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Deck Medicina ATLS > Spine and Spinal Cord Trauma > Flashcards

Spine and Spinal Cord Trauma Flashcards

1
Q

What are the criteria for excluding the presence of a spinal injury in a trauma patient?

A
  1. No neurological deficit
  2. No pain or tenderness along the spine
  3. NO evidence of intoxication that may confound your exam
  4. No distracting painful injuries
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2
Q

True or false: Most thoracic spine fractures are wedge compression fractures that are not associated with spinal cord injury.

A

True
-HOWEVER, when a fracture dislocation occurs in the thoracic spine, then it almost always results in a complete spinal cord injury because of the relatively narrow thoracic canal

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3
Q

What are the 3 tracts in the spinal column?

A
  1. Corticospinal tract
  2. Spinothalamic tract
  3. Dorsal column tract
    - each is a paired tract that can be injured on one or both sides of the cord.
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4
Q

What is the definition of a complete spinal cord injury?

-what is the definition of an incomplete spinal cord injury?

A

Complete spinal cord injury: when a patient has no demonstrable sensory or motor function below a certain spinal level

Incomplete spinal cord injury: Some degree of motor or sensory function remains

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5
Q

For each of the spinal cord tracts, list the location and function.

A
  1. Dorsal column (in the posteriomedial aspect of the cord): responsible for proprioception, vibration, some light touch from SAME SIDE of body. “DORSAL” means back so it’s most posteiror!!!
  2. Corticospinal (in the anterior and lateral segments of the cord): responsible for motor power on the SAME SIDE of the body
  3. Spinothalamic (in the anterolateral aspect of the cord) (spinothalamic has a P and a T in it AND the letters “ALA”): responsible for Pain and Temperature sensation on the contrALAteral side of the body

***Corticospinal and spinothalamic both have words “spinal” in it so remember that they are both anterior/anteriolateral

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6
Q

Differentiate between neurogenic shock vs spinal shock.

A

Neurogenic shock: loss of sympathetic innervation to the heart and loss of vasomotor tone.

Spinal shock: loss of muscle tone/flaccidity and loss of reflexes that occur immediately after spinal cord injury

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7
Q

Where does the injury have to occur to cause neurogenic shock?

A

Injury to spinal cord has to occur T6 and above to cause neurogenic shock

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8
Q

What is the most worrisome complication of a spinal cord injury?

A

Respiratory failure due to hypoventilation from paralysis of intercostal muscles (lower cervical or upper thoracic spinal cord injury) or loss of innervation to the diaphragm (C3-C5)

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9
Q

What are the ways you can classify spinal cord injury based on level?

A
  1. Bony level: the specific vertebral level at which bony damage has occurred
  2. Neurological level: the most caudal segment of the spinal cord that has normal sensory and motor function on BOTH sides of the body
    - sensory level: most caudal segment of the spinal cord with normal sensory function
    - motor level: most caudal segment of the spinal cord with motor function of at least a 3/5

***There is usually a discrepancy between the bony vs. neurological level of injury because the spinal nerves enter the spinal canal through the foramina and ascend or descend inside the spinal canal before actually entering the spinal cord

***Overall, use neurological level when describing injury level

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10
Q

What are the ways you can classify spinal cord injury based on severity of neurological deficit?

A
  1. Incomplete or complete paraplegia (thoracic injury)

2. Incomplete or complete quadriplegia/tetraplegia (cervical injury)

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11
Q

What are the 3 spinal cord syndromes?

A
  1. Central cord syndrome
  2. Brown-Sequard Syndrome
  3. Anterior cord syndrome
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12
Q

What are the features of central cord syndrome?

  • usually seen in what mechanism of injury?
  • what are the deficits?
A

Usually from hyperextension of the neck in a patient with preexisting cervical spine stenosis (usually in an elderly patient who has fallen forward onto their face)

Deficits: upper extremity weakness > lower extremity weakness with varying degrees of sensory loss

Usually better prognosis than other spinal cord syndromes

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13
Q

What are the features of anterior cord syndrome?

