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Spinal cord injury

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IF YES - NO X-RAY Results of Canadian C-Spine Study 8,924 patients enrolled 100 % sensitivity for identifying 151 clinically important C-spine injuries 42.5 % ... – PowerPoint PPT presentation

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Title: Spinal cord injury


1
Spinal cordinjury
  • HOANG TRONG AI QUOC, MD
  • EMERGENCY DEPARTMENT
  • HUE CENTRAL HOSPITAL, VIETNAM
  • 2011

2
Objectives
  • Describe the basic spinal anatomy and physiology
  • Evaluate a patient with suspected spinal injury
  • Identify the common types of spinal injuries and
    their X-ray features.
  • NEXUS and Canadian C-spine rules
  • Stable vs Unstable fractures
  • Appropriately manage the spinal-injured patient
    during the first hour from injury.
  • Determine the appropriate disposition of the
    patient with spine trauma

3
Introduction
  • Vertebral column injury, with or without
    neurological deficits, must always be sought and
    excluded in a patient with
  • Multiple trauma.
  • Any injury above the clavicle
  • Age and gender
  • 65-80 occur in men
  • 60 occur in 16-30 years of age
  • Mechanisms
  • MVC (48)
  • Falls (21)
  • Penetrating injuries (15)
  • Sports injuries (14)

4
Epidemiology
  • 40 of trauma patients with neuro deficits will
    have temporary or permanent SCI
  • Many more vertebral injuries that do not result
    in cord injury
  • 10-15 have non-contiguous injuries
  • Multiple injuries in non-adjacent vertebrae
  • Most commonly injured vertebrae
  • C5-C7
  • C1-C2
  • T12-L2

5
Beware
  • Excessive manipulation and inadequate
    immobilization of a patient with a spinal cord
    injury can cause additional neurological damage
    and worsen the patients outcome

6
Anatomy and physiology
  • The spinal column 7 cervical, 12 thoracic, and 5
    lumbar vertebrae as well as the sacrum and the
    coccyx.
  • For many reasons, the cervical spine is most
    vulnerable to injury
  • The thoracolumbar junction is a fulcrum between
    the inflexible thoracic region and the stronger
    lumbar levels. This makes it more vulnerable to
    injury, with 15 of all spinal injuries occurring
    in this region.

7
Anatomy and physiology
  • Cervical Spine
  • 7 vertebrae
  • very flexible
  • C1 also known as the atlas
  • C2 also known as the axis

8
Anatomy and physiology
  • Thoracic Spine
  • 12 vertebrae
  • ribs connected to spine
  • provides rigid framework of thorax

9
Anatomy and physiology
  • Lumbar Spine
  • 5 vertebrae
  • largest vertebral bodies
  • carries most of the bodys weight
  • Sacrum
  • 5 fused vertebrae
  • common to spine and pelvis
  • Coccyx
  • 4 fused vertebrae
  • tailbone

10
Anatomy and physiology
  • Vertebral body
  • posterior portion forms part of vertebral foramen
  • increases in size from cervical to sacral
  • spinous process
  • transverse process
  • Vertebral foramen
  • opening for spinal cord
  • Intervertebral disk
  • shock absorber (fibrocartilage)

11
Anatomy and physiologySpinal ligament
  • Intrasegmental
  • - Ligamentum flavum
  • - Intertransverse ligament
  • - Interspinous ligament
  • Intersegmental
  • ?? ALL
  • ?? PLL
  • ?? Supraspinous ligament

12
Anatomy and physiologySpinal Cord
  • Spinal cord ends at L1
  • Three tracts can be readily assessed clinically.
  • - The corticospinal tract
  • - The spinothalamic tract
  • - The posterior columns
  • Complete spinal cord injury no sensory or motor
    function below a certain level,
  • Incomplete spinal cord injury If any motor or
    sensory function remains, prognosis for recovery
    is much better.
  • Sparing of sensation in the perianal region
    (sacral sparing) may be the only sign of residual
    function.

