ATLS-spine and spinal cord trauma Flashcards
What percent of patients with a cervical spine fracture have a second, non-contiguous vertebral column fracture?
10%
True or false: As long as the patient’s spine is protected, evaluation of the spine and exclusion of spinal injury may be safely deferred, especially in the presence of systemic instability, such as hypotension and respiratory inadequacy
True
What is the max amount of time that a patient should remain on a backboard?
2 hours
What is the pedicle of the vertebrae?
the bone that connects the spinous process to the vertebral body
What happens to the spinal canal as it progresses from the top to bottom?
Gets narrower
What are the three spinal tracts that are easily tested by a clinician?
Lateral corticospinal
Spinothalamic
Dorsal columns
Where is the corticospinal tract located in the spinal cord? Spinothalamic? Dorsal columns?
Lateral corticospinal = posterolaterally
Spinothalamic = anterolateral
Dorsal columns = posteriorly
Where do the three spinal tracts cross?
Lateral corticospinal = medulla
Spinothalamic = at the level
Dorsal columns = medulla
Where does the following nerve provide sensory innervation to: C5
Over the deltoid
Where does the following nerve provide sensory innervation to: C6
Thumb
Where does the following nerve provide sensory innervation to: C7
Middle finger
Where does the following nerve provide sensory innervation to: C8
Little finger
Where does the following nerve provide sensory innervation to: T1
ulnar side of the forearm
Where does the following nerve provide sensory innervation to: T4
Nipple line
Where does the following nerve provide sensory innervation to: T8
Xiphisternum
Where does the following nerve provide sensory innervation to: T10
Umbilicus
Where does the following nerve provide sensory innervation to: T12
Symphysis pubis
Where does the following nerve provide sensory innervation to: L4
Medial aspect of the calf
Where does the following nerve provide sensory innervation to: L5
Web space of the first and second toes
Where does the following nerve provide sensory innervation to: S1
Lateral border of the foot
Where does the following nerve provide sensory innervation to: S3
ITs
Where does the following nerve provide sensory innervation to: S4 and S5
Perianal region
Where does the following nerve provide MOTOR innervation to: C5
Deloitd
Where does the following nerve provide MOTOR innervation to: C6
flexes forearm (biceps)
Where does the following nerve provide MOTOR innervation to: C7
Extends forearm (triceps)
Where does the following nerve provide MOTOR innervation to: C8
Flexed wrists and fingers
Where does the following nerve provide MOTOR innervation to: T1
Small finger abductors (abductor digiti minimi)
Where does the following nerve provide MOTOR innervation to: L2
Hip flexors (iliopsoas)
Where does the following nerve provide MOTOR innervation to: L3 and L4
Knee extension (quads and patellar reflexes)
Where does the following nerve provide MOTOR innervation to: L4,5 and S1
Knee flexion (hamstrings)
Where does the following nerve provide MOTOR innervation to: L5
Ankle and big toe dorsiflexors (tibialis anterior and extensor hallucis longus)
Where does the following nerve provide MOTOR innervation to: S1
Ankle plantar flexors (gastroc and soleus)
Neurogenic shock is rare in spinal cord injury below what spinal level? What is the significance of this?
- T6
- If no injury at or above this level in a shock patient, search for non-neurogenic cause
What is spinal shock?
Flaccidity and loss of reflexes seen after spinal cord injury
Why must you ensure no other serious trauma to other parts of the body with spinal cord injuries?
Patient may not be able to feel
What defines the lowest motor level in a spinal cord injury?
The muscle group with at least a 3/5 strength
What is the defining spinal cord level which defines quadriplegia vs paraplegia?
T1 (injury to C8 and above is quadriplegia)
DO sacral reflexes count as sacral sparing?
No
What characterizes central cord syndrome?
Central cord syndrome is characterized by a disproportionately greater loss of motor strength in the upper extremities than in the lower extremities, with varying degrees of sensory loss
What sort of trauma produces central cord syndrome?
Hyperextension injury, usually in a patient with preexisting cervical canal stenosis (e.g. forward fall with facial impact)
Describe the etiology of central cord syndrome.
Anterior spinal artery is compromised, leading to death of anterior tissue, which is predominately upper nerves
What are the clinical s/sx of anterior cord syndrome?
paraplegia and a dissociated sensory loss with a loss of
pain and temperature sensation
Describe the pathophysiology of anterior cord syndrome?
Infarct of the anterior spinal artery, causing loss of anterior parts of the spinal cord, with sparing of the posterior parts
With Brown-Sequard syndrome, which deficit is ipsilateral, and which is contralateral?
Ipsilateral = vibration are proprioception Contralateral = motor and pain
What are the four different types of morphologies of spinal cord injuries?
