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Senior - Emed 4 > 4 - Spine > Flashcards

4 - Spine Flashcards

1
Q

Vertbrae of the spine:

A 
7 cervical
12 thoracic 
5 lumbar
5 fused sacral
4 (usually fused) coccygeal

33 total

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2
Q

C1 and C2 are unique; they are designed for:

A

Rotary motion

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3
Q

C2 is AKA

A

The axis

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4
Q

C1 is AKA

A

The atlas

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5
Q

Components of the vertebral arch:

A

Two pedicles

Two laminae

Seven processes (one spinous, two transverse, four articular)

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6
Q

What is the MC’ly injured region of the spine?

A

Cervical

Because it’s the bend-iest

Most occur at C2 or C5-C7

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7
Q

The spinal cord gives rise to:

A

31 pairs of spinal nerves:

8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
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8
Q

Which zones of the spine sustain the greatest amount of stress during motion and are most vulnerable to injury?

A

The transitional zones (i.e. C7-T1)

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9
Q

Since the thoracic spine is more rigid thanks to its articulation with the ribcage, if your patient has injury to the thoracic spine:

A

It indicates that the patient was subjected to severe traumatic forces and is at high risk for intrathoracic injuries

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10
Q

Where does the SC turn into the cauda equina?

A

L1

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11
Q

What happens to the width of the SC as it moves from thoracic to thoracolumbar region?

A

It gets wider

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12
Q

Likelihood of an isolated lumbar spine fracture injuring the SC?

A

Rare

Why? Because the SC widens out and then splits into the cauda equina

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13
Q

Sacral fractures that involve the central sacral canal can produce:

A

Bowel or bladder dysfunction

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14
Q

A spine injury is considered unstable if:

A

At least 2 columns of a particular region are involved

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15
Q

It can be difficult to accurately identify an unstable spine injury in the setting of polytrauma, therefore:

A

Assume ANY spine fx is UNSTABLE and maintain APPROPRIATE precautions until expert consultation can be obtained from a spine surgeon

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16
Q

What are the two main types of injury that result in spinal cord damage?

A
  1. Primary injury from mechanical forces from traumatic impact
  2. Secondary injury (caused by primary) sets in motion a series of vascular and chemical processes that lead to secondary injury
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17
Q

The initial phase of SCI is characterized by:

A

Hemorrhage into the cord and formation of edema at the injured site and surrounding region

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18
Q

The secondary phase of SCI is characterized by:

A

Local ischemia of the cord

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19
Q

Cell death of the SC ensures from a combination of mechanisms including:

A

Electrolyte imbalances
Cell edema
Formation and release of oxidative substances

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20
Q

The American Spinal Injury Association defines a complete neurologic lesion as:

A

The absence of sensory and motor function below the level of injury

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21
Q

An incomplete lesion is defined as:

A

Sensory, motor, or both functions are partially present below the neurologic level of injury

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22
Q

Prognosis for complete lesions of SC?

A

Minimal chance of functional motor recovery

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23
Q

Patients in spinal shock will lose:

A

All reflex activities below the area of injury, and lesions cannot be deemed truly incomplete until spinal shock has resolved

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24
Q

The three most important spinal tracts to know:

A

Corticospinal (descending motor)

Spinothalamic (pain and temp sensation)

Doral (posterior) columns (vibration and proprioception)

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25
Q

Where do 90% of the corticospinal tract (motor) fibers decussate?

A

The lower medulla

Then they keep descending as the lateral corticospinal tract

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26
Q

Damage to the corticospinal tract neurons (upper motor neurons) in the SC results in:

A

Ipsilateral clinical findings such as muscle weakness, spasticity, increased DTR’s, and a (+) Babinski

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27
Q

The spinothalamic tract transmits:

A

Pain and temperature sensation

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28
Q

Where does the ascending sensory neuron of the spinothalamic tract decussate?

A

The second neuron immediately crosses the midline in the anterior portion of the spinal cord and ascends as the lateral spinothalamic tract

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29
Q

When the spinothalamic tract is damaged, the patient experiences:

A

Loss of pain and temperature sensation in the contralateral half of the body

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30
Q

The dorsal columns transmit:

A

Vibration and proprioceptive information

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31
Q

How do the dorsal column neurons (vibration and proprioception) differ from the pain and temperature neurons?

A

The dorsal column neurons do NOT immediately synapse in the spinal cord

Instead, they enter the ipsilateral dorsal column and do NOT immediately cross midline

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32
Q

Injury to one side of the dorsal columns will result in:

A

Ipsilateral loss of vibration and position sense

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33
Q

Light touch is not completely lost unless there is damage to both:

A

The spinothalamic tract

AND

The dorsal columns

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34
Q

The first seven spinal nerves - do they exit above or below the corresponding vertebral body?

