Spinal Trauma Flashcards
What is the typical mechanism/aetiology of spinal fractures?
- High energy e.g. falls from height/RTA/assault
- Low energy wedge fractures in elderly/osteoporotic
- Presume risk of spinal injury in all high energy trauma (protect spine until fracture excluded as in ATLS)
Summarise the initial assessment of a suspected spinal fracture.
- Immobilise the patient
- Full neurological examination
- PR examination
- Open/closed injury
- Other sites of injury or polytrauma
Summarise the appropriate imaging in suspected spinal trauma.
- X-RAYS : AP & LATERAL (& PEG VIEW IF C-SPINE)
- +/- CT IF X-RAYS NOT SUFFICIENT TO MAKE DIAGNOSIS
- +/- MRI IF NEUROLOGICAL INJURY OR ? LIGAMENTOUS INJURY
In what way should one consider the consequences of C-spine trauma?
- The container: C-spine
- The content: the spinal cord
- The outgoing nerve root
How should one assess damage to the vertebral structures?
- TENDERNESS
- OEDEMA
- BRUISING
- GAP OR STEP
- SPASM OF ASSOCIATED MUSCLES
How should one assess damage to the spinal cord?
- UMNL signs
How should one assess damage to the nerve roots?
- LMNL signs
- Exiting nerve roots
- Cauda equina (below conus/L1 level)
Outline in detail the assessment of suspected spinal trauma.
SENSATION (0-2 out of 2) •MOTOR FUNCTION (0-5 out of 5) •REFLEXES (UMNL VS LMNL) •PR EXAMINATION ( motor, sensation, tone re: nerves of cauda equina) •+/- BULBO-CAVERNOSUS REFLEX •DOCUMENT USING ASIA CHART (American spinal injury association)
Briefly outline spinal immobilisation.
• Whole spine should be immobilized in neutral
position on a firm surface.
- semi-rigid cervical collar, side head supports, & strapping (AKA sandbags, collar & tape)
- long spine board
- Log-roll until spinal injury excluded
- LEAVE IMMOBILISED! PRIORITY IN MULTIPLE SPINAL TRAUMA!
• IMAGING THE SPINE does NOT take precedence over life saving diagnostic and therapeutic procedures
Who needs C-spine imaging after trauma?
Image if ANY of these:
- Neck pain
- Midline neck tenderness
- Neurologic signs and symptoms
- Mental status less than alert or intoxicated
- Distracting injury (i.e. painful injuries elsewhere, e.g. limb fractures)
When may you “clinically clear” a patient after assessing their C-spine in a trauma?
Possible to “clinically clear” neck ONLY IF ALL of these:
- No neck pain,
- No neck tenderness on
palpation, with full, painless,
active range of motion of c-
spine, - No neurologic deficit
- No mental status change & no history of loss of consciousness
- No distracting symptoms.
What imaging is appropriate in suspected spinal trauma?
- AP and lateral + peg view for C-spine
- If C-spine views inadequate (cannot see from skull base to C7/T1 junction) then consider CT C-spine.
- Flexion and extension views may be considered later to exclude ligamentous instability if no fracture but ongoing pain
- Pan-scan whole body CT now common in polytrauma
- MRI if neurological defect present (can also visualise ligamentous injury)
NB/remember 10% of patients with spinal fractures have another fracture elsewhere.
Why are flexion-extension view X-rays performed in suspected C-spine injuries?
• IF standard XR / CT scan normal but persistent pain
- Active Flexion/Extension views at day 10
• Eliminates instability
Outline the ABCDE analysis of C-spine X-rays.
- ADEQUACY
- BONE ABNORMALITY
- CONTOURS
- DISCS & SPACES
- EXTRA-AXIAL SOFT TISSUES
Outline ‘adequacy’ in analysis of C-spine X-rays.
Count Vertebrae (lateral): occiput to C7 must be seen. If not seen, get a CT, (or swimmer’s view / pull-down view)
Outline ‘bone abnormalities’ in analysis of C-spine X-rays.
Check the contour of each bone on AP & lateral, including shape of vertebral bony & position of pedicles & facets
Outline ‘contours’ in analysis of C-spine X-rays.
Four lines:
- Anterior vertical line
- Posterior vertical line
- Spinolaminar line
- Posterior spinous line
NB/ also assess the general curvature e.g. lordosis in
cervical & lumbar, kyphosis in thoracic
Anterolisthesis indicates facet dislocation.
Outline ‘discs and spaces’ in analysis of C-spine X-rays.
- Predental space (< 3mm) sinon Fr. Odontoid process or transverse ligament rupture
- Disc spaces should be the equal and symmetric
- The height of the cervical vertebral bodies should be approximately equal
- The height of each joint space & spaces between spinous processes should be roughly equal at all levels.
- Spinous process should be in midline and in good alignment.
Outline ‘extra-axial soft tissues’ in analysis of C-spine X-rays.
- Prevertebral soft tissue shadow increase indicates bleeding/ swelling (>5mm at C3 or> width of vertebra at below level of larynx)
- If normal, does not exclude injury
- Difficult to interpret in crying infant, NG tube/ intubation, penetrating injury
What is meant by an unstable spinal injury?
• CLINICALLY UNSTABLE IF – DEFORMITY – OR NEUROLOGICAL DAMAGE – OR PAIN (NOT CONTROLLED ON SIMPLE ANALGESIA)
How are stable vertebral fractures managed?
No reduction required - maintained with analgesia +/- supporting brace.
How are unstable vertebral fractures managed?
GA ORIF i.e. spinal stabilisation +/- decompression of the spinal cord.
Outline the ‘3 columns of spinal stability’
• ANTERIOR COLUMN
– anterior 1/3 of vert. body & disc + anterior longitudinal ligament
• MIDDLE COLUMN
– posterior 1/3 of vert. body & disc + posterior longitudinal ligament
• POSTERIOR COLUMN
– “Posterior elements” i.e. rest of vertebra & ligaments
NB/ ALL fractures of middle column and one other column are unstable.
Outline C-spine stability.
• Remember the role of ligaments in
maintaining cervical bony alignment & stability e.g. anterior & posterior longitudinal ligaments, at facet
joints, & transverse ligament around odontoid peg
Describe a Jefferson fracture.
JEFFERSON FRACTURE (C1):
Compression fracture of the bony ring of C1
- lateral masses splitting
- transverse ligament tear
Outline odontoid (C2) fractures.
Type 1: Avulsion off tip (by alar
ligament)
Usually stable:
Treat in orthotic brace
Type 2: fracture at junction of dens (peg) with the C2 body. Most unstable: Consider halo brace or surgery if medically suitable, or orthosis if unsuitable for surgery
Type 3: fracture in body of C2 (primarily cancellous bone). Usually stable: Treat in orthotic brace
Outline ‘Hangman’s fracture’ - traumatic spondylolisthesis of C2.
- 25% of C2 injuries
- Motor vehicle accidents
- Usually due to hyperextension-axial compression forces (windshield strike)
• Neurological injury seen in only 5-10 % (acutely decompresses canal)
• Traditional treatment has been Halo-vest
• Collar adequate if < 6 mm displaced
