O&T SC061: Cannot Move My Limbs After A Dive: Paraplegia After Spinal Injury, Cervical Spine Injury

Question 1

X-ray of cervical spine

Answer 1

Exposure to ***C7

• Swimmer’s view (forward flex shoulder)
• Pulled shoulder view (pull down shoulder)

Question 2

**Approach + **Management to Spinal fractures +/- Cord injury

Answer 2

• Young people
• High energy trauma (e.g. fall from height)
• 43% multiple injuries (calcaneus, femoral, hip, pelvic fracture, brain injury)

Emergency management:

• ABCDE
• A: Airway + ***C-spine (prevent secondary injury e.g. improper mobilisation, inflammatory changes which can lead to further damage)

C-spine stabilisation:

1. Rigid collar (correct size) —> beneath chin + underneath angle of mandible
   - Philadelphia collar
   - Miami J-collar: better tolerance to pressure sore
   - both controls flexion + extension, lateral flexion, rotation
   - not very good in controlling motion around C1, 2 (30-40% residual movement)
2. Sand-bags + taped on spine board
3. Skull traction (in-patient e.g. Halo ring) —> stabilise + reduce unstable fracture
   - more stable than collar esp. for upper cervical spine
   (4. Surgery
   - anterior approach: fusion
   - anterior + posterior approach: for very unstable spine)

Transfer:

1. From scene of accident to hospital
2. From A/E to ward

Initial evaluation:
History taking:
1. Mechanism / Patterns of injury
- Motorcar / Fall / Diving / Gunshots

Pitfalls in delay in diagnosis:
- Head injury
- Alcohol
- Multiple injuries
—> Always suspect and protect spine

P/E:
Suspect neck injury if head and chest injured
1. Head to toe

2. Spine (by ***log roll)
   - bruising
   - palpate along spinous processes to look for stepping / gapping
   - tenderness
   - restricted movement
3. Neurological exam (Sensory, Motor, Reflex)
   - assess level of injury
   - assess severity of neurological damage
   - need for intervention
   - prognosis
   - prerequisite: patient is ***out of spinal shock

Investigations:

1. Trauma series
   - X-ray C-spine (AP + Lateral) —> ***NEXUS criteria
   - CXR
   - Pelvis

Question 3

Sensory and Motor neurological examinations

Answer 3

Sensory level:
Dermatome landmarks:
Nipple: T4
Xiphoid: T7
Umbilicus: T10
Groin: L1
Anus: S2-4

Motor function:
Level of intactness determine neurological function —> determine rehabilitation, orthosis may be required in the future
- e.g. injury of L1 can cause paraplegic —> need wheelchair

Question 4

Pathology of spinal injury

Answer 4

• Maximal damage occurs at the time of injury (Primary injury) —> damage already done, nothing can be done
• Inappropriate handling can result in further edema + cord damage —> want to decompress within 24 hours to decrease further injury (Time is Spine!)
• Recovery is due to partial recovery of damaged cells —> want to intervene asap to maximise regeneration potential of spinal cord
• Damage usually not clear cut —> Longitudinal damage up / down cord

Question 5

Spinal shock

Answer 5

• Period of temporary loss of function after injury (hours to days (up to 72 hours))
  —> NO motor / sensory function below level of lesion
  —> ALL reflexes absent + Flaccid paralysis
• Spinal shock is over if bulbocavenosus, anal wink reflex have returned
  —> Assess for motor / sensory function only AFTER spinal shock is over

Bulbocavernosus reflex:
- Local reflex arc: squeeze of glans penis in male / pull Foley catheter in female —> anal sphincter contraction

Anal wink:
- Anal sphincter contraction when stimulate peri-anal area

Question 6

ASIA impairment scale

Answer 6

• Assess extent of damage + Prognostication
• Differentiate Complete vs Incomplete
  —> Complete: Poor prognosis, no motor / sensory recovery at the end of spinal shock
  —> Incomplete: Good prognosis, some degree of sparing + speed of recovery

From SC033 SpC Interactive tutorial: Management of head injury:
A: Complete. No motor or sensory function in the lowest sacral segment