A

Above

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35
Q

What is the spinal nerve that exits between C7 and T1 called?

A

C8 (even though there’s not C8 vertebral body)

Then the remaining nerves are all named for the vertebral body above it (i.e. the T4 spinal nerve root exits below T4)

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36
Q

Even though its utility is debated, prehospital care of suspected spine injury still requires:

A

Rigid C-collar and long spine board

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37
Q

Should my fully conscious, neurologically intact patient with a penetrating neck injury get a rigid c-collar and long spine-board immobilization?

A

No - these interventions can delay resuscitation and obscure neck injuries - just tell em to not move around.

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38
Q

Any patient with an injury at C5 or above should probably receive what intervention?

A

Secure the airway with an ET tube

If time allows, do a brief focused neuro exam before you knock ‘em down and tube ‘em

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39
Q

High cervical injuries - be alert for:

A

Respiratory compromise

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40
Q

HOTN in patients with SCI may be due to:

A

Neurogenic shock

Blood loss

Cardiac injury

Tension pneumo

41
Q

What should you presume to be the cause of HOTN in the setting of SCI until proven otherwise?

A

Blood loss

42
Q

Why do we remove long boards ASAP?

A

They’re associated with pressure sores (and also crazy uncomfortable)

43
Q

Preferred method for getting patient off a long board?

A

Log-roll

You can check the back and butt while you do it

Whoever is holding the head does the count

44
Q

During the history portion of the SCI exam, pay particular attention to:

A 
Any sxs indicating present or impending respiratory compromise, including:
Dyspnea
Palpitations
Abdominal breathing
Anxiety
45
Q

Physical exam for SCI should focus on:

A

Delineating the level of the SCI

46
Q

During the PE for SCI, make sure you test for:

A

“Saddle anesthesia”

Sensory deficit in the region of the buttocks, perineum, and inner aspect of the thighs

47
Q

“Sacral sparing” with preservation of anogenital reflexes denotes:

A

An incomplete spinal cord level, even if the patient has complete sensory and motor loss

48
Q

How to do bulbocavernosus reflex?

A

Finger in butt

Squeeze penis

Should feel the anal sphincter contract

49
Q

Cremasteric reflex?

A

Stroke the thigh

If scrotum rises, some spinal cord integrity still exists

50
Q

Anal wink reflex?

A

Contraction of the anal musculature when the perianal region is stimulated with a pin

Indicates some sacral sparing

51
Q

In the setting of SCI, the presence of priapism implies:

A 
Overdose on Viagra
.
.
.
.
.
.
.
Or, more likely, complete SCI
52
Q

Slide 37

A

Chart of Major Incomplete Spinal Cord Syndromes

I’ll make some cards on it

53
Q

Anterior cord syndrome results from damage to the:

A

Corticospinal and spinothalamic pathways, with preservation of posterior column function

54
Q

Anterior cord syndrome is manifested by:

A

Loss of motor function and pain and temperature sensation distal to the lesion

Only vibration, position, and tactile sensation are preserved

55
Q

Overall prognosis for anterior cord syndrome?

A

Poor

56
Q

What is affected in central cord syndrome?

A

The centrally located fibers of the corticospinal and spinothalamic tracts

57
Q

How do central cord syndrome patients present?

A

Decreased strength and, to a lesser degree, decreased pain and temperature sensation, more in the upper than lower extremities

58
Q

What is preserved (usually) in central cord syndrome?

A

Vibration and position sense

59
Q

The majority of central cord syndrome patients will retain:

A

Control of bowels and bladder (though it may be impaired in severe cases)

60
Q

What is Brown-Sequard Syndrome?

A

Hemisection of the cord

61
Q

How does Brown-Sequard present?

A

Ipsilateral loss of motor function, proprioception, and vibratory sensation, and contralateral loss of pain and temperature sensation

62
Q

MCC of Brown-Sequard Syndrome?

A

Penetrating injury

63
Q

Sxs of cauda equina?

A

Bowel/bladder dysfunction

Decreased rectal tone

Saddle anesthesia

Variable motor and sensory loss in the lower extremities

Decreased lower extremity reflexes

Sciatica

64
Q

If you suspect cuada equina, order:

A

A STAT lumbosacral MRI

65
Q

What type of shock is neurogenic shock?

