Emergency - Level 3

Question 1

Definition of spinal cord injury?

Answer 1

o Complete = total lack of sensory or moto function below level of injury
o Incomplete = some motor or sensory function maintained below injury

Question 2

Definition of spinal shock?

Answer 2

o Immediate flaccidity, paralysis, areflexia and loss of sensation below level of acute spinal cord injury
o Some reflexes return after a few days and hyperreflexia typical of upper MN lesion in weeks
o In injuries above T6, neurogenic shock may occur from loss of autonomic innervation from brain
o Synergy between sympathetic and parasympathetic lost

Question 3

Risk factor for SCI?

Answer 3

o Major trauma
o Spinal pain, neurological signs, altered consciousness
o Malignancy, osteoporosis, RA, osteoarthritis

Question 4

Mechanism of SCI?

Answer 4

o Primary – mechanical disruption, transection, penetrating injuries, vertebral fracture, bony fragments
 Causes oedema and ischaemia leading to secondary injuries

o Secondary – arterial disruption, thrombosis or hypoperfusion

Question 5

Pattern of injury in SCI - complete?

Answer 5

 Absence of any motor or sensory function below level

 Minimal chance of recovery

Question 6

Pattern of injury in SCI - anterior?

Answer 6

 Direct anterior cord compression, flexion injuries of C-spine or thrombosis of anterior spinal artery
 Variable paralysis below level with loss of pain and temperature perception

Question 7

Pattern of injury in SCI - Brown-Sequard syndrome?

Answer 7

 Hemi-transection or unilateral compression of cord
 Ipsilateral spastic paresis and loss of proprioception and vibration sense
 Contralateral loss of pain and temperature perception

Question 8

Pattern of injury in SCI - central cord syndrome?

Answer 8

 Hyperextension injuries, spinal cord ischaemia, cervical spinal stenosis
 Motor weakness, pain and temperature sensation more likely to be affected
 Burning sensation in upper extremities

Question 9

Pattern of injury in SCI - posterior cord syndrome?

Answer 9

 Penetrating injuries to back or hyperextension

 Loss of proprioception and vibration sense

Question 10

Pattern of injury in SCI - neurogenic shock?

Answer 10

 Distributive shock from sympathetic fibre disruption causing vasodilation and hypotension
 Occurs in high thoracic and cervical spine injuries (T6 and above)
 Triad = hypotension, bradycardia, hypothermia
 Areflexia, loss of sensation and flaccid paralysis below lesion, loss of bladder and anal tone

Question 11

Symptoms of SCI?

Answer 11

 Neurogenic shock, paralytic ileus, aspiration, urinary retention, priapism, loss of thermoregulation

 Motor = fatigue, disturbance of gait, weakness

 Sensory = loss of sensory, paraesthesia, root pain

 Reflexes = Increased below, absent at level and normal above

 Autonomic = lack of sweating, loss of thermoregulation, hypotension, retention, paralytic ileus

Question 12

Levels of SCI corresponding to symptoms?

Answer 12

o Cervical lesions – quadriplegia, above C3/4/5 causes diaphragm paralysis
o Thoracic lesions produce paraplegia
o Lumbar lesions affect L4/5 and sacral nerve roots

Question 13

Phases of spinal shock?

Answer 13

o 0-1 day – areflexia/hyporeflexia, loss of descending facilitation
o 1-3 days – initial reflex return, denervation supersensitivity
o 1-4 weeks – hyperreflexia (initial), axon-supported synapse growth
o 1-12 months – hyperreflexia, spasticity, soma-supported synapse growth

Question 14

Spinal injury management - ABCDE?

Answer 14

 Protect cervical spine with manual spinal immobilisation and avoid moving spine

Question 15

Spinal injury management - assess spinal injury?

Answer 15

 Significant distracting, under influence of alcohol, confused or uncooperative, reduced consciousness, spinal pain, weakness, paraesthesia, priapism

Question 16

Spinal injury management - assess C-spine injury risk?

Answer 16

High Risk
• >65, dangerous mechanism of injury (fall >1m or 5 steps, axial load to head), paraesthesia in upper or lower limbs

Low Risk
• Simple rear-end collision, comfortable sitting, ambulatory since injury, no midline C-spine tenderness, delayed onset neck pain
• Unable to rotate neck 45o to left and right

No risk
• One of low-risk factors and able to rotate neck 45o to left and right

Question 17

Spinal injury management - assess thoracic or lumbosacral injury?

Answer 17

 Pain in area, dangerous mechanism of injury, osteoporosis risk, spinal fracture suspected, abnormal neurological symptoms

Question 18

Spinal injury management - when to perform full in-line immobilisation?

Answer 18

• High-risk for C-spine injury
• Low-risk for C-spine and unable to rotate neck 45o
• One or more factors of thoracic or lumbar injury

Question 19

Spinal injury management - how to perform full in-line immobilisation?

Answer 19

• Stabilise head with spine in line
• Fit semi-rigid collar
• Place on scoop stretcher
• Secure with head blocks and tape

Question 20

Imaging in SCI?

Answer 20

Suspected spinal cord or cervical column injury:
• <16 years old, MRI - Indicated by Canadian C-spine rule or abnormal neurological signs
• >16 years old, CT - Indicated by Canadian C-spine rule or suspicion of thoracic or lumbosacral injury with abnormal signs

Suspected column injury
• Whole-body CT

Suspected thoracic or lumbosacral column injury
• X-ray if normal neurological signs (T1-L3)
• CT if X-ray abnormal or clinical signs of spinal cord injury

Question 21

Management of SCI?

Answer 21

	Resuscitation where necessary
	Analgesics (IV morphine)
	Urinary catheter insertion
	NG tube
	Monitor: ECG, GCS, temperature
	Referral to neurosurgery and other specialities
•	Emergecny decompression

Question 22

Complications of shock?

Answer 22

• Volume overload-induced pulmonary oedema
• Acute Respiratory Distress syndrome
• Acute renal failure
• GI ulceration
• Multi-Organ Failure
• Disseminated intravascular coagulation
• Hospital acquired infections
• Death

Question 23

Signs of upper motor neurone lesion?

Answer 23

Muscle strength - weakness/paralysis
Muscle tone - hypertonia
Reflex - hyperreflexia
Wasting - muscle mass maintained

Causes - stroke, spinal cord section

Question 24

Signs of lower motor neurone lesion?

Answer 24

Muscle strength - weakness/paralysis
Muscle tone - hypotonia
Reflex - hyporeflexia
Wasting - rapid wasting

Causes - poliomyelitis, MND, peripheral nerve lesion, muscle myotonias, myasthenia gravis, muscular dystrophies