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Neurosurgical Training > Spinal Trauma > Flashcards

Spinal Trauma Flashcards

1
Q

Features of primary SCI

A

Thought to be irreversible

Caused by rapid and violent spinal cord compression and distortion from the displacement of normally protective structures due to fracture or dislocation.

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2
Q

Features of secondary SCI

A

A consequence of a cascade of injury mechanisms all initiated by the primary injury including

Hypoxic ischaemic injuries

Electrolyte derangements

Lipid peroxidation

Vascular mechanisms

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3
Q

Vascular mechanisms of 2o SCI

A

Changes in spinal cord blood flow with ischaemia persisting and worsening for 24h in animal models.

Vasopsams, endothelial oedema, hocal haemorrahges with throbmosis and excitatory amino acids are all thought to contribute

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4
Q

Histological findings in acute SCI

A

Severe haemorrahges, predominantly in the grey matter (likely 2o to damage to the anterior sulcal arteries)

Multiple lesions in the surrounding white matter including disrupted myelin and axonal oedema.

Intramedullary vein occlusion

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5
Q

SBP targets for transfer of SCI from the scene of injury

A

>100

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6
Q

What proportion of patients with SCI require intubation in the first 24h

A

1/3rd

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7
Q

SCI at what level shows paradoxical abdominal movements with respiration?

A

Injury above C5

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8
Q

Intubation in acute SCI

Vital capacity threshold

A

<1L

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9
Q

Trials on methylprednisolone in SCI

A

NASCIS

Based on subgroup analysis with non-standardised experimental design and statistical artefacts

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10
Q

Summarise evidence for steroids in traumatic SCI

A

there is no concrete evidence that methylprednisolone has a useful role in neurological protection in early spinal cord injury

the NASCIS studies are fatally flawed

adverse effects include increased sepsis and hyperglycemia

steroid use could be considered on a case-by-case basis, but situations where the risk-benefit balance favours administration would be rare

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11
Q

The sensitivity of CT for identifying fractures in spinal trauma

A

99.3%

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12
Q

Use of MRI in trauma

A

Useful in patients whose CT results do not explain the neurological status.

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13
Q

Benefits of closed cervical reduction

A

Can be used with a reported 80% success and 80% improved neurological function.

Though worsening neurologic status from disc herniation after cervical traction may also occur.

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14
Q

Definitive C-spine clearance

A

CT

MRI (to evaluate soft tissues)

Clinical

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15
Q

Mortality in SCI

A

15%

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16
Q

Cause of death at the scene of SCI

A

High level SCI

CV instability

Respiratory compromise

Highest mortality rates are immediately following and within the first hours after SCI

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17
Q

Factors increasing odds of early death after SCI

A

>20

Male

>1 comorbidity

Concomitant systemic injury (ISS >15)

Concomitant TBI

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18
Q

Use of admission ASIA in prognosis

A

Predicted neurological recovery at 1y post-injury

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19
Q

What proportion of patients will convert from AIS A to an incomplete injury

A

10-15%

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20
Q

What proportion of AISA A injuries will convert to AIS D

A

2%

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21
Q

What is the chance of AI C converting to AIS D or E at 1y?

A

70%

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22
Q

Chance of walking at 1y after complete paraplegia

A

5%

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23
Q

Chance of walking at 1y after complete quadriplegia

A

0%

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24
Q

GM1 ganglioside

A

Largest prospective RCT in SCI

Class III evidence of improvement of the clinical outcome via optimisation of SC perfusion, not reproduced in LT follow up, not used in clinical practice currently.

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25
Q

ASIA A

A

Complete

No sensory or motor function is preserved in the sacral segments S4-5

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26
Q

No sensory or motor function is preserved in the sacral segments S4-5

ASIA grade

A

ASIA A

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27
Q

ASIA B

A

Sensory incomplete

Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pinprick or deep anal pressure

AND

No motor function is preserved more than three levels below the motor level on either side of the body

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28
Q

Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pinprick or deep anal pressure

AND

No motor function is preserved more than three levels below the motor level on either side of the body

ASIA grade

A

ASIA B

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29
Q

ASIA C

A

Motor incomplete

Motor function is preserved at the most caudal segments for voluntary anal contraction or the patient meets the criteria for sensory incomplete status and has some sparing of motor function more than three levels below the ipsilateral motor level either side of the muscles

Less than half of the key muscles below the single NLI have a muscle grade >3

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30
Q

Motor incomplete

Motor function is preserved at the most caudal segments for voluntary anal contraction or the patient meets the criteria for sensory incomplete status and has some sparing of motor function more than three levels below the ipsilateral motor level either side of the muscles

