Spinal Trauma

Question 0

What group of people mainly present to ED with spinal trauma?

Answer 0

Over 80% in 15-24yo males

Question 1

What percentage of spinal injuries occur in the C-spine?

Answer 1

55%

Question 2

Name the regions of the spine and how many vertebrae in each

Answer 2

7 cervical
12 thoracic
5 lumbar
5 sacral 
4 fused 
Coccygeal

Question 3

What percentage of spinal injury have been attributed to by paramedic/hospital personnel?

Answer 3

3-25%

Question 4

Explain a complete spinal cord injury

Answer 4

No motor or sensory function below the injury level

Question 5

Explain an incomplete spinal cord injury

Answer 5

Any sensory/motor function below the level of injury

Question 6

What is anterior spinal cord syndrome and is it classified as a complete or incomplete SCI?

Answer 6

Corticospinal and spinothalamic tracts injured
Preservation of posterior column pathway
Aetiology: anterior SCI, flexion of cervical spine causing cord contus, thrombosis of anterior spinal artery
Incomplete SCI

Question 7

What is posterior spinal cord syndrome and is it classified as a compete or incomplete SCI?

Answer 7

Rare condition
Injury to dorsal column
Preservation of corticospinal and spinal pathways
Aetiology: penetrating trauma to posterior aspect of cord, hyperextension injury w/ vertebral arch fracture
Incomplete SCI

Question 8

Explain central cord syndrome and is it classified as a complete or incomplete SCI

Answer 8

Injury preferentially affects central portion of cord
Loss of function of central fibres of corticospinal and spinothalamic
Decreased strength and pain/temperature of upper extremities compared with lower extremities
Aetiology: hyperextension injuries, central spinal stenosis, disruptions of normal blood flow
Incomplete SCI

Question 9

Explain Brown Sequard syndrome and is it classified as a compete or incomplete SCI?

Answer 9

Transverse hemisection of spinal cord
Ipsilateral loss of motor function, proprioceptive/vibratory sensation
Contralateral loss of pain/temperature sensation
Aetiology: penetrating injury or lateral cord compression
Incomplete SCI

Question 10

Explain spinal shock

Answer 10

Temporary - characterised by loss of all spinal cord function caudal to level of injury
Symptoms flaccid paralysis, hypotonia, areflexia, priapism (erect penis)
Typical duration: 24-72 hours
Resolution: return to bulbocavernosus reflex
Outcome: spastic paresis, hyper-reflexia

Question 11

Explain Neurogenic Shock

Answer 11

Type of distributive shock characterised by loss of adrenergic tone due to sympathetic denervation
Classic triad: hypotension, bradycardia, hypothermia
Management: IV fluids, vasopressor support & atropine

Question 12

Describe brief pathophysiology of spinal trauma

Answer 12

Injury ➡️ microscopic haemorrhage to grey matter in spinal cord + oedema to white matter ➡️ microcirculation of cord impaired + releases noradrenaline, dopamine, serotonin and histamine ➡️ vasospasm + further dec microcirculation ➡️ dec in oxygen and vascular perfusion + inc in intracellular Ca + dec in extracellular Ca ➡️ ischaemia + cell death ➡️ necrosis + nerve function loss
Oedema extends 2 cord segments above and below injury

Question 13

What are the manifestations of spinal shock?

Answer 13

Flaccid paralysis of skeletal muscle, loss of sensation to pain, touch, temp, and pressure, bowel and bladder dysfunction loss of ability to perspire

Question 14

What are the manifestations of neurogenic shock

Answer 14

Bradycardia, dec CVP, decrease SV, hypotension w/ decrease MAP
Early stages: extremities are warm, pink due to blood pooling
Later stages: skin is cool and pale, low temp, Oliguric to Anuria UO, altered mental status (anxious, restless, lethargic to comatose)

Question 15

What are the diagnostic tests for SCI? Provide rationale.

Answer 15

Imaging: CT, MRI & chest X-Ray (show level of spinal cord injury)
Blood test: FBC, U&Es, coagulation profile, ABGs (respiratory acidosis - pH < 7.35 due to hypoventilation)
Neurological: motor examination & sensory mapping

Question 16

What is the specific nursing care required for SCI

Answer 16

No anticoagulants, TEDs/calf pumps, nutrition, monitor ileus, vital signs, O2 administration, BD calf and thigh measurements, placed in crucifix every 2 hours, hand splints insitu 2hrs on/2hrs off, regular PAC, heel mat, back board to prevent foot drop, TDS pin site care, full spinal precautions and neck hold for PAC, quad cough, suctioning

Question 17

Explain autonomic dysreflexia

Answer 17

Occurs in injuries at T6 and above
Sympathetic response to noxious stimuli (such as full bladder, line insertion, ingrown toenail, faecal impaction) resulting in bradycardia, hypertension and facial flushing
Patho: stimuli unable to ascend down cord ➡️ mass reflex stimulation of sympathetic nerves ➡️ triggers massive vasoconstriction ➡️ vagus nerves cause bradycardia and vasodilation above injury level
Can result in seizure activity, cerebral haemorrhage, or acute pulmonary oedema
Treatment: alleviating noxious stimuli

Question 18

Explain methylprednisolone

Answer 18

Potent anti-inflammatory drug steroid (corticosteroid)
Reduces inflammatory response by controlling rate of protein synthesis
Pt receives boils dose (3-8hrs post injury) followed by a 24-48hr continuous infusion
Aim is to prevent post traumatic spinal cord ischaemia, improving energy metabolism, restoring extracellular Ca + improving nerve impulse conduction
Side effects: fluid retention, muscle weakness, bone weakness, loss of ability to feel pain, joint pain, increased sweating, headache, dizziness, light headedness, mood changes, nausea, vomiting, itchy/peeling skin, loss of appetite, acne, excessive hairiness, diarrhoea, fatigue, persistent hiccups, bruising, red/purple/brown patches on skin

Question 19

Explain pregabalin (lyrica)

Answer 19

Anticonvulsant - controls brain chemicals which sends signals to nerves to prevent seizures
Neuropathic pain - interacts w/ noradrenergic and serotonergic pathways originating from brainstem
Side effects (common): dizziness, tiredness/drowsiness, constipation, diarrhoea, nausea, headache, increase in weight, unsteadiness when walking, shaking/tremors, dry mouth, blurred/double vision
Side effects (serious): unusual changes in mood/behaviour, signs of new or increased irritability or agitation,signs of depression, swelling of the hands ankles or feet, enlargement of breasts, unexplained muscle pain, tenderness and weakness
Dose: 150mg/ day max 600mg/day

Question 20

Explain diazepam

Answer 20

Benzodiazepine - skeletal muscle relaxant, antiepileptic
Action: modulates postsynaptic effects of GABAa transmission resulting in presynaptic inhibition
Side effects: euphoria, ataxia, somnolence, rash, diarrhoea, hypotension, fatigue, muscle weakness, withdrawal/addiction
Dose: 2-10mg po 6-12hourly