Spine Trauma Flashcards
cervical spine is overall the most commonly injured region of the spinal column, with most injuries occurring at the _________ and from ___________.
C2 level
C5 to C7
second most common region of injury is in the __________
thoracolumbar transition zone (T11 to L2)
When compressive forces exceed the absorptive capacity of the disk, the______(1)______ ruptures.
This allows the _____(2)________ to protrude into the vertebral canal, and this may result in spinal nerve or spinal cord compression.
(1) annulus fibrosus
(2) nucleus pulposus
called “clay shoveler “ fracture
Spinous process avulsion (stable)
—When a single avulsion is present
—caused by strong muscle contractions pulling on the bone via the ligamentous complex
Cervical
MOI:Flexion
Most common thoracic fracture
Simple wedge (compression) fracture
Vertical compression forces the occipital condyles downward and produces a burst fracture by driving the lateral masses of C1 apart.
This is best seen as outward displacement of the lateral masses on the open-mouth odontoid radiograph or on CT.
Jefferson burst fracture of atlas
(potentially unstable)
Hangman’s fracture aka _________ __________ is a fracture of both pedicles of ____, with the _______displacement of _____on _____.
This was associated with the neck hyperextension from judicial hangings, where the noose knot is placed under the subject’s chin and snaps the head backward.
Traumatic spondylolisthesis
C2
anterior displacement of C2 on C3
Secondary to high-energy impact. Historically, strongly associated with mortality.
The classic presentation is paralysis of upper extremities with lack of lower extremity paralysis or weakness (cruciate paralysis).
Another common presentation being lower cranial nerve deficits.
Atlanto-occipital dissociation (AOD)
(highly unstable)
In radiographs in the normal patient, the distance between the basion and the superior cortex of the dens (basion-dental interval [BDI]) should be ≤10 mm in adults (≤8.5 mm on CT).
In addition, the distance from the basion to the posterior border of the body of C2 (basion-atlantal interval [BAI]) should be ≤12 mm anterior displacement or ≤4 mm posterior displacement on a lateral radiograph.
If there are abnormalities in both the BDI and BAI, this strongly suggests the existence of AOD.
This is a high-energy disruption of all three columns of spine and is readily apparent both on radiographs and CT.
Patients commonly present with severe neurologic findings.
These fractures are most often unstable; however, in the absence of destabilizing rib cage fractures, lesions above T7 can be stable.
Translational fracture- dislocation
(unstable)
This fracture occurs when a vertebra is crushed by an axial load, causing fragments to displace in all directions.
The lateral radiograph may show an obvious fracture of the end plates, but sometimes all that is seen is a bowing or disruption of the posterior cortex of the affected vertebra.
The anterior radiographic view may show a vertical fracture through the vertebral body and widening of the interpedicular distance.
Burst fracture
(unstable)
True or false
Corticosteroids are contraindicated in patients with any type of penetrating spinal injuries
True
True or false
high-dose methylprednisolone therapy has NOT been found to be efficacious in penetrating spinal cord injury
True
True or false
The option to start corticosteroids should only be made in conjunction with the surgeon who will ultimately be caring for the patient and not given routinely.
True
What is National Acute Spinal Cord Injury Study (NASCIS) II High-Dose Methylprednisolone Protocol?
Sacral fractures that involve the _______________ can produce bowel or bladder dysfunction.
central sacral canal
These fractures occur as a result of a hyperflexion during an axial load that crushes the anterior portion of the vertebra.
If the percentage of loss of vertebral height is <40% = candidate for outpatient therapy.
If the loss of vertebral height is ≥50% or if the angle between the damaged vertebra and the rest of the spinal column is >25% to 30% =unstable
Compression fractures, also known as “wedge” or “anterior” compression fractures
compression- type fracture that involves the posterior half of the vertebrae and is reported to be 39.5% of thoracolumbar fractures
burst fracture
This fracture occurs via a flexion-distraction mechanism and involves minor anterior vertebral compression and significant distraction of the middle and posterior ligamentous structures.
Typical radiographic findings reveal a transverse fracture lucency in the vertebral body, an increased height of the posterior vertebral body, fracture of the posterior wall of the vertebral body, and posterior opening of the disk space.
Chance fracture
Define NEUROGENIC SHOCK
Neurogenic shock is a type of distributive shock that can occur with CNS or spinal cord injury that probably occurs in less than 20% of spinal cord–injured patients.
Loss of peripheral sympathetic innervation results in extreme vasodilatation secondary to loss of sympathetic arterial tone. This causes blood pooling in the distal circulation with resultant hypotension.
If the T1 through T4 cord levels are compromised, loss of sympathetic innervation to the heart leaves unopposed vagal parasympathetic cardiac innervation. This results in bradycardia or an absence of reflex tachycardia.
In general, patients with neurogenic shock are warm, peripherally vasodilated, and hypotensive with a relative bradycardia. Patients tend to tolerate hypotension relatively well, because peripheral oxygen delivery is presumably normal. Loss of sympathetic tone and subsequent inability to redirect blood from the periphery to the core may cause excessive heat loss and hypothermia.
