Spinal Trauma Flashcards
If you suspect a cervical spine injury until you can prove otherwise you want to……
If you suspect a cervical injury of C5 or higher, which nerve is involved? For this you would want to intubate.
_______, __________, __________ keep the diaphragm alive.
Mantain BP- MAP goal of ____________ + pressors if needed
immobilize with a hard collar and oxygenate.
C3, 4, 5
phrenic nerve
> 85
Priapism is a sign of _______________. Why does this occur?
spinal shock.
due to sudden loss of sympathetic tone to the pelvic vasculature following SCI causes an increase in the parasympathetic tone and uncontrolled arterial blood flow into the penile sinusoidal spaces. When occurring immediately after an acute SCI, its generally self-limiting and settles within a few hours.
What is the significance of rectal tone?
if it winks- the sacrum may be spared.
What is the significance of bulbocavernosus reflex?
if absent may represent spinal shock and cant declare if this is a complete or incomplete SCI- can also be cauda equina syndrome.
What is the significance of cremasteric sign?
instrument run up thigh causes scrotum to rise
What is the significance of hoffmans sign?
flicking of finger causes contracture- sign of chronic cord compression
What is the significance of clonus?
look for off beats, associated with spinal cord compression - often more chronic finding
Why do we check for anal reflex, bulbocavernous reflex, priapism?
because it is innervated by S2,3,4 which keeps the penis off the floor, - pelvic floor
What is spinal shock?
immediate temporary loss of total power, sensation and reflexes below the level of injury
Spinal shock:
BP
Pulse
Bulbocavernosus reflex
motor
time
mechanism
hypotension
bradycardia
absent
flaccid paralysis
24-72 hrs immediate after SCI
peripheral neurons become temporarily unresponsive to brain stimuli
Neurogenic shock:
BP
Pulse
Bulbocavernosus reflex
motor
time
mechanism
hypotension
brady
variable
variable
24-72 hours
disruption of autonomic pathways > loss of sympathetic tone and vasodilation
Neurogenic shock occurs with SCI of _______________ and above this is due to the sympathetics coming out of the cord ________, __________, ____________.
Hypotension is due to ___________________.
Brady due to increase in the ____________________ of the heart
T2
C8, T1, T2
loss of sympathetic drive.
-lose the inotropic drive (contractility)
-vasodilation= BP drops
chronotropic effect (cant beat faster)
In the treatment of neurogenic shock, you need a ______________ to increase the BP. What is the most common one?Why is this not a good choice? Instead, you want a pressor with a ________________ such as ________________
PRESSOR- neosynephrine- alpha agonist ONLY. however not a good choice because it makes blood vessels contract but it increases vagal tone so youre asking a heart that cant squeeze and cant go faster to fight against resistance = BAD, more brady.
BETA AGONIST
LEVOPHED****
In the treatment of neurogenic shock, the goal is to maintain SBP _______________ with MAP __________________ typically for 7 days. There is also a need for DVT prophylaxis- what do you want to give?
> 90
> 85-90
high + SQH or Lovenox
What med is not recommended for a patient in neurogenic shock?
STEROIDS
What is the name of the grading scale used for characterizing spine injuries?
ASIA- american spinal cord injury association
In the spinal cord, ascending tracts are __________________ while descending tracts are __________________
sensory, motor
Central cord syndrome is most caused by _____________. There is greater loss of motor function in the ____________ compared to the ____________. There is variable degrees of ____________ loss. It is a hyperextension injury in the setting of stenosis. There is vascular compromise of the _________________. The _________ recovers before the ___________
extension.
UE
LE
sensory
anterior spinal artery
LE
UE
Anterior cord syndrome is loss of ___________ function, ____________ and _____________ below the lesion and preservation of ____________ and ______________ function.
motor
temp
pain
position, vibratory
What is the most common cause of anterior cord syndrome?
infarction of the cord in the territory of the anterior spinal artery
Posterior cord syndrome is impaired ______________ and loss of ______________ because of the lack of ____________. The patient has sensory ataxia meaning poor __________ and unsteady gait. These patients also present with impaired vibration and fine touch. These patients have preserved _________ AND _________.
voluntary movement
coordination
proprioception
balance
pain
temp
What is brown sequard syndrome?
half of the spinal cord is injured
- ipsilateral loss of motor, vibratory sense, proprioception,
- contralateral loss of pain and temperature- spinothalamic
What are the causes of cauda equina syndrome?
compression, trauma, damage to multiple nerves. The most common cause is lumbar disc herniation.
hematoma, epidural abscess, tumor, spinal stenosis, AS, spondylolisthesis
Cauda Equina Syndrome MUSTTTTT include all of the following symptoms:
- weakness in LE
- saddle anesthesia
- urinary retention or urinary incontinence
- bowel incontinence
- hyporefelxia or aflexia
- pain
What diagnostics are ordered for cauda equina? You have to be treated within 24 hours max (ideal to decompress incomplete cord injuries SCI within 24 hours) or the patient will be left with permanent deficits MAX 48
STAT MRI, STAT NSGY, ortho
You CANNOTTTTT have true cauda equina without _______________
weakness
What are the resp, GU, GI and skin complications from c spine injury?
Resp: hypoventilation > paralysis of diaphragm
GU: urinary dysfunction, loss of sensation
GI- Ileus- section/antiemetics KEEP NPO, NGT
Skin: high risk of pressure ulcers, prevent hypothermia, loss of sensation
3-column model of denis (has pic slide 34)
1. anterior column
2. middle column
3. posterior column
- ALL, anterior 1/2 of VB and annulus
- Posterior 1/2 of VB and annulus, PLL
- posterior elements
Sacral and coccygeal fractures:
- Which types of fractures in this region are most significant?
