Spine Trauma & Traumatic Spinal Cord Injury (TSCI) Flashcards
bimodal peak of spinal injuries?
- 1st peak- 16-30 years old (most frequent age 19)
- 2nd peak- 65+
who is at increased risk of underlying spinal disease?
- cervical spondylosis
- osteoporosis
- atlantoaxial instability
- spinal arthropathies, e.g, RA, ankylosing spondylitis
mechanism of injuries in TSCI?
extremes motion
- hyperflexion, e.g diving
- hyperextension, e.g, hitting dashboard/windshield in MVA
- lateral flexion (bending)
Axial loading
- vertical (axial) compression, e.g, direct impact to head from above, land on feet from height
- distraction
others
- Penetrating
- electrocution
Who should be treated as having a SCI?
- all significant trauma victims: sudden decelerations, compression injuries, blunt trauma, violent mechanisms
- trauma patients with loss of consciousness
- minor trauma victims with spine symptoms, i.e, c/o back pain or tenderness; extremity numbness/tingling or weaknes
Acute evaluation of ED managment
Spine precautions
- Manual immobilization; hard cervical collar, spine in neutral position
- back board
- log roll
- extrication
- ABC’s–> emergency resuscitation
- Maintain oxygenation
- avoid hypotension
neurological evaluation
- focused history i.e mechanisms of injury, LOC, motor/sensory sxs, neck/back pain
- assess GCS (glascow coma scale) score
- palpitation of spine for point tenderness, “step-off” (seeing if there is any spinal dislocation
- DTRs
- Assess anal sphincter tone
neurologcial evaluation in an awake pt?
motor and sensory in all extremities
neurological evaluation of unconscious patient?
muscle tone, reflexes, rectal sphincter tone, priapism
who needs a cervical collar?
- altered mental status
- evidence of intoxication
- neruological deficit
- suspected extremity fracture
- spine pain/tenderness
low risk NEXUS criteria?
If criteria is met= no radiography
- no posterior midline C-spine tenderness
- no evidence of intoxication
- a normal level of alertness
- no focal neurological defects
- no painful distracting injuries
high risk factors that mandates radiography?
- age > 65 years
- dangerous mechanism (fall from > 3ft or 5 stairs, an axial load to head, a MVA, a collision involving a motorized recreaional vehicle, a bicycle collision)
- paresthesias in extremities
radiographic evaluation of the spine should show?
AABCDS
- Adequacy: must see C7-T1 transition
- alignment: lines
- bone: landmarks, symmetry
- cartilage
- disc: disc space height
- soft tissue (soft tissue space measurements: nasopharyngeal space (C1) < 10mm adults; retropharyngeal (prevertebral) space < 7mm, retrotracheal (C5-C7) < 20mm
- be prepared to intubate with significant edema; steroids
awake, asymptomatic patient [level 1]
- no radiographic C-spine evaluation
- discontinue cervical immobilization
awake, symptomatic (back pain etc.) patient [level 1]
high quality CT recommended; if not available 3-view C-spine series recommended
Awake, symptomatic patient [level III]
- awake patient w/ neck pain or tenderness and normal high-quality CT imaging or normal 3 view-C-spine series
- continue cervical immobilization until asymptomatic
- discontinue immobilization forllowing normal and adequate dynamic flexion/extension radiographs
- discontinue immobilization following a normal MRI obtained w/in 48hrs of injury
- discontinue immobilization at discretion of treating physician
obtunded or unevaluable patient [level 1]
- high-quality CT imaging recommended as initial imaging modality; if CT is done, routine 3-view C-spine radiographs not recommended
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Obtunded or evaluable patient [level II]
Consult physicians trained in diagnosis
obtunded or unevaluable patient [Level III]
- in obtunded or enevaluable patient w/ a normal high quality CT scan or normal 3-view C-spine series
- continue cervical immobilization until asymptomatic
- discontinue immboilization following a normal MRI study obtained w/in 48hrs of injury or
- discontinue immobilization at the discretion of the treating physician
what are other indications for radiologic assessment?
- thoracolumbar spine imaging is indicated if there is pain, bruising, swelling, deformity or abnormal neurology attributable to the thoracic or lumbar spinal regions
- the presence of a fracture anywhere in the spine mandates full spinal imaging
- unconscious patients who cannot be assessed clinically also require radiological clearance of the entire spine
what are concerns when there is a spinal column fracture identified?
- is there a dislocation causing cord compression
- are fractures “unstable” that may lead malalignment and cord compression at present or in the fution
- if there is evidence of compression–> decompression should be urgent–> w/in 2 hours for best chance of return to function
consists of the anterior longitudinal ligament and the anterior one half of the body, disc and annulus.
anterior column
consist of the posterior one half of the body, disc and annulus and the posterior longitudinal ligament
middle column
consists of the facet joints, ligamentum flavum, the posterior elements and the interconnecting ligaments
posterior column
- unstable
- MRI, flexion-extension films diagnostic for these injuries
ligamentous injuries
- mild anterior subluxation
- simple burst (1 column fx)
- simple wedge
- clay shoeveler’s
Stable spine fractures
- flexion teardrop
- jefferson fx
- hangman fx
- dens (type III, II)
- complex burst fracture (2-3 column fx)
unstable spine fracture
- does not immobilize
- comfort measure
- not recommended for most soft tissue injuries (rather, range of motion exercises)
soft collar
- does immobilize
- comfort
- must be worn 24:7
- philadephia collar; miami J collar; aspen collar
hard collar
indications and goals for surgical intervention in spinal injury
indications
- significant spinal cord compression with neuro deficit
- unstable fracture or dislocation
- instability of spine
Goals
- stabilize spine
- reduce dislocation
- decompress natural elements
refer to spine surgeon
- traumatic soft tissue injury in cervical spine region (muscles, ligaments, discs, facet jts); no fractures, no neurologic deficit
- commonly due to sudden hyperextension, hyperflexion, rotational injury in absence of fracture, dislocation or herniated disc
- symptoms appear 12-24 hrs after injury; neck pain, HA, radiating pain across shoulders, muscle spasm, hand paresthesias, LBP
- most common MVA injury
- reassure, prescribe activities, manage pain (heat, NSAIDs)
- usually recover 3-6mos; 10% have pain at 2 years
Cervical strain/sprain (Whiplash)
