Neck and Spinal Trauma Flashcards
Define Neck Trauma
penitrating neck trauma
zones
Penitrating Neck Trauma: anything that violates the platysma
Anatomical Zones of the Neck
Zone I: suprasternal notch & calvicale boarder –> inferior cricoid cartialge
Zone II: inferior cricoid cartilage to the angle of mandible the worst
Zone III: angel of manidble to base of skull
Penitrating Neck Trauma
- evaulation of airway
- vasculature evalauation
- esophageal evaulation
Evaluation
- knives, bullets, FB = left in place beucase they can provide local tamponade
- CT is done to assess injury
- surgery used to be standard ofc are –> now selective (usually only for zone II injuries is exporatory surgery needed)
Evaluate airway
- look for leak, PTX, air in mediastium
- often = need endotracheal or surgical airway
- should do a bronchosopcy to evalute airway
- often need C-collar stabilization
Vasucalture Evaluation
- bleeding control
- hematomas can compromise airway
- need to identify injury via angiogrpahy or CT angio
- nerve injury needs to be assessed to for focal deficts
esophageal evaluation
- often esophagus can be aymptomatic but lead to nek space infections or mediastinitis
- crepitus, hematemesis, NG-tube blood etc. can be signs
- water-soluable contrast esophagram can evaultae damage
Blunt Neck Trauma
- types of injury
- imaging
Types of Injury
- blunt trauma = tracheal, laryngeal and c spine injuries
(less likely will these have vascualr or esophagela injuries)
- if they do; shearing vessels (break apart)
- Carotid and vertebral arteries shear = hematoma, dissection or CVA
Imaging
- CT PLAIN
- if all injury can be ruled out these pts. can be d/c
Spinal Truama
Etiology
Assessment of spine
Etiology
- spinal cord or spinal nerve root injuries
- bone injuries to spine
- deceleration MVAs, compression (diving)
the pt. who presents with significant head trauma, unconscious, neuro deficts or spinal tenderness = assume C-spine trauma untile ruled out
Assessment
- Primary survery: when assessing airway can assess C spine
- spinal immobilization should be done
- mechanism will guide type of imaging
How to Assess
- inspect for step-offs, tenderness, edema, brusing, muscle spams
- through neuro exam
- arm abduction (C5,C6) & elbow flextion
- Wrist Extension (C6,C7)
- Elbow extension (C7, C8)
- Finger abduction (C8, T1) & Hand Grip
- Hip flexion (L1, L2, L3)
- Knee Extension (L2, L3, L4)
- Knee Flexion (L4, L5, S1, S2)
- ankle dorsiflexion (L4, L5)
- big toe extension (L5, S1)
- ankle plantarflexion (S1, S2)
- Rectal Tone (S2, S3, S4)
Spinal Trauma: C Spine
how is Imaging guided
criteria?
NEXUS criteria & Canadian cerical spine rule decide who need imaging
NEXUS
- absent tenderness in posterior midline
- no intoxication
- GCS = 15
- no neuro deficts
- no painful injuries
anyone who fails this: gets imaging
Canadain C spine= also takes into account the mechanism of injury and teh examination findings
(neither for peds!!!)
Imaging
CT is the test of choice
- plain film xray can help but they miss c-spine fractures
- MRI can he used in those with negative CT but have signs of a SC injury
C-Spine Fractures
Etiology
- due to hyperflexion (chin to chest)
- axial loading (diving) or hyperextension (MVA)
Classification
- stable or unstable: depends on the 3 columns of the SC
- anterior column : anterior ligament, anterior aspect of vertebra & anterior disc
- middle column: posterior ligament, posterior verebra, posteriod disc
- posterior column: the pedicles, trasnverse processes, laminae and teh posterior ligamentous complex
inturruption of 2+ of these columnc = UNSTABLE C-Spine
C-Spine Fracture
Occipital Condyle fx.
UNSTABLE: need CT + neruologic deficts
- a fracutre of the base of the skull and articualtion with the C1
- three types (dont need to know)
C-Spine Fracture
Jefferson Fx.
UNSTABLE
- fracture of the C1 (atlas) due to compression type injury displacing the lateral aspects of C1 to the sides
(a burst of C1)
- on xray: odontoid view: see the fx.
C-Spine Fracture
Odontoid Fracture
UNSTABLE (usually)
- a fracture of C2 dens
- neurologic deficts
3 types
type 1 : avulasion of the tip
type 2: fracture at the base
type 3 : fracture line extends to the body of C2
Type II and III are unstable
C-Spine Fracture
Hangman’s fracture
unstable
- fracture of teh pedicles of C2 bilaterally: so teh spinous processis completelt removed
- due to MVA (or hanging…) and hyperextension (backward)
C-Spine Fracture
Burst Fracture
unstable
- cord disruptuion
- a burst fracture = C3-C7 shattering of teh vertebral body
- due to axial loading (head-firsy dive)
- causes retropuslion of the pieces : impacting the SC
- disrupting middle and anterior columns
C-Spine Fracture
Clay Shoveler’s Fracture
Stable : an avulsion fracture of teh end of teh spinous process of the lower cervical vertebrae
- due to abrupt flexion of the neck
- the ligaments essentailly are pulled so tight they pull the bone off
C-Spine Fracture
Flexion Teardrop
UNstable
- extreme flexion causes the fracture of the anteriorinferior vertebral body
- these are super unstable as this alos the ligaments in the back to become disconnected from the rest of teh spine
C-Spine Fracture
extension teardrop
UNSTABLE
- hyperextension causes the anterior longitudinal ligament to avulse the anteriorinferior portion of the vertebral body to fracture
C-Spine Fracture
simple wedge fracture
stable: unless significant ligament issues
- flexion and compression of teh anterior vertebral body get smushed between teh above and below one
- this could inturrupr the posterior lig relaly ad
C-Spine Sprain
“Whiplash”
Whiplash
- abrupt hyperextension from MVa usually
- pt = pain, neck spasm and HA
- no neruologic deficts and NO fracture of c-spine
Treatment
- immoblize them with C collar and follow up
Spinal Cord Injury
Etiology
Etiology
- commonly co-occur with spinal fractures, etc.