- Fractures
- Fracture-dislocation
- SCIWORA
- Penetrating injuries
True or false: all patients with radiographic
evidence of injury and all those with neurologic deficits
should be considered to have an unstable spinal injury.
True
What is the prognosis of atlanto-occipital dislocation?
Death or ventilator-dependent quadriplegic
What is a Jefferson fracture? What is the usual MOI? What is the best diagnostic image? Treatment?
- Burst fracture of C1 (anterior and posterior parts break)
- Axial loading
- Open mouth radiograph
- Cervical collar and surgery
Do Jefferson fractures usually result in spinal cord damage?
No
What is a C1 rotary subluxation injury? How does it present? Treatment?
- C1 is rotated, causing torticollis
- Immobilized and refer
What will imaging show with a C1 rotary subluxation injury?
Dens is not equidistant to the lateral masses of C1
What holds the odontoid in place?
Transverse cervical ligament
What are type I, II, and III odontoid fractures?
I = tip of dens is fractures
II = body is fractured
III - body is fractured and extends through to the body of the axis
What are the components of the mnemonic “Jefferson Bit off a hangman’s tit”?
- Jefferson fracture
- Bilateral locked facets
- Odontoid fractures
- Atlanto-occipital dislocation
- Hangman’s fracture
- Teardrop fracture
What is a Hangman’s fracture? What is the typical MOI? Treatment?
- Anterior dislocation of C2 vertebral body and bilateral C2 pars interarticularis (pedicle) fractures
- Hyperextension (e..g chin hitting windshield/dashboard)
- Immobilize and surgery
What is the best x-ray view to evaluate for a Hangman’s fracture?
Lateral
What is the most common cervical spinal level fractured? Least?
Most common = C5
Least common = C3
What happens to the incidence of neurologic injury with facet dislocations?
go up dramatically–over 80%
What is a Teardrop fracture? What is the typical MOI? Treatment?
A fracture of the anteroinferior aspect of a cervical vertebral body due to extension of the spine along with vertical axial compression
What are bilateral locked facets? What is the typical MOI? Treatment?
- Subluxation of superior vertebral body forward by 50% compared to inferior vertebral body, caused by both anterior and posterior ligamentous disruption
- Severe flexion without axial loading
- Immobilize and surgery
What are the four broad categories of thoracic spine fractures?
- Anterior wedge compression injuries
- Burst injuries
- Chance fractures
- Fracture-dislocation
What is an anterior wedge fractures, and what is the MOI?
When anterior aspect of the vertebral body is smashed, causing a wedge shape. Usually the result of axial loading with flexion
What is an burst injury, and what is the MOI?
Vertical axial compression causes bursting of vertebral bnody
What are chance fractures? What causes them?
- Transverse fractures through the vertebral body
- Flexion about an axis anterior to the vertebral column (MVCs)
What must always be assessed for with Chance fractures?
Intraabdominal injuries
What are fracture dislocation injuries of the spine? Usual MOI?
- Fractures of vertebra and dislocation from disruption of ligaments
- Usually from direct blunt trauma to spine or extreme flexion
True or false: simple compression fractures of the spine are usually stable.
True
What are simple compression fractures of the spine usually treated with?
Rigid brace
What is the general treatment for Chance and fracture-dislocation fractures?
Extremely unstable–immobilize and surgery
True or false: thoracolumbar fractures are unstable
True
At what spinal level does the spinal cord terminate?
L1
Why should patients with thoracolumbar fractures be logrolled with extreme care?
Rotational movements occur around this area
What are the three indications to assess for carotid/vertebral injuries?
- C1-C3 fractures
- Cervical fracture with subluxation
- Fractures involving the foramen transversarium
A CT or x–ray of the cervical spine may not show any fractures, but the neck still may be unstable. What should be done in these cases?
MRI or discharge in cervical collar with close follow up
True or false: as long as the CT scan is clear, the patient and you can move the patient’s neck any way
False–never move with pain
True or false: Approximately 10% of patients with a cervical spine fracture have a second, non-contiguous vertebral column fracture. Therefore, if a cervical fracture is found, imaging of the entire spine is warranted
True
What type of imaging should be obtained for patients with neck trauma and neurologic deficits? Why?
- MRI or CT myelogram
- Need to exclude traumatic herniated disk or other soft tissue injury
As with any injury, how far from the injury should immobilization of the spine take place?
Above and below
True or false: Attempts to align the spine for the purpose of immobilization on the backboard should still be performed even if they cause pain
False–Attempts to align the spine for the purpose of immobilization on the backboard are not recommended if they cause pain.
What should be immobilized prior to transfer of a patient with a cervical spine injury?
Entire patient with backboard, straps, and semirigid cervical collar
Complete loss of respiratory function can occur with injury at or above what spinal level?
C6