13
Anatomy and physiologySpinal Cord
  • Blood supplied by vertebral and spinal arteries
  • Gray matter core pattern resembling butterfly
  • White matter longitudinal bundles of myelinated
    nerve fibers

14
Anatomy and physiologySpinal Cord
  • Thoracic and lumbar levels supply sympathetic
    nervous system fibers
  • Cervical and sacral levels supply parasympathetic
    nervous system fibers

15
Anatomy and physiologySpinal Cord Pathways
  • Spinothalmic Tracts (anterolateral)
  • Convey nerve impulse for sensing pain,
    temperature light touch
  • Impulses cross over in the spinal cord not the
    brain
  • Lateral tracts conduct impulses of pain and
    temperature
  • Anterior tracts carry impulses of light touch
    and pressure

16
Anatomy and physiologySpinal Cord Pathways
  • Ascending Nerve Tracts (sensory input)
  • Carry sensory impulses from body structures
  • Posterior column (dorsal)
  • Conveys nerve impulses for proprioception,
    discriminative touch, pressure, vibration,
    two-point discrimination
  • Cross over at the medulla from one side to the
    other (impulses from left side of body ascend to
    the right side of the brain)

17
Anatomy and physiologySpinal Cord Pathways
  • Descending Motor Tracts (motor output)
  • Conveys motor impulses from brain to the body
  • Pyramidal tracts Corticospinal Corticobulbar
  • Corticospinal tracts
  • cause precise voluntary movement and skeletal
    muscle activity
  • lateral tract crosses over at medulla
  • - Extrapyramidal tracts
  • Rubrospinal, pontine reticulospinal,
    medullary
  • reticulospinal, lateral
    vestibulospinal and tectospinal

18
Example Motor and Sensory Pathways
To thalamus and cerebral cortex (sensory)
Spinothalmic tract
Motor Cortex
Brain Stem
Posterior column
Corticospinal tract
Spinal Cord
LMN
Pain - Temp
Proprioception (conscious)
Example Motor Pathway (corticospinal tract)
19
Spinal Nerves
  • 31 pairs originate from the spinal cord
  • Carry both sensation and motor function
  • Named according to level of spine from where they
    arise
  • Cervical 1-8
  • Thoracic 1-12
  • Lumbar 1-5
  • Sacral 1-5
  • Coccygeal 1

20
Cord level
  • C2 C7 add 1 for cord level
  • T1 T6 add 2
  • T7 T9 add 3
  • T10 L1, L2 level
  • T11 L3, L4 level
  • L1 sacro coccygeal segments

21
Dermatomes and key muscles
22
Dermatomes and key muscles
  • A dermatome is the area of skin innervated by the
    sensory axons within a particular segmental nerve
    root. They are important to determine level of
    injury

23
Dermatomes and key muscles
  • C5 Deltoids/biceps
  • C6 Wrist extensors
  • C7 Elbow extensors
  • C8 Finger flexors
  • T1 Finger Abductors
  • L2 Hip flexors
  • L3 Knee extensors
  • L4 Ankle dorsiflexors
  • L5 Long toe extensors
  • S1 Ankle plantar flexors

24
Common mechanism
  • Compression
  • Flexion
  • Extension
  • Rotation
  • Lateral bending
  • Distraction
  • Penetration

25
Suspect spinal injury with...
  • Sudden decelerations (MVCs, falls)
  • Compression injuries (diving, falls onto
    feet/buttocks)
  • Significant blunt trauma (football, hockey,
    snowboarding, jet skis)
  • Very violent mechanisms (explosions, cave-ins,
    lightning strike)
  • Unconscious patient
  • Neurological deficit
  • Spinal tenderness

26
High index of suspicion
  • Missed or delayed diagnosis most often attributed
    to
  • failure to suspect injury
  • inadequate radiology
  • incorrect interpretation of radiographs
  • A missed spinal injury can have devastating long
    term consequences
  • As such, spinal column injury must therefore be
    presumed until it is excluded

27
Spinal stabilization and management pre hospital
  • Protect spine at all times during the management
    of patients with multiple injuries.
  • Up to 15 of spinal injuries have a second,
    possibly non adjacent, fracture elsewhere in the
    spine
  • Ideally, whole spine should be immobilized in
    neutral position on a firm surface.
  • Can be done manually or with a combination of
    semi-rigid cervical collar, side head supports,
    long spine board and strapping.