  • usually seen in what mechanism of injury?
  • what are the deficits?
A

Remember that the spinothalamic and corticospinal tract runs in the anterior/anteriolateral aspects of the spinal cord

Anterior cord syndrome results from injury to the motor and sensory pathways in the anterior part of the cord and affects both sides

  • paraplegia and bilateral loss of pain and temperature sensation
  • since the dorsal column is spared, you have intact proprioception, vibration sensation and light touch sensation

Most common mechanism of injury: anything causing ischemia to the spinal cord

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14
Q

Out of the 3 spinal cord syndromes, which one has the worst prognosis?

A

Anterior cord syndrome

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15
Q

What are the features of Brown-Sequard syndrome?

  • usually seen in what mechanism of injury?
  • what deficits are seen?
A

Usually results from hemisection of the cord, usually due to penetrating trauma (so one side of the spinal cord is impacted - all three spinal tracts are then impacted including dorsal column, spinothalamic tract, and corticospinal tract)

-Get ipsilateral loss of motor function, ipsilateral loss of proprioception/vibration sense/light touch, and contralateral loss of pain/temperature sensation

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16
Q

What does SCIWORA stand for?

A

Spinal cord injury without radiographic abnormalities

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17
Q

What is more common in children: upper or lower cervical spine injuries?

A

Upper! (C1-C4)

-this is because of their huge heads, their fulcrum is higher than in adults

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18
Q

What are the symptoms of atlanto-occipital dislocation?

A

Either immediate death from brainstem destruction/apnea OR profound neurological impairments (ventilator dependence of quadriplegia/tetraplegia)

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19
Q

Quadriplegia vs. tetraplegia?

-what is paraplegia?

A

Technically these are the same condition - people just refer to it by either name. This means a spinal cord injury above T1 resulting in some loss of motor and sensory function to arms/legs/trunk
-paraplegia: loss of motor and sensory function to legs. Spinal cord injury below T5

20
Q

What is a Jefferson fracture?

  • typical mechanism?
  • how do you make the diagnosis on C spine xray?
A

Burst fracture of C1

  • typical mechanism: axial loading (ie. diving into a shallow pool or a large load falling on top of the head)
  • disruption of the anterior and posterior rings of C1 with lateral displacement of the lateral masses
  • best seen on an open-mouth view of the C1-C2 region
21
Q

What are the features of a C1 rotary subluxation on clinical exam and on a C spine xray?

  • what population is this most common in?
  • causes?
A

Clinical exam: pt presents with torticollis and cannot rotate their head past midline

C-Spine xray: the odontoid process is not equidistant from the lateral masses of C1

Seen most commonly in children!

Causes:

  1. Upper respiratory tract illness
  2. Rheumatoid arthritis
  3. Major or minor trauma
22
Q

What are the two types of C2 fractures that most commonly occur?

A
  1. Odontoid fractures

2. Posterior element fractures (Hangman’s fracture)

23
Q

What holds the odontoid process in place between the C1 lateral masses?

A

The transverse ligament

24
Q

What are the 3 types of odontoid fracture?

A

Type 1: Fracture through the tip of the odontoid
Type 2: Fracture through the base of the dens (most common)
Type 3: Fracture through the base of the dens and extends obliquely into the body of the axis

25
Q

What is a Hangman’s fracture?

A

Fracture of C2 through the pars interarticularis (ie the posterior elements of C2)
-usually caused by extension type injury

26
Q

In adults, where is the most common level of cervical vertebral fracture?

A

C5

-this is because the area of greatest flexion/extension of the cervical spine occurs at C5-C6

27
Q

What are the 4 categories of thoracic spine fractures?

A
  1. Chance fractures
  2. Burst fractures
  3. Anterior wedge compression fractures
  4. Fracture-Dislocations
28
Q

What is a Chance fracture?

A

Transverse fracture through the vertebral body

  • caused by flexion about an axis anterior to the vertebral column
  • usually caused by MVC in which the patient was restrained by only an improperly placed lap belt
  • can be associated with retroperitoneal and abdominal visceral injuries (seat belt syndrome)
29
Q

What is the triad of features in seat belt syndrome?

A
  1. Abdominal wall trauma from seat belt
  2. Intraabdominal injuries
  3. Chance fracture
30
Q

What is the management of vertebral compression fractures?

-what about burst fractures, chance fractures and fracture-dislocations?

A

Vertebral compression fractures: usually bed rest, rigid brace

Burst fractures/Chance fractures/fracture-dislocations: these are unstable fractures and require internal fixation

31
Q

Where does the spinal cord terminate in adults?

