Trauma: skull, brain, vascular trauma, spinal cord, nerve trauma

Question 1

When should cord injury be assumed?

Answer 1

• Significant falls (>3m)
• Decceleration injuries
• Blunt trauma to head / neck / back

Question 2

When can cauda equina syndrome occur?

Answer 2

With any spinal cord injury below T10.

Question 3

Types of spinal cord injuries?

Answer 3

• Complete / incompete transection
• Cord oedema
• Spinal shock

Question 4

Hx in ?spinal trauma?

Answer 4

• AMPLE

- ?neck pain / paralysis / paresthesia

Question 5

Exam in ?spinal trauma workup?

Answer 5

• ABCDE
• Abdo: ecchymosis, tenderness
• Total neuro
• Spine: maintain neutral position, palpate C spine; logroll, then palpate Tspine and L spine, assess rectal tone
• Extremities: cap refill, suspect thoracolumbar injury with calcaneal #

Question 6

What should be assessed for when palpating spine in examination?

Answer 6

• Tenderness
• Muscle spasm
• Bone deformities
• Step off and spinal process malalignment

Question 7

Imaging in ?spinal injury?

Answer 7

• Full C spine X ray series for trauma (AP, lateral, odontoid)
• Thoracolumbar Xrays (AP and lateral)
• Consider CT, MRI

Question 8

What are the indications for thoracolumbar X-rays?

Answer 8

• Pt w/ C spine injury
• Unconscious pts
• Pts w/ neurological sx/signs
• pts with palpable deformities on log roll
• pts w/ back pain
• pts w/ bilateral calcaneal #

Question 9

When can C spine be cleared?

Answer 9

Can clear C spine if:

• no posterior midline cervical tenderness
• no evidence of intoxication
• oriented to P/P/T/E
• no focal neurological deficits
• no painful distracting injuries (e.g. long bone #)

Question 10

Mx of spinal cord injury?

Answer 10

• Immobilise
• ABCs
• Treat shock
• Insert NGT and Foley catheter
• High dose steroids
• Complete imaging of spine
• Continually reassess high cord injuries (oedema can travel up cord)
• Watch for resp insufficiency if C cord injury
• Warm blanket, volume infusion, ?vasopressors

Question 11

Sequelae of acute phase SCI?

Answer 11

• Spinal shock

- Neurogenic shock

Question 12

What is spinal shock?

Answer 12

Absence of all voluntary and reflex activity below level of injury (decreased reflexes, no sensation, flaccid paralysis below level of injury)

Question 13

What is neurogenic shock?

Answer 13

Loss of vasomotor tone, SNS tone. Occurs w/in 30min of SCI at level T6 or above.
Watch for: hypotension (no SNS), bradycardia (unopposed PNS), poikilothermia (no SNS so no shunting of blood from extremities to core)

Question 14

What are the high dose steroids used in SCI?

Answer 14

-Methylprednisolone 30mg/kg bolus

Then 5.4mg/kg/h drip within 6-8h or injury.

Question 15

What are the types of spinal #?

Answer 15

• Compression # (58%)
• Burst # (17%)
• Flexion distraction injury (6%)
• Fracture dislocation (6%)

Question 16

Features of spinal compression #?

Answer 16

• Produced by flexion
• Posterior ligament complex remain intact
• Stable but produce kyphotic deformity

Question 17

What is the posterior ligament complex?

Answer 17

• Supraspinous and interspinous ligaments
• Ligamentum flavum
• Intervetebral joint capsule

Question 18

What are the features of spinal burst #?

Answer 18

Stable: anterior and middle columns parted with bone retropulsed nearby
Unstable: same + posterior column disruption (usually ligamentous)

Question 19

What are the hallmarks of burst fracture on Xray?

Answer 19

Pedicle widening on AP XR

Question 20

What is flexion distraction injury?

Answer 20

Hyperflexion and distraction of posterior elements (middle and posterior columns fail in distraction)
Classic = chance: horizontal fracture through posterior arch, pedicles, posterior vertebral body

Question 21

What is fracture dislocation?

Answer 21

Anterior and cranial dislocation of superior vertebral body --> 3 column failure.
3 types:
-flexion rotation
-flexion distraction
-shear/hyperextension