28
Spinal stabilization and management pre hospital
  • PROTECTION gt PRIORITY
  • DETECTION gt SECONDARY
  • Rigid cervical collar
  • Log-rolling
  • Rigid transportation board
  • Rigid transfer slides

29
Spinal stabilization and management pre hospital
  • Immobilization devices should not take precedence
    over life saving procedures
  • If neck is not in the neutral position, alignment
    should be made.
  • If the patient is awake and cooperative, actively
    move their neck into line themselves.
  • If the patient does not want to move neck because
    of pain do not force movement of neck
  • Initial immobilization of C-spine with a
    hard-collar is a priority during extrication
  • Long spine boards are valuable primarily for
    extrication from vehicles.
  • Rapid evacuation to a trauma center

30
Spinal stabilization and management hospital
  • PROTECTION gt PRIORITY
  • DETECTION gt SECONDARY
  • Rigid cervical collar
  • Log-rolling
  • Rigid transfer slides

31
Spinal stabilization and management hospital
  • Spinal immobilization is a priority in trauma,
    spinal clearance is not
  • The spine should be assessed and cleared when
    appropriate, given the injury characteristics and
    physiological state
  • Imaging the spine does not take precedence over
    life saving diagnostic and therapeutic procedures

32
Clinical evaluation
  • Inspection and palpation Occiput to Coccyx
  • Tenderness to the vertebrae
  • Gap or Step-off (both very rare)
  • Edema and bruising
  • Spasm of associated muscles
  • Neurological assessment
  • Sensation
  • Motor
  • Reflexes
  • Rectal examination

33
Assessment
  • Sensory Dermatomes
  • Motor Key muscles

34
AssessmentRectal tone
  • Tone the presence of rectal tone in itself does
    not indicate an incomplete injury
  • Sensation
  • Volition A voluntary contraction of the
    sphincter or the presence of rectal sensation
    presence of communication lower spinal cord-
    supraspinal centers favorable
    prognosis
  • Bulbocavernosus reflex
  • Positive presence of reflex lack
    of supraspinal input to the sacral outflow
    complete spinal injury
  • Negative absent in spinal shock

35
SCI GRADING SYSTEMASIA AMERICAN SPINAL INJURY
ASSOCIATION
  • Neurological Classification
  • Use the ASIA International standards
  • Motor and sensory assessment
  • ASIA Impairment Scale (A-E)
  • Clinical Syndromes (patterns of incomplete injury)

36
SCI GRADING SYSTEMASIA IMPAIRMENT SCALE
  • A Complete No motor or sensory function is
    preserved in the sacral segments S4-S5
  • B Incomplete Sensory but not motor function is
    preserved below the neurological level and
    includes sacral segments S4-5
  • C Incomplete Motor function is preserved below
    the neurological level, and more than half of key
    muscles below the neurological level have a
    muscle grade less than 3
  • D Incomplete Motor function is preserved below
    the neurological level, and at least half of key
    muscles below the neurological level have a
    muscle grade of 3 or more
  • E Normal motor and sensory function are normal

37
SCI General Assessment
  • ABCs
  • Airway and/or Breathing impairment
  • Inability to maintain airway
  • Apnea
  • Diaphragmatic breathing
  • Cardiovascular impairment
  • Neurogenic Shock
  • Hypotension and bradycardia
  • Patient appears warm and dry
  • Hypoperfusion

38
SCI General Assessment
  • Neurologic Status
  • Level of Consciousness
  • Brain injury also?
  • Cooperative
  • No impairment (drugs, alcohol)
  • Understands Recalls events surrounding injury
  • No Distracting injuries
  • No difficulty in communication

39
SCI General Assessment
  • Assess Function Sensation
  • Palpate over each spinous process
  • Sensation (Position and Pain)
  • weakness, numbness, paresthesia
  • pain (pinprick), sharp vs dull, symmetry
  • Motor function
  • Shrug shoulders
  • Spread fingers of both hands and keep apart with
    force
  • Hitchhike T1
  • Foot plantar flexors (gas pedal) S1,2
  • Priapism- Reflexes

40
Spinal Cord Injuries
  • Primary Injury
  • occurs at the time of injury
  • may result in
  • cord compression
  • direct cord injury
  • interruption in cord blood supply
  • Secondary Injury
  • occurs after initial injury
  • may result from
  • swelling/inflammation
  • ischemia
  • movement of body fragments

41
Spinal Cord Injuries
  • Cord concussion Cord contusion
  • temporary loss of cord-mediated function
  • Cord compression
  • decompression required to minimize permanent
    injury (may have permanent injury)
  • Laceration
  • permanent injury dependent on degree of damage
  • Hemorrhage
  • may result in local ischemia

