Editing Spinal injuries

* 5% of patients with spinal injury have worsening/new neurological symptoms after arriving in ED
** Typically due to ischaemia or progression of spinal cord oedema
** Can also result from excessive movement of the spine
** Ok to wait for spinal clearance if there are other more pressing pathologies around
** Don't keep patients on long backboards while awaiting clearance
** Avoid hypotension in spinal patients, even though that can be difficult in the setting of neurogenic shock


Clearing the spine can be straightforward

* Exclude neurological deficit
* Exclude midline pain/tenderness
* Absent intoxication
* No distracting injuries

== Anatomy ==

* Three columns - vertebral bodies and posterolateral pedicles 
**
** Anterior column: anterior longitudinal ligament, most of vertebral body (ant 2/3), ant fibres of annulus fibrosis and nucleus pulposis
** Middle: posterior cortex of vertebral body and posterior longitudinal lig and post fibres of annulus fibrosis
** Posterior: pedicle, llamina, facet joints, spinous process, interspinous/supraspinous ligaments, ligamentum flavum
** In general, a single-column injury is stable
** A middle column injury usually implies a 2 or 3 column injury, implying instability
** Instability requires two column injury AT THE SAME LEVEL
* Cervical spine most vulnerable to injury - 55% of spinal injuries begin here
* Cervical canal wide from foramen magnum to lower C2 - if patients survive initial injury, likely to be neurologically intact - can also die at the scene from apnoea from phrenic nerve injury
* C3 and below - small spinal canal - likely spinal cord injury
* Children >12yo have fairly similar spines to adults
* Spinal cord - foramen magnum to L1, then cauda equina

== Terminology ==

* Complete spinal cord injury - no demonstrable sensory or motor function below a certain level
* Incomplete - some degree remains
* Neurogenic shock - loss of vasomotor tone and sympathetic innervation to the heart (T6 and above)
** Results in bradycardia, lack of sympathetic response to hypovolaemia
* Spinal shock - flaccidity and loss of reflexes that occurs immediately after spinal cord injury
* Central cord syndrome - disproportionately greater loss of motor strength in upper extremities than lower extremities
** Occurs after hyperextension when there is pre-existing cervical canal stenosis
** Common after a fall forwards onto face in elderly patient
* Anterior cord syndrome - loss of motor, pain and temperature innervation, but preservation of position, vibration and temperature sensation (dorsal column)
** Common after cord ischaemia
* Brown-Sequard syndrome - hemisection of the cord - ipsilateral motor loss (corticospinal tract) and loss of position sense (dorsal column), contralateral loss of pain and temperature sensation beginning one to two levels lower (spinothalamic tract)
* Unstable injury - radiographic injury or any neurologic deficits (at least initially)

== Clinical assessment ==

* Time of assessment
* Use ASIA worksheet
* Sensation - light touch and pinprick
* Reflexes - triceps, brachioradialis, patellar, Achilles
* Four-extremity motor evaluation focusing on C5-T1 and L2-S1 myotomes
* Rectal exam

=== Documenting injury ===

* Level
** Bony level is the vertebra that is damaged
** Neurological level if the most caudal segment of spinal cord that has normal sensory and motor function on both sides of the body
*** Motor level - normal means at least 3/5 power
* Examination
** 10 different muscle groups bilaterally rated 0-5, and add the 20 scores to determine total ASIA motor score
** Sensation on a 0-2 scale all dermatomes
** Combination of ASIA impairment scale with motor score is best description of neurologic status after SCI
** See bottom for ASIA worksheet

== Syndromes ==

* Central cord syndrome
** Contusion/ischaemia/haemorrhage in central part of the spinal cord, associated with traumatic injury in the cervical or upper thoracic spine
** Tetraparesis with arms weaker than legs, and burning hands
** Variable amount of sensory loss that does not affect the face
* Cervicomedullary syndrome
** Injury from lower medulla to C4
** Respiratory difficulty
** Spinal shock
** Sensory deficit C1-C4
** Facial sensory loss from damage to ascending tract of spinal trigeminal nerve
* Anterior cord syndrome
** Incomplete spinal injury - vascular compromise in the anterior spinal artery distribution, and subsequent ischaemic injury to anterior two-thirds of the cord
** Can occur after blunt trauma mechanisms or ischaemic injuries
** Loss of motor function and pain and temperature sensation below the level of injury
** Preservation of vibration and light touch
** Low chance of recovery
* Posterior cord syndrome
** Rare
** Tetraparesis
** Profound sensory loss with preservation of pain and temperature
* Brown-Sequard
** Incomplete spinal cord syndrome resulting from hemitransection, usually from penetrating injuries
** Ipsilateral paralysis
** Ipsilateral vibration and loss of light touch
** Contralateral pain and temperature loss
* Conus medullaris syndrome
** Burst fractures T12/L1
** Paraparesis along with loss of bowel and bladder function
** Sensory loss in legs
** Sparing perianal sensation