- Central sacram cranial involvement >
- transverse fractures
- bowel/bladder
What is the national emergency x-ray utilization study (NEXUS) criteria?
It is for cervical spine fractures- lists who needs imaging.
- HIGH RISK age >65, dangerous mechanism like fall from height, axial load injury, high speed MVC, paresthesia in extremities or neuro symptoms
- low risk- simple low speed rear end collisions, sitting up and ambulatory, delayed neck pain, no midline tenderness
Less radiation HOWEVERRRRRRRRR neurosurg will frequently order a CT bc we cant see true anatomy on XR but this does allow saving time to keep patient mobilized in collar.
WHEN IN DOUBT LEAVE COLLAR IN PLACE
Who DOESNT need imaging for a cervical spine fracture?
if awake, oriented, no intoxication, no distracting injury, normal neuro, unsuspecting mechanism, no posterior midline tenderness
Cervical spine injury imaging indications
- midline neck tenderness/pain
- AMS including intoxication
- significant mechanism with distracting injury
The gold standard for cervical spine injury is….. and +/- ______________ if vert injury poss.
CT scan.
CTA
What needs to be seen on a cervical spine xray for a satisfactory film?
plain films- lateral, AP, open mouth views.
base of skull
7 cervical vertebrae
1st thoracic vertebrae on lateral view
In the case of a cervical spine injury, when do you obtain a flex/ex imaging ?
to see if theres minor instability with dynamic views and r/o ligament involvement after obtaining CT if patient can cooperate
The gold standard imaging for T/L spine is
CT
If you have significant foot fractures (calcaneal) you should image the ______________ as well given the loading injury and force required to cause this break.
spine
What is nonop management?
imaging every 3-4 weeks for approx 3 months
it will take fractures of a spine on average 2-3 months to start to show radiographic evidence of bridging across fracture defects or sclerosis (hardening)
PTS CANNOT DRIVE IN A HARD COLLAR
A C1 fracture ring usually breaks in___________ places.
two
What is the mechanism of an occipital condyle fracture?
related to fractures seen in trauma and typically related to axial loading and blunt craniocervical injury- hit head on roof of car, knocked in head, often seen in poly trauma cases.
What is the diagnostics/ treatment of an occipital condyle fracture?
Dx: CT +/- CTA given proximity to vertebral arteries and type of trauma that causes these fractures.
Tx: hard collar immobilization but if type II-surgical fixation O-C Fusion.
Type I occipital condylar fracture
nondisplaced communuted fracture. axial loading- stable
Type II occipital condylar fracture
Type IIA…..
Type IIB….
fracture through skull base extending to condyle. Stable
Type A: stable
Type B: unstable
Type III occipital condylar fracture
avulsion fracture of ipsilateral condyle by alar ligament- UNSTABLE
C1 rotary subluxation/atlantosubluxation is most often seen in _________________ and it can be congenital e.g. Downs or Marfans). If chronic, it can present with _________________ but TYPICALLY it presents with rotation of ____________ and inability to face _________. It is diagnosed by ____________________. What is the treatment?
children
torticollis
neck
midline
Open mouth odontoid view or CT
Treatment: immobilize in position- neurosurg eval
C2: dens
Type I axis fracture:
Type II axis fracture:
Type 3 axis fracture:
I= tip
II= base of dens
III= base of dens with oblique fx into body of axis
GET CT to see them
Out of all of the dens fractures, which type is the most common?
Type II, can be operative depending on ligamentous connections and alignment.
What are the radiographic findings of C3-7 fractures/dislocations that makes them unstable?
- ant subluxation of more than 4 mm
- associated compression fracture of more than 25% of the affected vertebral body
- increase or decrease in normal disk space
- fanning of the interspinous distance
Typically, shock from the bullet will cause so much damage to the cord or nerves that we can only ________________. The KEYYY is to determine ______________ wounds. You want to do a __________ scan.
stabilize
entry/exit
CT
Neuro deficits are common with _______________ AND ______________ from adjacent injury.
direct vertebral column injury
energy transfer
What neck zone REQUIRES operative exploration? What other structures in the neck could be involved and what imaging may be needed to r/o injury? What imaging needed to r/o injury?
Zone II
structures: carotid and vertebral arteries, jugular veins, pharynx, larynx, trachea, esophagus. cervical spine, spinal cord
imaging: CT angiography, 2D doppler, esophagoscopy
Blunt cerebrovascular injury (BCVI) is a term used to describe blunt force trauma to the neck which injures the ______________ and ____________ arteries. This is why obtaining a _______________ is important.
cervical carotid, vertebral
CTA
What are the symptoms of an airway injury? It requires a ___________ for diagnosis. What is the treatment?
subcutaenous pneumomediastinum
PTX with persistent airleak
stridor
hoarseness
painful phonation
hemoptysis
HTX (hemothorax)
bronchoscopy
treatment: close observation, RSI (rapid sequence intubation), surgical correction
Symptoms of esophageal injuries? How is it diagnosed? What is the treatment?
hematemesis
dysphagia
odynophagia
soft tissue crepitus
saliva leak from wound
blood in NGT
prevertebral air on lateral c-spine
pneumomediastinum
diagnosed via esophogram or esophagoscopy
tx: NPO status, observation, may need to be surgically corrected
Hard signs of a vascular injury
active arterial (pulsatile) bleeding
pulseless/ischemia
expanding pulsatile hematoma
bruit or thrill
API <0.9
OPERATION IS MANDATORY
What are soft signs of a vascular injury?
minor bleeding, injury in proximity to major vessel, small to moderate size hematoma, associated nerve injury, further work up needed