B. Incomplete. Sensory but not motor function is preserved in the lowest sacral segment.

C. Incomplete. Less than 1/2 of the key muscles below the neurological spinal level have grade 3 or better strength.

D. Incomplete. At least 1/2 of the key muscles below the neurological level have grade 3 or better strength.

E. Normal. Sensory and motor functions are normal.

Question 7

NEXUS criteria

Answer 7

1. No posterior midline cervical spine tenderness
2. No evidence of intoxication
3. A normal level of alertness
4. No focal neurologic deficit
5. No painful distracting injuries
   —> ALL met —> spine is cleared —> No need X-ray C-spine (AP + Lateral)
   —> No to one —> X-ray C-spine (AP + Lateral)

Question 8

Multiple spinal fractures

Answer 8

• 3-5%
• Examine and X-ray ***whole spine
• Cervical spine CT becoming standard of care in suspicion of injury

Question 9

***X-ray C-spine evaluation

Answer 9

1. ***Pre-vertebral / Retropharyngeal soft tissue shadow
   - at C2 level: soft tissue thickness anterior vertebra should be <1/2 width of vertebral body (2-3mm)
   - at C4 level: soft tissue starts widening (∵ epiglottis + esophagus)
   - at C7 level: < entire width of vertebral body
   - children: “apparent” thicker soft tissue due to cartilaginous bone making vertebral body smaller
2. Alignment (4 lines)
   - Anterior vertebral line
   - Posterior vertebral line
   - Spinal laminar line
   - Spinous processes
   (Spondylolisthesis:
   - Bilateral facet dislocation: translation of 50% of width of vertebral body
   - Unilateral facet dislocation: translation of 25% of width of vertebral body)
3. Bone densities
4. Fractures

Question 10

Spinal cord syndromes in Incomplete injuries

Answer 10

Patterns:

1. ***Central cord syndrome (most common cause of incomplete spinal cord injury in HK)
2. ***Brown-Sequard syndrome
3. Anterior cord syndrome (worst prognosis)
4. Posterior cord syndrome (poor prognosis)
5. Mixed
6. Cauda equina syndrome (LMN lesion)
7. Conus medullaris syndrome (mixed UMN + LMN lesion)

Question 11

1. Central cord syndrome

Answer 11

Cause:
1. **Hyperextension injury (e.g. hit in forehead)
- esp. in **narrowed C-spine canal from degeneration, **cervical arthritis
- most common in **middle age after trivial injury
- worse prognosis
- may occur in absence of spinal fracture
(- 炸豆腐: 外脆內軟 —> central portion more prone to injury, outer portion protected by dura)
2. Spondylotic myelopathy
3. Syringomyelia
4. Neoplasm (metastatic, glial, lymphoma)

Clinical features:

1. ***Quadriparesis
   - Upper limbs deficits > Lower limb deficits
   - Distal > Proximal
2. Sensory sparing variable
   - Pain + Temp > Posterior column sensations
   (From JC031:
   - Decussating 2nd order sensory neurons affected
   - Bilateral upper limb pain / numbness)
3. Sacral sparing
   - 50% return of bowel / bladder function

Prognosis:
- Relatively good outcome, most patients ambulatory, recovery of upper limb sensation / power from proximal to distal —> but residual sensory / motor deficit in hands may persist

Question 12

2. Brown-Sequard syndrome

Answer 12

Cause:

1. Unilateral fracture / Subluxation
2. Trauma: Penetrating (e.g. stab in back)
3. Radiation
4. Decompression sickness
5. Multiple sclerosis

Clinical features:

1. ***Ipsilateral motor weakness
2. ***Ipsilateral loss of proprioception + fine touch
3. ***Contralateral loss of pain + temp

Prognosis:
- Good
—> 75-90% ambulate on discharge
—> 70% independent ADL
—> 89% bladder, 82% bowel continent

Question 13

3. Anterior cord syndrome

Answer 13

Causes:

1. Hyperflexion injury with bone / disc fragment protruding posteriorly
2. Anterior spinal artery compression (territory ischaemia)
3. Retro-pulsed disc