- these pts. ahve permanent neuro deficts
- Primary: SCI as a result of mechanical disruption, transection or distraction of the natural elements = primary = as a result of fracture or dislocation of the spine
- secondary : result of a vascualr, chemical or inflammatory process following a primary injury = like edema or hemorrhage causing decreased blood flow leading to inflammation and continued damange
SCI: how is the neurologic imparied decided
the level, location and complete or incompleteness of the injury determiens the outcome of impairment
Complete Lesion = the absence of motor or sensory function below the level
Incomplete Lesion = lesions where there is some motor, sensory or both functions below the level of the lesion
Spinal shock is different: because the inflammation and stuff can temporarily cause complete loss but it can resolve with decreased inflammation
remmeber…
- corticospinal tracts: run laterally (and ventral)
- spinothalamic tract runs ventrally
- dorsal column runs posteriorly
- decending = motor
- ascending = sensory
- spinothalamic: synpase and cross at spinal cord level (pain and temperature)
- dorsal = travel up and cross & synpase at medulla
- corticospinal = cross at medulla travel then synpase at SC
Damange to Corticospinal
- lossof motor function on the ipsilateral side
Damage to the spinothalamic tract
- loss of sensory function on the contralateral side below the lesion level
Damange to the dorsal column
- loss of vibration, proprioception and two point touch on the ipsilateral side
SCI
Diagnosic Imaging
Spinal Cord INjruy: MRI is needed to visualize the cord
a complete lesion: can show no motor or sensory function at level and below: if this doesnt return within 24 hours, recovery is poor
SCI: Anterior Cord Syndrome
Anterior Cord Syndrome
- corticospinal and spinothalamic tracts are here
- injury = impaired motor and pain/temp. at the level and below
- doral column is preserved
due to…
- mass
- thrombosis of anterior spinal artery
- hyperextension injury
- prognosis and recovery is poor
SCI: Central Cord Syndrome
Etiology
- a lesion to the central cord: most often damage to the corticspinal tracts and the spinothalmaic
- +/- effected dorsal column
Symptoms
- the UE fibers of the corticospinal tract are more medial, thus loss to UE»_space; LE
- sensory loss is varibale, more likely affecting pain and temperature
Due to…
- yperextension injruy
- decreased perfusion
- spinal stenosis (squeezed cord with degeneration)
recovery and prognosis is good after decompression
SCI: Brown Sequard Syndrome
Brown Sequard Syndrome : lateral cord lesion
If its a lateral lesion = impact all the three spinal tracts but only half the SC
Symptoms
- ipsilateral loss of proprioception & vibration (dorsal)
- ipsilateral loss of motor function (corticospinal)
- contralateral loss of pain and temperature sensation distal to the lesion (spinothalamic)
Due to..
- lateral compression of bone due to injury
- disc protrusion
- hematoma
- mass
- penitrating GSW
Prognosis
- GOOD! with decompression
SCI: Cauda Equina Syndrome
not a true spinal cord injury
- affects nerve roots of cauda equina
Symptoms
- bladder/bowel dysfunction
- sadle anesthesai
- decreased rectal tone
- lost motor and sensory of the extremities (lower)
what is a SCIWORA?
Spinal Cord Injury without Radiologic abnormalities (SCIWORA)
- can be a tranisent or persistent symptoms of neuro deficts without evildence
- comony in kids sine they have flexible spines
- NEED MRI and neurosurg. evaluation
Spinal Shock
temporary loss of spinal reflex activity that occurs below a complete or incomplete lesion
Symptoms
- flaccid quadraplegia - mimic SCI
- can resolve; needs to resolve before a SCI can be diagnoses
- this is different than neurogenic shock because spinal schok causes loss of ALL NEUROLOIGC function while neurogenic shockis just loss of autonomic dysfunction
Neurogenic Shock
lack of autonmic function as a result of an injury ABOVE C6 (because this is where the autonmic nerves run)
Symptoms : dysautonmoia occurs
- hypotension
- bradycardia
- peripheral vasodilation
Treatment
- IV fluids to maintain MAP 85-90 x 7 days post injury
- pressors (dopamine, epinephrine, etc.) can be used to help ensure proper perfusion
if bradycardai is bad = atropine !!
Treatment of SCI
first — ABCs
- hypotension : IV fluids
- blunt trauma: high dose methylprednisone (not for penitrating trauma!)
- antibiotics for penitrating
Cervical Orthoses: for well-reduced and stable cervical fractures/subluxations
surgical intervention for SCI and unstable spinal injuries
Indications for Surgery
- progressive neurologic deterioration
- spinal instability
