Chapter 7, Spine and Spinal Cord Trauma

ObjectivesEvaluate for suspected spinal injury.Appropriately manage spinal injury.Determine appropriate patient disposition.

Key QuestionsWhen do I suspect spine injury?How do I confirm the presence or absence of a significant spine injury?How do I protect the spine during evaluation and transport?How do I assess the patients neurologic status?

More Key QuestionsHow do I identify and treat neurogenic and spinal shock?How do I treat the patient with spinal cord injury and limit secondary injury?

Unconscious patient Neurologic deficitSpine pain / tenderness

Spinal Injury ScreeningIf patient is ConsciousCooperative Able to concentrate on c-spine

If no neck or spine pain or tendernessIf still no pain or tenderness with voluntary movement No further evaluation or x-ray necessaryRemove c-collar

Spinal Injury Screening Radiographic: Normal x-raysClinical Normal neurologic exam and Absence of spinal pain and tendernessDrugs, alcohol, and other injuries may mask spinal injury

Spine Injury ScreeningAltered SensoriumRadiographic visualization of entire spinePlain films CT scan of suspicious or poorly visualized areas

C-spine X-raysCrosstable lateral film excludes 85% of fracturesAddition of AP and odontoid views exclude most fracturesAlso may require Swimmers viewCT scan for bony detail MRI

C-spine X-rays10% of patients with a c-spine fracture have a 2nd, associated noncontiguous vertebral column fractureIdentify 1 abnormality? Look for another!Radiographic screening of entire spine required in this situation

How do I protect the spine?Immobilize entire patient on long spine board with proper paddingApply semirigid cervical collarProtection is priority; detection is secondary

How do I protect the spine?Spinal evaluation complicated by altered sensoriumRemove spine board as soon as possible and logroll patientPressure sores occur early in unconscious or paralyzed patients

At least 5% of patientsWith spinal cord injuries Worsen neurologically at hospital.

Assess neurologic status?Neurologic levelMost caudal level of motor / sensory functionMotor and sensory may not be same Sensory may vary on each side Bony level: Site of vertebral column damage

Assess neurologic status Complete: No motor or sensory function below injury levelIncomplete:Any motor or sensory preservation below injury level Sacral sparing may be only residual function

Injury effect on assessment / management?Inadequate ventilationAbdominal evaluation compromisedOccult compartment syndrome

Identify / treat neurogenic shock?Associated with cervical / high thoracic spine injuryHypotension and slow heart rate Treatment: Fluid Resuscitation and occasional atropine and vasopressors

Identify spinal shock?Neurologic, not hemodynamic phenomenonOccurs shortly after cord injury Variable duration Flaccidity and loss of reflexes

Treat / prevent secondary injury?Ensure adequate ventilation and oxygenationMaintain blood pressureAtropine as needed for bradycardiaMethylprednisolone

Assess for associated bleeding Consider neurogenic shock Monitor urinary output

Blunt injury only Start within 8 hours of injury30 mg / kg over 15 minutes5.4 mg / kg over next 23 hours if started within 3 hours of injury48 hours if started within 3 to 8 hours after injury

Management Provide respiratory support as needed Properly immobilize entire patientAvoid transfer delay!

Who do I transfer?Unstable fractures Neurologic deficitAvoid transfer delay!

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