A

Level of L1

32
Q

What are the clinical features of spinal cord injury at level of L1?

A

Bladder and bowel dysfunction

Decreased sensation and strength to lower extremities

33
Q

What is the Canadian C Spine Rule?

A

To be applied in patients with GCS score 15

High risk factors = C-Spine xray

  1. Age > 65 years
  2. Dangerous mechanism (fall from > 1 m/5 stairs, an axial load to the head, MVC at high speed, rollover or ejection, motorized recreational vehicle collision, bicycle collision)
  3. Paresthesias in extremities

Low-Risk factors that allows safe range of motion assessment:

  1. Simple rear end MVC
  2. Sitting position in the ED
  3. Ambulatory at any time
  4. Delayed onset of neck pain
  5. No midline cervical tenderness
    * **If one of these, then ask the patient to rotate neck actively 45 degrees to left and right - if ABLE to do this, then no C spine xray. If UNABLE to do this, then get C spine xray
34
Q

What is the NEXUS criteria for C-spine xrays?

A

If a patient meets ALL these low risk criteria, then do not need to do C spine xray:

  1. No posterior midline C spine tendernesss
  2. No evidence of intoxication
  3. Normal level of consciousness
  4. No focal neurological deficit
  5. No painful distracting injuries
***NEXUS mnemonic:
N - Neuro deficit
E - ETOH (intoxication)
X - eXtreme distracting injury
U - Unable to provide history (altered LOC)
S - Spinal tenderness (midline)
35
Q

True or false: when assessing clinically for C spine injury, never use passive ROM.

A

TRUE! Under no circumstances should clinicians force the patient’s neck into a position that elicits pain. All movements must be voluntary

36
Q

What is your next step if a patient still complains of neck pain/unable to move neck despite normal C spine xray and CT of the neck?

A

Immobilize in soft collar and order MRI - may have a ligamentous injury. MRI is the most sensitive tool for identifying soft tissue injuries

37
Q

You have diagnosed a patient with a C spine fracture. Should you obtain xrays of thoracic and lumbar spines too?

A

YES. Approximately 10% of patients with cervical spine fractures have a second noncontiguous vertebral column fracture so you should xray the entire spine in any patient with a C spine fracture

38
Q

What is the best imaging test for patients who have neurological deficits and you suspect a spinal cord injury?

A

MRI! Can identify spinal epidural hematomas, traumatic herniated disks, etc.

39
Q

How do you prevent spinal movement of a patient with a suspected spine injury?

A
  1. Place a C spine collar
  2. Lie patient supine without rotating or bending the spinal column on a firm surface

***overall: maintain spinal motion restriction until an injury is excluded

40
Q

What is the number of people needed to do a log roll?

A

4 people - 1 person at head of bed providing in line C spine stabilization, 2 people at one side to log roll the patient and 1 person on the other side to remove the backboard and palpate the entire column of the spine for step deformities/pain

41
Q

How do you clear a C-spine?

A
  1. With the patient in a supine position, remove the C-collar and palpate the spine
  2. If there is no significant tenderness, ask the patient to voluntarily move his or her neck to from side to side and flex and extend their neck. If no pain, C-spine films are not necessary and the C-spine collar can be safely removed

***Patients who DO have neck pain or midline tenderness require radiographic imaging

42
Q

What is the normal prevertebral space?

A

At C3 should be < 7 mm. At C7 should be < 21 mm. (Remember 3 and 7: 3x7 = 21 mm)

***Increased prevertebral space should make you suspicious for C2 fracture

43
Q

When should you consider the possibility of neurogenic shock in a trauma patient?
-management?

A

Patient with hypotension and inappropriately normal HR or bradycardia - very suspicious for neurogenic shock.
1. Attempt fluid challenge - if no improvement in hypotension and no other source of occult hemorrhage are found, start vasopressors (phenylephrine or norepinephrine)

44
Q

What is the evidence on use of steroids in spinal cord injury?

A

There is insufficient evidence to support the use of steroids in spinal cord injury

45
Q

Fill in the blank: Cervical spine injuries above C__ can result in partial or total loss of respiratory function.

A

Above C6
(C3-C5 innervate the diaphragm)
(Intercostal muscles are innervated by upper thoracic nerves, T1-T6ish)

Deck Medicina ATLS (13 decks)

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