42
Spinal Cord Injuries
  • Cord transection
  • Complete
  • all tracts disrupted
  • cord mediated functions below transection are
    permanently lost
  • determined 24 hours post injury
  • possible results
  • quadriplegia
  • paraplegia

43
Terminology
  • Paraplegia
  • loss of motor and/or sensory function in
    thoracic, lumbar or sacral segments of SC (arm
    function is spared)
  • Quadriplegia
  • loss of motor and/or sensory function in the
    cervical segments of SC

44
Spinal Cord Injuries
  • Cord transection
  • Incomplete
  • some tracts and cord mediated functions remain
    intact
  • potential for recovery of function
  • Possible syndromes
  • Brown-Sequard Syndrome
  • Anterior Cord Syndrome
  • Central Cord Syndrome

45
Brown Sequard Syndrome
  • Incomplete Cord Injury
  • Injury to one side of the cord (Hemisection)
  • Often due to penetrating injury or vertebral
    dislocation
  • Complete damage to all spinal tracts on affected
    side
  • Prognosis for recovery is variable

46
Brown Sequard Syndrome
  • Exam Findings
  • Ipsilateral loss of motor function motion,
    position, vibration, and light touch
  • Contralateral loss of sensation to pain and
    temperature
  • Bladder and bowel dysfunction (usually short term)

47
Anterior Cord Syndrome
  • Anterior Spinal Artery Syndrome
  • Supplies the anterior 2/3 of the spinal cord to
    the upper thoracic region
  • caused by bony fragments or pressure on spinal
    arteries

48
Anterior Cord Syndrome
  • Exam Findings
  • Variable loss of motor function and sensitivity
    to pinprick and temperature
  • loss of motor function and sensation to pain,
    temperature and light touch
  • Proprioception (position sense) and vibration are
    preserved

49
Central Cord Syndrome
  • Usually occurs with a hyperextension of the
    cervical region
  • Exam Findings
  • weakness or paresthesias in upper extremities but
    normal strength in lower extremities
  • varying degree of bladder dysfunction

50
Cauda Equina Syndrome
  • Injury to nerves within the spinal cord as they
    exit the lumbar and sacral regions
  • Usually fractures below L2
  • Specific dysfunction depends on level of injury
  • Exam Findings
  • Flaccid-type paralysis of lower body
  • Bladder and bowel impairment

51
Neurogenic Shock
  • Temporary loss of autonomic function of the cord
    at the level of injury
  • Usually results from cervical or high thoracic
    injury
  • Does not always involve permanent primary injury
  • Effects may be temporary and resolve in hours to
    weeks
  • Goal is to avoid secondary injury

52
Neurogenic Shock
  • Presentation
  • Flaccid paralysis distal to injury site
  • Loss of autonomic function
  • hypotension or relative hypotension
  • vasodilation
  • loss of bladder and bowel control
  • priapism
  • loss of thermoregulation
  • warm, pink, dry below injury site
  • relative bradycardia
  • may have class SNS response presentation above
    injury

53
Autonomic Hyperreflexia Syndrome
  • Associated with SCI patients (usually T-6 or
    above) after initial injury (weeks to months)
  • Vasculature has adapted to loss of sympathetic
    tone
  • Blood pressure normalized
  • No vasodilation response to increased BP
  • ANA reflexively responds with arteriolar spasm
  • increased BP
  • stimulates PNS
  • results in bradycardia
  • peripheral and visceral vessels unable to dilate

54
Autonomic Hyperreflexia Syndrome
  • Presentation
  • Paroxysmal hypertension, possible extreme
    headache
  • blurred vision
  • sweating and flushed skin above level of injury
  • increased nasal congestion
  • nausea
  • bradycardia
  • distended bladder or rectum

55
Effect on other Organ Systems
  • Hypoventilation due to the paralysis
  • Intercostal muscles
  • Diaphragm
  • The inability to perceive pain may mask a
    potentially serious injury elsewhere
  • Abdominal injury no abdominal tenderness
  • Lower extremity injury no tenderness

56
Classifications of Spinal Cord Injuries level
of injury
  • Determination of the level of injury on both
    sides is important.
  • Injury above the T-1 level-------quadriplegia
  • Injury below the T-1 level-------paraplegia
  • Apart from the initial management to stabilize
    the bony injury, all subsequent descriptions of
    the level of injury are based on the neurologic
    level.

