Spine Trauma & Traumatic Spinal Cord Injury (TSCI)

Question 1

bimodal peak of spinal injuries?

Answer 1

• 1st peak- 16-30 years old (most frequent age 19)
• 2nd peak- 65+

Question 2

who is at increased risk of underlying spinal disease?

Answer 2

• cervical spondylosis
• osteoporosis
• atlantoaxial instability
• spinal arthropathies, e.g, RA, ankylosing spondylitis

Question 3

mechanism of injuries in TSCI?

Answer 3

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

Question 4

Who should be treated as having a SCI?

Answer 4

• 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

Question 5

Acute evaluation of ED managment

Answer 5

Spine precautions

• Manual immobilization; hard cervical collar, spine in neutral position
• back board
• log roll
• extrication
• ABC’s–> emergency resuscitation
• Maintain oxygenation
• avoid hypotension

Question 6

neurological evaluation

Answer 6

• 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

Question 7

neurologcial evaluation in an awake pt?

Answer 7

motor and sensory in all extremities

Question 8

neurological evaluation of unconscious patient?

Answer 8

muscle tone, reflexes, rectal sphincter tone, priapism

Question 9

who needs a cervical collar?

Answer 9

• altered mental status
• evidence of intoxication
• neruological deficit
• suspected extremity fracture
• spine pain/tenderness

Question 10

low risk NEXUS criteria?

If criteria is met= no radiography

Answer 10

• no posterior midline C-spine tenderness
• no evidence of intoxication
• a normal level of alertness
• no focal neurological defects
• no painful distracting injuries

Question 11

high risk factors that mandates radiography?

Answer 11

• 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

Question 12

radiographic evaluation of the spine should show?

Answer 12

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

Question 13

awake, asymptomatic patient [level 1]

Answer 13

• no radiographic C-spine evaluation
• discontinue cervical immobilization

Question 14

awake, symptomatic (back pain etc.) patient [level 1]

Answer 14

high quality CT recommended; if not available 3-view C-spine series recommended

Question 15

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

Answer 15

• 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

Question 16

obtunded or unevaluable patient [level 1]

Answer 16

• high-quality CT imaging recommended as initial imaging modality; if CT is done, routine 3-view C-spine radiographs not recommended
  *

Question 17

Obtunded or evaluable patient [level II]

Answer 17

Consult physicians trained in diagnosis

Question 18

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

Answer 18

• 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

Question 19

what are other indications for radiologic assessment?

Answer 19

• 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

Question 20

what are concerns when there is a spinal column fracture identified?

Answer 20

• 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

Question 21

consists of the anterior longitudinal ligament and the anterior one half of the body, disc and annulus.

Answer 21

anterior column

Question 22

consist of the posterior one half of the body, disc and annulus and the posterior longitudinal ligament

Answer 22

middle column

Question 23

consists of the facet joints, ligamentum flavum, the posterior elements and the interconnecting ligaments

Answer 23

posterior column

Question 24

• unstable
• MRI, flexion-extension films diagnostic for these injuries

Answer 24

ligamentous injuries

Question 25

• mild anterior subluxation
• simple burst (1 column fx)
• simple wedge
• clay shoeveler’s

Answer 25

Stable spine fractures

Question 26

• flexion teardrop
• jefferson fx
• hangman fx
• dens (type III, II)
• complex burst fracture (2-3 column fx)

Answer 26

unstable spine fracture

Question 27

• does not immobilize
• comfort measure
• not recommended for most soft tissue injuries (rather, range of motion exercises)

Answer 27

soft collar

Question 28

• does immobilize
• comfort
• must be worn 24:7
• philadephia collar; miami J collar; aspen collar

Answer 28

hard collar

Question 29

indications and goals for surgical intervention in spinal injury

Answer 29

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

Question 30

• 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

Answer 30

Cervical strain/sprain (Whiplash)