Less than half of the key muscles below the single NLI have a muscle grade >3

A

ASIA C

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31
Q

The threshold for motor function differentiating between ASIA C and D

A

C- less than half of key muscles below the single NLI have a muscle grade >=3

D- at least half of key muscles below the single NLI have muscle grade >=3

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32
Q

ASIA D

A

Motor incomplete status as defined in C with at least half or more of key muscle functions below the single NLI having a muscle grade >=3

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33
Q

Motor incomplete status as defined in C with at least half or more of key muscle functions below the single NLI having a muscle grade >=3

ASIA grade

A

D

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34
Q

ASIA E

A

Normal motor and sensory function in all segments

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35
Q

Normal motor and sensory function in all segments

ASIA grade

A

E

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36
Q

TRH for SCI

A

Demonstrated improvements in the NASCIS and Sunnybrook scales for incomplete SCI patients but criticised for T1 error (attrition with analysis of only 20 patients)

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37
Q

Ganacyclidine in SCI

A

Benefit in the treatment group that did not persist at 1y (insufficient statistical power).

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38
Q

Nimodipine in SCI

A

Compared nimodipine and MPSS to placebo (NASCI II) showed no beneift

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39
Q

Dynormin in SCI

A

Endogenous opioid, administered in NASCIS II

No benefit

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40
Q

Categories of current trials in SCI

A

Neuroprotective agents to limit secondary injury

Neuroregenerative agents aimed at promoting and supporting repair/regeneration.

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41
Q

Neuroprotective measures for SCI

A

CSF drainage via intrathecal line (there is some evidence of similar strategies reducing paraplegia during thoracic AAA surgery)

Electrica feild along the spinal axis.

Hypothermia showed some benefit in animal moels.

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42
Q

STATSCIS trial

A

RCT looking at early (<24h) vs late (>24h) decompression in traumatic SCI

Decompression prior to 24 hours after SCI can be performed safely and is associated with improved neurologic outcome, defined as at least a 2 grade AIS improvement at 6 months follow-up

43
Q

Decompression in central cord syndrome

A

Poor outcome after early decompression has been published and hence there has been a move to avoiding early decompression though controversy has arisen in subsequent studies

44
Q

Timing of surgical decompression of thoracic spinal injury

A

Limited, retrospective study found some benefit to early surgery in respect to ventilator-dependence, length of ICU stay, length of hospital stay, mortality, pulmonary failure.

45
Q

Goal of spinal surgeon in managing cervical spine fractures

A

Prevent secondary neurological injury

Deformity

Pain

Re-establish stability

46
Q

Epidemiology of cervical spine fracture

A

Biphasic, 15-45 then 65-80y

M>F

47
Q

What proportion of cervical spine fractures are associated with neurological injury?

A

10%

48
Q

Mechanism of c-spine fractures in young group

A

High velocity injuires

49
Q

Mechanism of c-spine fracture in elderly group

A

Low energy, simple fall, commonly fracturing the odontoid process

50
Q

Incidence of cervical spine truama in head injury patients

A

Up to 14%

51
Q

3 view XR

A

lateral

Open-mouth odnotoid

AP XR

52
Q

NEXUS criteria

A

No neurology

No midline neck tenderness

No intoxication

No altered GCS

No distracting injury

Can clinically clear low risk patients if all absent

53
Q

Cervical spine clearance in the unconscious head injury

A

Remove collar if fine-cut CT scan demonstrates no bony misalignment or bony injury.

54
Q

Immobilisation of AS patients

A

Should be in thier pre-injury fixed position, not forced into supine.

55
Q

General adjuncts to the management of SCI patients

A

Careful immobilisation

Catheter

NGT

LMWH

PPI

56
Q

Allen’s Classification

A

Mechanistic classification of C-spine injury

Compressive flexion, vertical compression, distractive flexion, compression extension, distractive extension and lateral flexion.

Each further category then subdivided based on the radiological severity of the injury.,

57
Q

SLIC

A

Subaxial injury classification

Used to categorise fractures below the level of the C2

Based on morphology, disruption of ligamentous complex and neurology.

58
Q

What radiological features suggest disruption of the ligamentous complex?

