr but overall mortality at 1 year was not

CORTICOSTEROIDS

• Implications for practiceMethylprednisolone sodium succinate (MPSS) enhance sustained neurologic recovery in a phase three randomized trial.

Therapy must be started within 8 hours of injury

Initial bolus of 30 mg/kg by IV for 15 mins

Followed 45 mins later by a continuous infusion of 5.4mg/kg/hour for 24 hrs.

CORTICOSTEROIDS

• Implications for practice

Further improvement in motor function recovery when the maintenance therapy is extended for 48 hours.

This is particularly evident when the initial bolus dose could only be administered 3-8 hours after injury.

CORTICOSTEROIDS

CONCLUSIONS

THANK YOU

FOR

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C-spine injury

Health & Medicine

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sensation motor function

motor recovery

motor functionc

complete absence of

motor functionbrowner

level of injury

sensory function caudal