spine trauma ASIA class and trauma guidelines

Question 1

In the ASIA classification, what is meant by the single neurological level?

Answer 1

most caudal segment of the SC with intact sensation and antigravity muscle function, identified as the most rostral of the total 2 sensory and 2 motor levels

Question 2

What is the sensory neurological level?

Answer 2

• most caudal “intact” dermatome for both LT & PP

both score 2 at that level and above

Question 3

what is the motor neurological level?

Answer 3

lowest key muscle function with grade of at least 3, providing key muscle function of segments above that level are grade 5

Question 4

how does one determine the motor level in the thoracic spine?

Answer 4

Where there are no muscles to test the sensory level defines the motor level

Question 5

when determining the neurological level, what should occur if sensation at C4 is abnormal?

Answer 5

If the sensory level is not normal at C4, the C5 motor testing can not be used to define the patients motor level
(sensation at C4 must be normal to determine motor level with upper extremity key muscle testing)

Same rule applies to L1 sensory level with respect to L2 motor testing

Question 6

How does one define an ASIA A complete injury?

Answer 6

No sensory or motor function is preserved in the sacral segments S4-S5

Question 7

What is an ASIA B classification?

Answer 7

Sensory, no motor function preserved below the neurological level; includes sacral segments S4-S5 (LT, PP at S4-S5: or DAP), AND no motor function is preserved more than three levels below the motor level on either side of the body

Question 8

What is an ASIA C, motor incomplete injury?

Answer 8

Motor function is preserved below the neurological level, more than half of key muscle functions below SNL has a muscle grade less than 3 (Grades 0-2)

Question 9

What is an ASIA D, motor incomplete injury?

Answer 9

Motor function is preserved below the neurological level, at least half (or more) key muscle functions below the SNL have a muscle grade > 3.

Question 10

What is the zone of partial preservation?

Answer 10

ZPP is only used with complete injuries (AIS A)
ZPP refers to the dermatomes and myotomes caudal to the sensory and motor levels that remain partially innervated
The most caudal segment with some sensory and/or motor function defines the extent of the sensory and motor ZPP respectively and are recorded for the right and left sides

Question 11

What are the guidelines with regard to early closed reduction after cervical spine dislocation?

Answer 11

Early closed reduction of cervical spinal
fracture/dislocation injuries with craniocervical
traction for the restoration of anatomic
alignment of the cervical spine in awake
patients is recommended.
• Closed reduction in patients with an additional
rostral injury is not recommended.

Question 12

what are the guidelines with regard to medical management of a spinal cord injury patient

Answer 12

Manage in an ICU or similar monitored
setting is recommended.
• Use of cardiac, hemodynamic, and respiratory
monitoring devices to detect cardiovascular
dysfunction and respiratory insufficiency
• Correction of hypotension (systolic blood pressure , 90 mm
Hg) when possible and as soon as possible is
recommended.
• Maintenance of MAP
between 85 and 90 mm Hg for the first 7
days following an acute spinal cord injury is
recommended.

Question 13

what are the guidelines for pharmacotherapy after SCI?

Answer 13

Do not give methylprednisilone or any other agent outside of a trial setting

Question 14

what are the guidelines with regard to the diagnosis and management of occipital condyle fractures?

Answer 14

Diagnostic:
Level II:
• Computed tomographic (CT) imaging is
recommended to establish the diagnosis of
occipital condyle fractures (OCFs).
Level III:
• Magnetic resonance imaging (MRI) is recommended
to assess the integrity of the craniocervical
ligaments.
Treatment:
Level III:
• External cervical immobilization is recommended
for all types of OCFs. More rigid
external immobilization in a halo vest device
should be considered for bilateral OCF.
• Halo vest immobilization or occipitocervical
stabilization and fusion are recommended for
injuries with associated atlanto occipital ligamentous
injury or evidence of instability.

Question 15

What are the guidelines with regard to the diagnosis of AOD?

Answer 15

Diagnostic
Level I
• Computed tomography (CT) imaging to determine
the CCI (condyle-C1 interval) in pediatric
patients with potential atlanto-occipital dislocation
(AOD) is recommended.

Level III
• If there is clinical or radiographic suspicion of
AOD, CT of the craniocervical junction is
recommended.

• A lateral cervical radiograph is recommended
for the diagnosis of AOD.

the basionaxial
interval-basion dental interval (BAIBDI)
method is recommended. The presence
of upper cervical prevertebral soft tissue
swelling (STS) on an otherwise non-diagnostic
plain cervical radiograph should prompt
CT imaging to rule out AOD.

Question 16

What are the guidelines with regard to the management of AOD?

Answer 16

Level III
• internal fixation and fusion
• Traction is not recommended, and is associated
with a 10% risk of neurological deterioration.

Question 17

what are the guidelines for isolated fracture of the atlas?

Answer 17

For an isolated fracture of the atlas with an
intact transverse atlantal ligament, cervical
immobilization is recommended.

with disruption
of the transverse atlantal ligament, either cervical
immobilization alone or surgical fixation and
fusion is recommended.