57
Severity of the Neurologic Deficit
  • Incomplete paraplegia
  • Complete paraplegia
  • Incomplete quadriplegia
  • Complete quadriplegia
  • Signs of incomplete injury may include
  • Any sensation ( including position sense) or
    voluntary movement in the lower extremities.
  • Sacral sparing

58
Morphology
  • Spinal injuries can be described as,
  • Fractures
  • Fracture dislocations
  • SCIWORA
  • Penetrating injuries
  • Injuries can be stable or unstable
  • All patients with x-ray evidence of injury and
    all those with neurologic deficits should be
    considered to have an unstable spinal injury
    until proven otherwise.

59
imaging
  • Who needs a cervical spine x-ray ?
  • Two papers have attempted to address this
    question
  • NEXUS -The National Emergency X- Radiograph
    Utilization Study
  • Canadian C-Spine rules

60
Imaging NEXUS
  • Prospective study to validate a rule for the
    decision to obtain cervical spine x- ray in
    trauma patients
  • Hoffman, N Engl J Med 2000 34394-99

61
NEXUS
  • NEXUS Criteria
  • 1. Absence of tenderness in the posterior midline
  • 2. Absence of a neurological deficit
  • 3. Normal level of alertness (GCS score 15)
  • 4. No evidence of intoxication (drugs or alcohol)
  • 5. No distracting injury/pain

62
NEXUS
  • Any patient who fulfilled all 5 of the criteria
    were considered low risk for C-spine injury and
    as such did not need C-spine radiography
  • For patients who had any of the 5 criteria,
  • radiographic imaging was indicated in the
  • form of AP, lateral, and odontoid C-spine views

63
Results of NEXUS study
  • 34,069 patients were enrolled
  • 818 had significant C-spine injury
  • 810 were identified by the decision rule
  • 8 patients were identified as low risk but in
    fact had radiographic injury

64
NEXUS
  • Sensitivity 99
  • Negative predictive value 99.8
  • Specificity 12.9
  • Positive predictive value 2.7
  • Study was well received
  • But..some felt criteria to be too ambiguous and
    open to interpretation

65
Canadian C-Spine Rules
Prospective study whereby patients were evaluated
for 20 standardized clinical findings as a basis
for formulating a decision as to the need for
subsequent cervical spine radiography Stiell I.
JAMA. 2001 2861841-1846
66
Rules were as follows..
  • 1. Was there any high risk factor that mandates
    radiography?
  • Agegt65
  • Dangerous mechanism of injury
  • Presence of paresthesias
  • IF YES -gt X-RAY

67
Rules were as follows..
  • 2. Were there any low risk factors that allow
    some assessment of range of motion?
  • Simple rear end MVC
  • Sitting position in ER
  • Ambulatory at any time
  • Delayed onset of neck pain
  • Absence of midline c-spine tenderness
  • IF NONE -gt X-RAY

68
Rules were as follows..
  • 3. Was the patient actively able to move their
    neck?
  • IF YES -gt NO X-RAY

69
Results of Canadian C-Spine Study
  • 8,924 patients enrolled
  • 100 sensitivity for identifying 151 clinically
    important C-spine injuries
  • 42.5 specificity
  • Deemed a highly sensitive decision rule for use
    of C-spine radiography in alert and stable trauma
    patients

70
The Canadian C-spine Rule for alert and stable
trauma patients where cervical spine injury is a
concern.
  • Any high-risk factor that mandates radiography?
  • Agegt65yrs, or
  • Dangerous mechanism, or
  • Paresthesias in extremities

NO
YES
Any low-risk factor that allows safe assessment
of range of motion? Simple rear-end MVC, or
Sitting position in ED, or Ambulatory at any
time, or Delayed onset of neck pain, or
Absence of midline C-spine tenderness
NO
Radiography
UNABLE
YES
Able to actively rotate neck? 45 degrees left
and right
ABLE
No Radiography
From Stiell I et al JAMA Oct 2001
71
National Emergency XRadiography Utilization
Study(NEXUS)
Vs
The Canadian C-spine rule?
  • Both have
  • Excellent negative predictive value for excluding
    patients identified as low risk
  • Poor positive predictive value as most no-low
    risk patients do not have a fracture

72
Clearance of Cervical Spine Injury inConscious,
Symptomatic Patients
  • 1. Radiological evaluation of the cervical spine
    is indicated for all patients who do not meet the
    criteria for clinical clearance as described
    above
  • 2. Imaging studies should be technically adequate
    and interpreted by experienced clinicians