Clinical features:

1. ***Motor loss
2. ***Pain + temp loss
3. Dorsal column preserved

Prognosis:
- ***Worst (∵ involve arterial supply + motor involvement)
—> 10-20% muscle recovery, poor muscle power + coordination
—> severe disability

Question 14

4. Posterior cord syndrome

Answer 14

Causes:

• Least common
  1. Posterior spinal artery damage
  2. Diffuse atherosclerosis: deficient collateral perfusion
  3. B12 deficiency

Clinical features:

1. ***Loss of proprioception
2. Motor preserved
3. Pain + temp preserved

Prognosis:

• Better than Anterior cord syndrome
• Poor ambulation prospect ∵ proprioceptive deficit

Question 15

Treatment of Spinal cord injury

Answer 15

Aim: Prevent secondary damage after primary insult —> Protection of ***remaining neurology

1. High dose steroid (Methylprednisolone)
   - bolus then infusion
   - within 8 hours has shown efficacy
   - risk of peptic ulcer, infection may outweigh benefit
2. Decompression
   - if deteriorating ***neurology
   - Anterior / Posterior
3. Stabilisation
   - if structural ***instability
   - Internal (Anterior / Posterior) / External

Question 16

Indications for surgery

Answer 16

1. Structural instability
2. Decompression due to deteriorating neurology
3. Multiple injuries
4. Early mobilisation
5. Reduced length of hospital stay

Question 17

Long-term issues of spinal cord injury

Answer 17

Long-term issues:

1. ***Respiratory problems (e.g. pneumonia ∵ sputum retention, atelectasis)
2. ***Bowel and bladder care (at risk of overflow incontinence, UTI)
3. ***Autonomic dysreflexia (injury at mid thoracic or above unable to dampen sympathetic response from noxious stimuli —> sympathetic overflow —> tachycardia, HT, sweating)
4. Limited mobility
5. Mental health
6. ***Cardiovascular health (main cause of death in developed world ∵ sedentary —> MI)
7. Housing and employment

Rehabilitation:

• Multiple team approach (e.g. Urologist for bladder problem)
• Develop the functions which remain normal
• Compensate for those that have been lost

Question 18

1. Respiratory problems

Answer 18

Mechanisms:

1. Respiratory muscle paralysis (high C-spine injury affecting diaphragm + intercostal muscle)
   - Intercostal / Abdominal muscles: T1-T12
   - Diaphragm: C3-5
   - Accessory muscles (Trapezius, SCM): Above C3

Paralysis of Intercostal:

• Easily become tired ∵ lack of reserve
• Paradoxical breathing —> diaphragm flatten but intercostal space collapse during inspiration —> reduced diaphragm efficiency

Paralysis of Abdominals:

• Inability to cough
• Sputum retention —> Atelectasis + Chest infection
• Vigorous PT + Postural drainage
• Suction (bradycardia)
• Mini-tracheostomy
• Bronchoscopy

2. Direct chest injuries
   - Haemo / Pneumothorax
   - Pulmonary contusion
3. Autonomic dysfunction

Question 19

SpC O/T Seminar: Cervical spine disorders

Classification of Spinal cord injury (SCI)

Answer 19

Complete SCI: No motor / sensory function below neurologic level
Incomplete SCI: Some motor / sensory function below neurologic level

In practice: Test ***lowest sacral segments

1. Voluntary anal contraction
2. Perianal sensation
3. Deep rectal sensation

Neurologic level:
- Most caudal neurologic segment that retains **normal motor (key muscle of >=grade 3) + sensory function on **both sides

ASIA impairment scale (American Spinal Injury Association):
A: Complete. No motor or sensory function in the lowest sacral segment
B. Incomplete. Sensory but not motor function is preserved in the lowest sacral segment.
C. Incomplete. Less than 1/2 of the key muscles below the neurological spinal level have grade 3 or better strength.
D. Incomplete. At least 1/2 of the key muscles below the neurological level have grade 3 or better strength.
E. Normal. Sensory and motor functions are normal.