A

Distributive

Loss of sympathetic arterial tone -> extreme vasodilation -> pooling of blood in the distal circulation -> HOTN

66
Q

If the T1 through T4 cord levels are compromised, leads to:

A

Loss of sympathetic innervation to the heart -> unopposed vagal parasympathetic cardiac innervation -> bradycardia (or an absence of reflex tachycardia)

67
Q

In general, patients in neurogenic shock are:

A

Warm

Peripherally vasodilated

Hypotensive with relative bradycardia

68
Q

Spinal shock is:

A

The temporary loss or depression of spinal reflex activity that occurs below a complete or incomplete SCI

NOT the same thing as neurogenic shock

Flaccidity, loss of reflexes, loss of voluntary movement

69
Q

What are among the first reflexes to return as spinal shock resolves?

A

Delayed plantar

Bulbocavernosus

70
Q

How long does spinal shock last?

A

Variable: could be days to weeks, or persists for months

71
Q

Canadian C-Spine test thing

A

Decision point for whether they need imaging

Three questions

Must answer “yes,” to everything to get a “go”

If “no,” gotta get the imaging

SLIDE 50

72
Q

NEXUS or CCR for for c-spine?

A

Either is fine

73
Q

Three view for c-spine plain films:

A

AP
Lat
Odontoid

A single lat gets about 90% of injuries

The others are for insurance

74
Q

Important to make sure your c-spine films have:

A

All seven vertebrae

Superior border of first thoracic vertebrae

75
Q

What view may be necessary to visualize the cervical-thoracic junction?

A

Swimmers view

76
Q

Main disadvantage of plain films for c-spine?

A

Not great for imaging C1-C2

77
Q

Most trauma centers use what study for initial c-spine eval?

A

CT

78
Q

If you see an injury to c-spine on plain films, you gotta order:

A

CT

So may as well just get the CT since you’re gonna have to do it anyways if you see something

79
Q

Sxs of ligamentous spine injury

A

Persistent neck pain / midline tenderness

Extremity paresthesias

Focal neuro findings despite normal plain radiographs and/or CT

80
Q

Study of choice for suspected spine ligamentous injuries?

A

MRI

81
Q

What if no MRI available?

A

Reliable patients can be sent home in firm foam collar with instructions to get outpatient MRI in 3-5 days

82
Q

MRI not be as good as CT for bones, but it’s superb at defining:

A

Neural, muscular, and soft tissue injury

83
Q

Diagnostic test of choice for describing the anatomy of nerve injuries?

A

MRI

84
Q

If pt has neuro findings with no clear explanation after plain films and CT, order:

A

MRI

85
Q

What do you if you determine that there is a spinal column injury at one level?

A

Get a CT of the entire remainder of the spine

86
Q

Imaging if spine in obtunded patient?

A

No clear consensus

Most likely, (-) CT is good enough to clear ‘em

87
Q

What are the goals of txt?

A

Prevent secondary injury

Alleviate cord compression

Establish spinal stability

88
Q

Regardless of neuro compromise, all spinal column fractures or ligamentous injuries require:

A

Consult from either a neurosurgeon or orthopedic surgeon, depending on the facility

89
Q

Management of a “wedge” or “anterior” compression fx?

A

If less than 40% loss of vertebral height, may be a candidate for outpatient therapy

If over 50% or if the angle between the damaged vertebrae and the rest of the spinal column is >25% to 30%, it’s generally considered unstable

90
Q

Burst fractures may result in:

A

Retropulsed fragments that can impinge on the spinal canal and cause neurologic injury

Its like iron man but not nearly as cool

91
Q

Chance fracture

A

Caused by flexion-distraction mechanism and involves minor anterior vertebral compression and significant distraction of the middle and posterior ligamentous structures

92
Q

Chance fx on radiograph

A

Transverse fx lucency in the vertebral body, increased height of the posterior vertebral body, fracture of the posterior wall of the vertebral body, posterior opening of the disk space

93
Q

If you see compression fx’s of the thoracolumbar spine on plain films:

A

Get a CT

94
Q

Txt for stable wedge fx with no neuro sxs

A 
Analgesia
Heat
Massage
Rest
PT
95
Q

Does an isolated coccyx fx need an emergent consult?

A

Nah

Can be dx’d clinically

Txt symptomatic, analgesics, rubber donut pillow

96
Q

Slides 72-76

A

A BUNCH of shit about steroids - i have no idea if this is important. I’m sorry i’m at the end and i cant.

Basically, don’t use steroids to txt spinal injuries routinely.

No roids for penetrating spine injuries

97
Q

Treating neurogenic shock

A

Normal stuff

Fluids

If that doesn’t do it, pressors

Keep SBP > 90mmHg

If they’re really brady, consider atropine

98
Q

For spinal GSW’s through the belly:

A

Give prophylactic broad spectrum ABX

99
Q

Kid: i’ll call you later

A

Dad: dont call me later; Call me dad

Senior - Emed 4 (6 decks)

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