73
Cervical Spine Imaging Options
  • Initial Screening Options
  • Plain films Lateral, AP, and Odontoid,
  • Optional Oblique and Swimmers (if necessary)
  • CT- much better than plain films for bony
    fractures/dislocations. Poor evaluation of
    ligamentous injuries.
  • Other cervical spine imaging options
  • MRI- Very good for soft tissue/ligamentous
    injuries.
  • Flexion-Extension Plain Films- to determine
    stability (may replace MRI if unavailable or
    contraindicated)

74
Plain Film Radiology
  • The standard 3 view plain film series is the
    lateral, antero-posterior, and open-mouth view
  • The lateral cervical spine film must include the
    base of the occiput and the top of the first
    thoracic vertebra
  • The lateral view alone is inadequate and will
    miss up to 15 of cervical spine injuries

75
Plain Film Radiology
  • If lower cervical spine difficult to see, caudal
    traction on the arms may be used to improve
    visualization
  • Swimmers views
  • Repeated attempts at plain radiography are
    usually unsuccessful
  • If the lower cervical spine is not visible, a CT
    scan of the region is then indicated

76
Radiological evaluation
  • X-ray Guidelines (cervical)
  • Mnemonic AABBCCDS
  • Adequacy, Alignment
  • Bone abnormality, Base of skull
  • Cartilage, Contours
  • Disc space
  • Soft tissue

77
How to read the LateralCervical Spine X-Ray
adequacy
  • Lateral cervical spine x ray must visualize
    entire cervical spine .
  • A film that does not show the upper border of T1
    is inadequate
  • Caudal traction on the arms may help
  • If not get swimmers view or CT

78
Swimmers View
79
Alignment
  • The anterior vertebral line, posterior vertebral
    line, and spinolaminar line should have a smooth
    curve with no steps or discontinuities
  • Malalignment of the posterior vertebral bodies is
    more significant than that anteriorly, which may
    be due to rotation
  • A step-off of gt3.5mm is
  • significant anywhere

80
Bones
81
Lateral Cervical Spine X-Ray
  • Anterior subluxation of one vertebra on another
    indicates facet dislocation
  • Less than 50 of the width of a vertebral body
    implies unifacet dislocation
  • Greater than 50 implies bilateral facet
    dislocation
  • This is usually accompanied by widening of the
    interspinous and interlaminar spaces

82
Cartilage
  • Predental Space should be no more than 3 mm in
    adults and 5 mm in children
  • Increased distance may indicate fracture of
    odontoid or transverse ligament injury

83
Shift of gt 3.5mm impliesinjury to transverse
ligament, and gt 5mm indicates complete rupture
and instability C1-C2 interspinous space should
not be gt10mm wide
84
Cartilage
  • Disc Spaces
  • Should be uniform
  • Assess spaces between the spinous processes

85
Disc space
  • Vertebral body and intervertebral disc
    examination reveal compression and burst type
    injuries
  • Bodies normally regular cuboids similar in size
    and shape to the vertebrae immediately above and
    below (not C1/C2)
  • Anterior wedging of vertebral body or teardrop
    fractures of antero-inferior portion of body
    implies compression fracture

86
Disc space
  • Anterior compression of greater than 40 of
    normal vertebral body height indicates a burst
    fracture with retropulsion of fragments of the
    vertebral body into the spinal canal

87
Disc space , soft tissue
  • Loss of height of an intervertebral disc space
    may indicate disc herniation
  • Analysis of prevertebral soft tissues may allow
    the diagnosis of cervical injuries
  • Soft tissue shadow is created by pharyngeal and
    prevertebral tissues

88
Soft tissue
  • Nasopharyngeal space (C1) - 10 mm (adult)
  • Retropharyngeal space (C2-C4) - 5-7 mm
  • Retrotracheal space (C5-C7) - 14 mm (children),
    22 mm (adults)
  • Extremely variable and nonspecific

89
AtlantoOccipital dissociation
  • Atlanto-occipital dissociation can be very
    difficult to diagnose and is easily missed
  • The distance from the occiput to the atlas should
    not exceed 5mm anywhere on the film

90
Anterior/Posterior C-spine Films
  • Spinous processes should line up.
  • Disc space should be uniform
  • Vertebral body height should be uniform. Check
    for oblique fractures.