== Specific injuries ==

* Atlanto-occipital dislocation
** Mostly die at scene due to apnoea
** Common cause of death in shaken baby syndrome
* Atlas (C1) fracture
** 40% are a/w C2 fracture
** Commonly burst fracture - axial loading
** Uncommon to be a/w spinal cord injury, but are certainly unstable, keep in collar
** Unilateral fractures are uncommon
* C1 rotary subluxation
** Most often seen in children
** Doesn't take much force sometimes
** Patient presents with torticollis
** Restrict motion with head in rotated position and refer
* C2 fractures
** 18% of all C-spine fractures
** Odontoid fractures
*** Normally positioned in contact with anterior arch of C1, held in place by transverse ligament
*** Type 1 fracture - odontoid tip
*** Type 2 - base
*** Type 3 - extend into body of C2
** Posterior element fracture (Hangman's)
*** Involves posterior elements of C2 - pars interarticularis
*** Usually caused by extension
*** Rigid collar and refer
* C3-C7
** C5-6 is most flexible, therefore most vulnerable to injury
** Incidence of neurologic injury is much higher with facet dislocations
* Thoracic
** Anterior wedge compression
*** Axial loading with flexion
*** Rarely more than 25%
*** Mostly kept stable by rigidity of ribcage
*** Mostly treated with a rigid brace
** Burst injuries
*** Vertical-axial compression
*** Probably needs fixation
** Chance fractures
*** Transverse fractures through vertebral body
*** Caused by flexion about an axis anterior to the vertebral column - MVA with poorly-placed seat belt
*** Can be a/w retroperitoneal and abdominal injuries - pancreas, duodenum
*** Probably needs fixation
** Fracture-dislocations
*** Relatively uncommon
*** Nearly always extreme flexion or severe blunt trauma to spine, which disrupts the posterior elements
*** Commonly results in complete neurological deficits
*** Probably needs fixation
* Thoracolumbar junction fractures (T11-L1)
** Combination of acute hyperflexion and rotation
*** Falls from height, restrained drivers at high speed
** Usually unstable
** Beware of spinal cord injury at L1 (bladder/bowels/lower limbs)
** Extremely vulnerable to rotational forces, be careful when logrolling
* Lumbar
** Similar to thoracic injuries
** Lower risk of spinal cord injury than thoracic
* Penetrating injuries
** Usually stable
* Blunt carotid/vertebral artery injuries
** Indications for screening (carotid angio and generally COW, but can be decided by radiology reg):
*** C1-C3 fractures
*** Cervical spine fracture with subluxation
*** Fractures involving foramen transversarium
*** Bruising to neck is soft, but can be indicated
*** Spinous process fractures probably doesn't need one
*** Base of skull fractures indicated
***


== Applying a cervical spine collar ==

* Supine
* Someone else stands behind the head and stabilise either side of head
* Slide the posterior part of the collar behind the neck
* Bring the anterior part round the front and place chin in the chin holder
* Secure the collar - allow mouth opening

== Process for clearing C-spine ==

* Apply Canadian or Nexus rules
* Wait for CT report if indicated
** Obvious bony deformity
** Loss of alignment of posterior aspect of vertebral bodies
** Increased distance between spinous processes
** Narrowing of vertebral canal
** Increased prevertebral soft-tissue space
* If CT report clear, reassess
** Awake, alert, sober patient
** No neck pain or midline tenderness
** Voluntarily move from side to side, flex, extend. If no pain, C-spine is cleared.
* If ongoing pain/midline tenderness/any neurological deficit, probably needs MRI
* If fracture detected, 10% have a further spinal injury - should image whole spine









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[[Category:Trauma]]