The diagnosis of neurogenic shock is one of exclusion. Certain clues, such as bradycardia and warm, dry skin, may be evident, but hypotension in the trauma patient can never be presumed to be caused by neurogenic shock until other possible sources of hypotension are excluded.
Define SPINAL SHOCK
Spinal shock is not neurogenic shock; the two terms have very different meanings and are not interchangeable.
Spinal shock is the temporary loss or depression of spinal reflex activity that occurs below a complete or incomplete spinal cord injury.
The typical presentation involves flaccidity, loss of reflexes, and loss of voluntary movement.
The lower the level of the spinal cord injury, the more likely it is that all distal reflexes will be absent. Loss of neurologic function that occurs with spinal shock can cause an incomplete spinal cord injury to mimic a complete cord injury. Therefore, cord lesions cannot be called complete until spinal shock has resolved.
The delayed plantar and bulbocavernosus reflexes are among the first to return as spinal shock resolves. The duration of spinal shock is variable; it generally lasts for days to weeks but can persist for up to 6 months.
In alert, stable, adult trauma patients who have no neurologic deficits (i.e., low-risk trauma patients), two major clinical decision rules have been defined to avoid unnecessary radiography.
The first decision rule was derived by the National Emergency X-Radiography Utilization Study (NEXUS), which determined that plain cervical spine imaging can be safely avoided in patients who have all five clinical criteria. What is the NEXUS Criteria?
The most common cause of Brown-Séquard syndrome is
PENETRATING INJURY
It can also be caused by lateral cord compression secondary to disk protrusion, hematomas, spine fractures, infections, spinal cord infarctions, multiple sclerosis, or tumors
The Canadian Cervical Spine Rule for Radiography (CCR) was developed for alert, stable trauma patients to reduce practice variation and inefficiency in the ED use of plain cervical spine radiography.
The Canadian rule consists of three assessments, which are asked in sequential order.
To proceed to the next assessment, the answer to the previous assessment must be “Yes.”
If the answer to any assessments is “No,” then imaging is immediately performed.
What is the CCR Criteria?
Dangerous Mechanism of Injury in CCR means?
Defined as:
FALL from a height of >3 feet;
an AXIAL loading injury;
HIGH-SPEED motor vehicle crash, rollover, or ejection; motorized recreational vehicle or bicycle COLLISION.
True or false
CT is the initial imaging modality of choice to evaluate the traumatized cervical spine.
True
Imaging of the thoracic and lumbar spine is indicated in a multisystem blunt trauma patient when any of the following criteria are met:
results from damage to the corticospinal and spinothalamic pathways, with preservation of posterior column function
anterior cord syndrome
manifested by loss of motor function and pain and temperature sensation distal to the lesion
Only vibration, position, and tactile sensation are preserved
anterior cord syndrome
anterior cord syndrome mechanism
Direct injury to the anterior spinal cord
Flexion of the cervical spine may result in cord contusion or bone injury with secondary cord injury
Thrombosis of the anterior spinal artery can cause ischemic injury to the anterior cord.
Extrinsic mass that is amenable to surgical decompres- sion.
The overall prognosis for recovery of function is POOR
usually seen in older patients with pre- existing cervical spondylosis who sustain a hyperextension injury
central cord syndrome
Decreased strength and, to a lesser degree, decreased pain and temperature sensation, more in the UPPER than the lower extremities
Vibration and position sensation are usually preserved
What Spinal Cord Syndrome and why?
Central cord syndrome
The centrally located fibers of the corticospinal and spinothalamic tracts are affected. The neural tracts providing function to the upper extremities are most medial in position compared with the thoracic, lower extremity, and sacral fibers that have a more lateral distribution.
Test C7 by
Wrist and Elbow extension
Test for L1, L2, L3
Iliopsoas, Hip Flexion
Test for L2 L3 L4
Quadriceps, Knee Extension
Test for L4 L5 S1 S2
Knee Flexion, Hamstrings
Test for L5 S1
Extensor Hallucis longus, Great toe extension
Test for S1 S2
Gastrocnemius, Ankle plantar flexion
Test for S2 S3 S4
Bladder and anal sphincter, Voluntary rectal tone
Test for C8 T1
Hand intrinsics: Finger abduction
Flexor digitorum profundus: Hand grasp
Test for C5 C6
Deltoid: arm abduction
Biceps: Elbow flexion
Test for C6 C7
Extensor carpi radialis, Wrist extension
Test for C7 C8
Triceps, elbow extension
adult spinal cord ends as the
conus medullaris at the level of the lower border of the first lumbar vertebra
any patient with an injury at ___________ should have the airway secured by endotracheal intubation
C5 or above
Pay particular attention to any symptoms indicating present or impending respiratory compromise, including dyspnea, palpitations, abdominal breathing, and anxiety, which may indicate a
high cervical spine injury
True or false
priapism implies a complete spinal cord injury
True