A

Facetal malalignment

Abnormal widening of anterior disc space

Kyphosis over a motion segment

High signal on STIR MRI sequence

59
Q

Cervical fracture morphology

SLICs score:

No abnormality

A

0

60
Q

Cervical fracture morphology

SLICs score:

Compression

A

1

61
Q
A

Compression fracture

62
Q

Cervical fracture morphology

SLICs score:

Burst

A

2

63
Q
A

Burst fracture

64
Q

Cervical fracture morphology

SLICs score:

Distraction fracture

A

3

65
Q
A

Distraction fracture

66
Q

Cervical fracture morphology

SLICs score:

Translation rotation

A

4

67
Q
A

Translation rotation

68
Q

Discoligamentous complex

SLICs Score:

Intact

A

0

69
Q

Discoligamentous complex

SLICs Score:

Indeterminate

A

1

70
Q

Discoligamentous complex

SLICs Score:

Disrupted

A

2

71
Q

Neurological status

SLICs score:

Intact

A

0

72
Q

Neurological status

SLICs score:

Root injury

A

1

73
Q

Neurological status

SLICs score:

Complete cord injury

A

2

74
Q

Neurological status

SLICs score:

Incomplete cord injury

A

3

75
Q

Neurological status

SLICs score:

Cord compression

A

4

+1 in context of neurolgoical deficit

76
Q

Cervical spine injury severity score

A

Proposed by Anderson

Used to grade the instability of fractures.

Proposes four columns of the cervical spine (Anterior, posterior, right and left lateral)

Uses a scoring system where 0-5 points are awarded based on the severity of the injury to bone and ligamentous structures in the four columns.

The sum of these scores gives the final CSISS.

77
Q

Jefferson’s fracture

A

Burst fracture affecting C1 ring.

Initially used to describe a four-point fracture of the C1 bone with fractures affecting the anterior arch and posterior arch.

78
Q
A

Jefferson fracture

79
Q

What proportion of C1 fractures are associated with a C2 fracture?

A

30%

80
Q

Why are isolated C1 fractures only rarely associated with neurological deficits?

A

As the bony elements tend to move outwards, away from the neural elements

81
Q

Typical mechanism for Jefferson fracture?

A

Axial loading

82
Q

What must be assessed in the presence of a C1 fracture?

A

The integrity of the transverse ligament

Measure the ADI

<3mm in adults and <5mm in children

83
Q

What happens to the lateral masses of C1 when the transverse ligament is disrupted?

A

The lateral masses move outwards

84
Q

What is Spence’s rule of 7

A

On a PEG view or coronal CT, the distance between the lateral edge of C1 and C2 can be measured.

If the sum of the two sides is >7mm then the transverse ligament is disrupted

85
Q
A

Odontoid PEG view XR of the cervical spine showing likely disruption of the transverse ligament due to significant lateral mass overhang (Spence’s rule)

86
Q

Management of C1 fractures

A

Very rarely surgically

If the transverse ligament is damaged- HALO

If the transverse ligament is intact- collar

87
Q

C1 fracture with disrupted transverse ligament

A

HALO

88
Q

C1 fracture with intact transverse ligament

A

Collar

89
Q

Hangman’s fracture

A

Traumatic spondylolisthesis of axis.

90
Q
A

Hangman’s fracture

91
Q

Classification of Hangman’s fractures

A

Levine and Edwards classification

92
Q

MOI Hangman’s fracture

A

RTA most common

93
Q

Levine and Edwards classification

Type 1

A

Minimal translation (<3mm) without C2-3 angulation, stable

94
Q

Levine and Edwards classification

Type 2

A

Significant C2-3 angulation and translation >3mm

Disc disruption

Unstable

95
Q

Levine and Edwards classification

Type 2a

A

More angulation than type 2 without translation, unstable due to flexion-distraction injury

96
Q

Levine and Edwards classification

Type 3

A

Severe C-3 angulation and translation; sometimes uni/bilateral facet dislocation

Unstable

97
Q

Which Levine Edwards type fractures should be managed surgically?

A

Type 2a and 3

98
Q

Approach to surgical fixation of Hangman’s fracture

A

Anterior approach with C2/3 discectomy and fusion

99
Q

Epidemiology of Odontoid peg fractures

A

Common in elderly patients after a fall or young patients following cervical hyperflexion or hyperextension injury

Accounts for 10-15% of C-spine fractures

100
Q

Classification of odontoid peg fractures?

A

Anderson D’Alonzo

101
Q

Anderson D’Alonzo

Type 1

A

Fracture of the tip of the odontoid peg above the transverse ligament

Caused by avulsion of the alar ligament

102
Q

Anderson D’Alonzo

Type 2

A

Fracture across the base of the peg, beneath the transverse ligament

103
Q

Anderson D’Alonzo

Type 3

A

Fracture in the C3 vertebral body such that the peg is disconnected from the rest of the vertebral body.

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