Question 18

what are the guidelines for odontoid fractures?

Answer 18

Level II:
• Consideration of surgical stabilization and fusion
for type II odontoid fractures in patients >50
years of age is recommended.

Level III:
• Initial management of nondisplaced type I, type
II, and type III odontoid fractures with external
cervical immobilization is recommended, recognizing
that a decreased rate of union (healing)
has been reported with type II odontoid fractures
compared with type I or type III odontoid
fractures.

• Surgical stabilization and fusion of type II and
type III odontoid fractures with dens displacement
> 5 mm, comminution of the odontoid
fracture, and/or inability to achieve or maintain
fracture alignment with external immobilization
are recommended.

• If surgical stabilization is elected, either anterior
or posterior techniques are recommended.

Question 19

What are guidelines for treatment of Traumatic Spondylolisthesis of the Axis
(Hangman Fracture)

Answer 19

Level III:
• External immobilization as the initial management
of traumatic spondylolisthesis of the
axis is recommended.
• Surgical stabilization and fusion for the
treatment of Hangman fractures in cases of
severe angulation of C2 on C3, disruption
of the C2-3 disk space, and/or inability to
achieve or maintain fracture alignment with
external immobilization are recommended.

Question 20

What are guidelines for treatment of Fractures of the Axis Body
(Miscellaneous Fractures)

Answer 20

Level III:
• External immobilization for the treatment of
isolated fractures of the axis body is recommended.

Consideration of surgical stabilization
and fusion in unusual situations of severe
ligamentous disruption and/or inability to
achieve or maintain fracture alignment with
external immobilization are recommended.

• In the presence of comminuted fracture of the
axis body, evaluation for vertebral artery injury
is recommended.

Question 21

What are guidelines for management of combination C1/2 fractures?

Answer 21

Level III:
The treatment of combination atlas-axis fractures
based primarily on the specific characteristics
of the axis fracture is recommended.
• External immobilization of most C1-C2 combination
fractures is recommended.
• C1-type II odontoid combination fractures
with an atlanto-dental ratio of > 5 mm and
C1-Hangman combination fractures with C2-
C3 angulation of > 11 should be considered
for surgical stabilization and fusion.

Question 22

what are guidelines for the management of os odontoidium?

Answer 22

Level III:
• Clinical and radiographic surveillance or posterior
C1-C2 internal fixation and fusion are
recommended for patients with os odontoideum
without symptoms or neurological signs.

• Posterior C1-C2 internal fixation and fusion
- with neurological symptoms, signs,
or C1-C2 instability.

• Postoperative halo immobilization as an adjunct to posterior internal
fixation and fusion unless rigid C1-C2 internal
fixation is accomplished.

• Occipital-cervical internal fixation and fusion
with or without C1 laminectomy -
in patients with os odontoideum who
have irreducible dorsal cervicomedullary compression
and/or evidence of associated occipital-atlantal instability.

• Ventral decompression should be considered in
patients with os odontoideum who have irreducible
ventral cervicomedullary compression.

Question 23

What are the 3 components of the SLIC classification for subaxial cervical injuries?

Answer 23

Morpohology
DLC
Neurology

Question 24

How are each scored?

Answer 24

Morphology
no abnorm - 0
compression + 1
burst +1
distraction (perched facet, hyperextension) +3
rotation / translation (dislocated facet) +4

DLC
intact 0
indeterminate +1
disrupted +2

Neurology
intact 0
root injury +1
complete +2
incomplete +3
(ongoing compression +1)

0-3 no surgery
4 - indeterm.
5+ surgery

Question 25

What are the treatment guidelines for subaxial cervical spine injury

Answer 25

Level III:
• Closed or open reduction of subaxial cervical
fractures or dislocations - Decompression of the spinal cord/restoration of the spinal canal is the goal.

• Stable immobilization by either internal fixation
or external immobilization to allow for
early patient mobilization and rehabilitation

• Treatment of subaxial cervical fractures and
dislocations with prolonged bed rest in traction
is recommended if more contemporary treatment
options are not available.

• The routine use of computed tomography and
magnetic resonance imaging of trauma victims
with ankylosing spondylitis - even after minor trauma.

• For patients with ankylosing spondylitis who
require surgical stabilization, posterior long segment
instrumentation and fusion or a
combined dorsal and anterior procedure is
recommended. Anterior standalone instrumentation
and fusion procedures are associated
with a failure rate of up to 50% in these
patients.

Question 26

what are the treatment guidelines for central cord syndrome?

Answer 26

Intensive care unit management of patients
with acute traumatic central cord syndrome
(ATCCS), particularly patients with severe
neurological deficits, is recommended.

• Medical management, including cardiac,
hemodynamic, and respiratory monitoring,
and maintenance of mean arterial blood
pressure at 85 to 90 mm Hg for the first
week after injury to improve spinal cord
perfusion is recommended.

• Early reduction of fracture-dislocation injuries
is recommended.

• Surgical decompression of the compressed
spinal cord, particularly if the compression
is focal and anterior, is recommended.