91
Odontoid view
  • Adequacy all of the dens and lateral borders of
    C1 C2
  • Alignment lateral masses of C1 and C2
  • Bone Inspect dens for lucent fracture lines

92
Mechanisms of Injury
  • Hyperflexion i.e. diving in shallow water
  • Axial compression i.e. landing directly on head
  • Hyperextension i.e. hitting dashboard in MVC
  • Rotation

93
Where is the fracture?
94
Where is the fracture?
95
Jefferson Fracture
  • Compression fracture of C1 ring
  • Most common C1 fracture
  • Unstable
  • Commonly see increase in predental space on
    lateral if transverse ligament is damaged and
    displacement of C1 lateral masses on odontoid.
  • Obtain CT

96
Burst Fracture
  • Fracture of C3-C7 from axial loading
  • Spinal cord injury is common from posterior
    displacement of fragments into the spinal canal
  • Stable if ligaments intact

97
Clay Shovelers Fracture
  • Flexion fracture of spinous process
  • C7gtC6gtT1
  • stable

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Flexion Teardrop Fracture
  • Flexion injury causing a fracture of the
    anteroinferior portion of the vertebral body
  • Unstable because usually associated with
    ligamentous injury (posterior ligaments torn)

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Bilateral Facet Dislocation
  • Flexion injury
  • Subluxation of dislocated vertebra of greater
    than ½ the AP diameter of the vertebral body
    below it
  • High incidence of spinal cord injury
  • Extremely unstable

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Hangmans Fracture
  • Extension injury
  • Bilateral fractures of C2 pedicles (white arrow)
  • Anterior dislocation of C2 vertebral body
    secondary to Anterior longitudal ligament tear
    (red arrow)
  • Unstable

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Dens Fracture
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Odontoid Fractures
  • Complex mechanism of injury
  • Generally unstable
  • Type 1 fracture through the tip
  • rare
  • Type 2 fracture through the base
  • Most common
  • Type 3 fracture through the base and body of axis
  • Best prognosis

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Odontoid Fracture Type II
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Odontoid Fracture Type III
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Odontoid Fracture
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Stable vs Unstable Fractures
  • Stability of cervical spine is provided by two
    functional vertical columns
  • Anterior column vertebral bodies, the disc
    spaces, the anterior and posterior longitudinal
    ligaments and annulus fibrosus
  • Posterior column pedicles, facets and apophyseal
    joints, laminar spinous processes and the
    posterior ligament complex
  • As long as one column is intact the injury is
    stable.

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Jefferson Bit Off A Hangmans Thumb
  • Jefferson C2 Burst Fx
  • Bifacet Dislocation or Fracture
  • Odontoid II-body or III-Lateral masses
  • Any Fx with dislocation/subluxation
  • Hangmans posterior C2 secondary to
    hyperextension
  • Teardrop anterior chip of any vertebrae

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X-Ray evaluation
  • Thoracic and lumbar spine
  • A.P film
  • Thoracic Spine Fractured ( T-1 Through T-10)
  • Thoracolumbar Junction Fractures ( T-11 through
    L-1)
  • Lumbar Fractures
  • Penetrating Injuries

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CT Scanning
  • Thin cut CT scanning should be used to evaluate
    abnormal, suspicious or poorly visualized areas
    on plain radiology
  • The combination of plain radiology and directed
    CT scanning provides a false negative rate of
    less than 0.1

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MRI
  • Ideally (ie. US) all patients with an abnormal
    neurological examination should be evaluated with
    an MRI scan
  • Patients who report transient neurological
    symptoms but who have a normal exam should also
    undergo an MRI assessment of their spinal cord

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Management of SCI
  • Primary Goal
  • Prevent secondary injury
  • Stabilization of the spine begins in the initial
    assessment
  • Treat the spine as a long bone
  • Secure joint above and below
  • Caution with partial spine splinting
  • Dr. Roberts Rule All or None
  • Immobilization vs Motion Restriction

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Management of SCI
  • Neutral positioning of head and neck if at all
    possible
  • allows for the most space for cord
  • most stable position for spinal column
  • dont force it

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Management of SCI
  • Cervical Motion Restriction
  • Manual method
  • Rigid collar comes later
  • Interim device (KED)
  • Move to long board or full body vacuum splint
  • Manual continues until trunk and head secured
  • CID
  • Dont use sand bags or IV fluid bags as head
    blocks
  • Tape works wonders!
  • Improvise with blanket rolls

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Management of SCI
  • Dont forget the Padding
  • Maintains anatomical position
  • Limits movement on board
  • especially during transport on board or in
    vehicle
  • fill all the voids
  • curvature of the lower back is normal - fill it
  • pillows, blankets, towels
  • Tape along (even duct tape) is not enough

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Management of SCI
  • Securing to the Board
  • Straps, Tape, Cravats
  • Torso first
  • then legs and feet and head
  • Even patients extricated with a KED are secured
    to the board

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Management of SCI
  • Pediatric Patient Considerations
  • Elevate the entire torso if large occiput
  • Pad underneath
  • Short board underneath
  • Vacuum mattress
  • Lots of voids to fill
  • Difficult to find a correctly sized rigid collar
  • Improvise with
  • horse collar
  • blanket or towel rolls

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Management of SCI
  • Helmeted Patients
  • Removal should be limited to emergent need for
    access to airway and ventilation
  • Leave in place if
  • good fit with little or no head movement within
  • no impending airway or breathing problems
  • can perform spinal motion restriction with helmet
    on
  • no interference in airway assessment or
    management
  • no cardiac arrest

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Management of SCI
  • General
  • Manual Spinal Motion Restriction
  • ABCs
  • Increase FiO2
  • Assist ventilations as needed
  • IV Access fluids titrated to BP 90-100 mm Hg
  • Look for other injuries Life over Limb
  • Transport to appropriate SCI center once
    stabilized

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Management of SCI
  • Consider High Dose methylprednisolone
    SoluMedrol
  • 30 mg/kg bolus over 15 mins
  • After bolus infusion 5.4mg/kg IV for 23 hours
  • Controversial as recent evidence questions
    benefit
  • Must be started lt 8 hours of injury
  • Harmful if started gt 8 hours after injury
  • Most spine surgeons do not use for penetrating
    trauma

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Clearing Protocols
  • Spinal Clearance
  • First initiated in Maine with a state-wide
    protocol
  • Now much more common in US
  • Current Practice
  • Assess scene and MOI
  • Assess neuro status
  • Immobilize
  • Most MOIs
  • Prevent further injury
  • No 100 method to rule out in the field
  • fear of litigation
  • devastating consequences possible

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Whats Wrong with Immobilizing Nearly Everyone?
  • Concern for secondary injuries resulting from
    immobilization
  • Increases scene time
  • Increased pain to patient
  • Impaired ventilatory ability
  • Increases safety risk to providers
  • Increased risk of soft tissue injury
  • Difficulties in ED exam
  • Several published studies support the conclusion
    that
  • many persons are immobilized when it is clearly
    not necessary
  • patients do experience adverse effects from
    immobilization
  • field screening tools can be developed and have
    been proven effective

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When should the screening tool be used?
  • One of three paths is chosen
  • Positive or Obvious Severe Mechanism
  • Violent impact
  • High likelihood of spinal injury
  • Negative or Obviously Minimal Mechanism
  • No reasonable probability of spinal injury
  • Uncertain Mechanism (Very Common)
  • Injury may or may not be possible
  • Difficult to determine
  • Then, use screening tool or algorithm

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Clearing Protocols - Dr. Roberts
  • No significant MOI or evidence of spine injury
  • No neck or back pain (Palpate all)
  • Normal Neuro Exam (no motor/sensory losses)
  • Normal Level of Consciousness
  • Adult, Reliable Patient w/o anxiety reaction or
    normally abnormal mental status
  • No ETOH or drugs
  • No language barriers
  • No distracting injuries or penetrating injury
    near spine

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Clearing Protocols General Consensus
  • Absence of pain or tenderness of the spine
  • Lack of neurologic deficits
  • Normal level of consciousness
  • Includes ability to understand cause effect
  • Able to make own healthcare decisions
  • No evidence of alcohol or drug use
  • No distracting injuries

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Points to Remember
  • Maintain cervical spine immobilization until
    spine properly evaluated
  • Either clinical or radiographic clearance
  • Criteria exist (NEXUS and Canadian C-spine Rule)
    that identify the need for cervical spine imaging
  • Patients negative for either criteria may have
    their spine clinically cleared
  • Screen patients with plain radiograph or CT
  • CT better than plain radiographs
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