Vertebral Column Trauma

Question 1

what are the types of injuries that can occur to the vertebral column?

Answer 1

1. fractures or luxations
2. acute disc herniations
3. soft tissue injuries
4. contusions or lacerations
5. nerve root injury or entrapment

Question 2

which is worse – the primary spinal cord injury or the secondary?

Answer 2

secondary

primary injury occurs first and secondary injury (ischemia, neuroinflammation, excitotoxicity, edema, myelomalacia) occurs second and these can be more devestating than the initial injury.
Thus our goal is to minimize secondary injury.

Question 3

what forces do vertebral bodies resist?

Answer 3

bending forces

Question 4

what forces does articular facets of vertebral bodies resist?

Answer 4

ALL forces

Question 5

what forces do intervertebral discs resist?

Answer 5

lateral bending and torsional forces

Question 6

T/F: forces dictate the type of injury that occurs

Answer 6

true
forces include: bending, torsional, shear, and axial-loading

Question 7

what are stress-riser regions and what are the 4 regions?

Answer 7

junctions between 2 different types of vertebrae which lead to a decreased ability to resist forces as strongly.

examples of stress riser regions are:
1. craniocervical junction (c1-c2)
2. cervicothoracic junction (c6-t2)
3. T-L junction
4. L-S junction *

Question 8

when a potential vertebral trauma cases presents to you, what is the first thing you and your team should do?

Answer 8

ABCs
then asses for concurrent injuries – cardiovascular, appendicular fractures, ST trauma, head trauma, and urinary tract injuries.

Question 9

what position should your neuro exam be done in during a possible vertebral trauma?

Answer 9

lateral recumbency

Question 10

what is argubaly the most important part of your neuro assessment on a patient with potential vertebral trauma?

Answer 10

conscious proprioception of deep pain

Question 11

How can we assess the stability of a vertebral trauma?

Answer 11

disruption of 2/3 compartments of the vertebra = UNSTABLE

if the patient is progressively deteriorating after the trauma occurred, then this is considered UNSTABLE

Question 12

Give word descriptions for the following modified frankel grades:
0
1
2
3
4
5

Answer 12

0: normal
1: pain only
2: ambulatory paraparesis, ataxia
3: non-ambulatory paraparesis
4: paraplegia with intact deep pain
5: paraplegia with absent deep pain

Question 13

T/F: if a patient presents in schiff sherrington or has spinal shock, this automatically means a poor prognosis

Answer 13

false
you must assess deep pain to determine prognosis

Question 14

what is the prognosis for most cervical spinal cord injury?

Answer 14

if they survive the acute injury, prognosis is actually good (60-70%)

Question 15

what is the prognosis for either T-L or L-S spinal cord injury both with INTACT pain perception?

Answer 15

T-L – good with surgery
L-S – good with conservative tx
generally 60-80%

note that this is a little worse than disc disease prognosis (80-90%)

Question 16

what is the prognosis for a patient that has a cervical or T-L spinal cord injury and NO deep pain perception?

Answer 16

grave :(

note: if this were IVDD, it would be 50:50 prognosis

Question 17

What is involved in the INITIAL treatment of spinal cord injury patients?

Answer 17

1. immobilize them
2. supportive care to minimize secondary spinal cord injury (maintain BP, oxygen therapy, analgesics - full mu)

Question 18

What type of imaging is indicated for spinal cord / vertebral trauma?

Answer 18

1. xray first – all views taken in lateral recumbency to avoid moving patient
2. advanced imaging (CT/MRI) indicated if no lesion found on xray, xray does no match exam, sx therapy is indicated, or if needing to eval the integrity of the spinal cord

Question 19

IN GENERAL (like very general), what are the treatment options for spinal cord / vertebral trauma patients – stable vs unstable injuries?

Answer 19

stable – conservative treatment (cage rest 6 weeks + analgesia)

unstable – surgical tx* or conservative

Question 20

why is conservative treatment indicated for cervical spinal cord injuries?

Answer 20

high mortality rate for surgery (40%)

Question 21

T/F: conservative management is indicated for patients with absent deep pain perception

Answer 21

false – its indicated for those with intact deep pain perception.

Question 22

what does conservative therapy look like for patients with spinal cord / vertebral injruies?

Answer 22

EXTERNAL COAPTATION – this entails rigid immobilization of high-motion segments above and below the lesion

Cervical – behind eyes –> behind shoulder
TL and lumbar: cranial shoulder –> tail (full body)

Question 23

why is external coaptation difficult and not the BEST option for everyone?

Answer 23

its expensive (Requires multiple rechecks with sedation to place the cast)
its difficult to obtain rigid immobilization
it has complications such as wounds and infection

Question 24

how do we assess the success of external coaptation in patients with vertebral trauma?

Answer 24

1. keep them hispitalized for the 1st 2-5 days
2. recheck them weekly for 3 weeks
3. on week 4, repeat xrays and remove the brace if it is healed.

Question 25

why do some dogs with cervical injury only have mild injury/signs?

Answer 25

the canal:cord diameter is larger this is favorable

Question 26

why should you consider performing surgery in a patient with unstable thoracolumbar injruies?

Answer 26

they are very difficult to rigidly fixate and if decompensation were to occur, the consequences would be severe.
It is very common for them to residual deficits with conservative therapy.

Question 27

Most morbidity with lumbosacral injuries is associated with what?

Answer 27

incontinence

Question 28

what is the classic clinical sign of sacrocaudal injury (tail pull injury) in cats?

Answer 28

platigrade stance**

others:
flaccid tail
decreased or absent perineal reflex, anal tone, or tail pain perception
urinary and/or fecal incontinence

Question 29

what is the treatment for tail pull injuries?

Answer 29

cage rest
analgesics
bladder management

maybe tail amuputation or internal fixation

Question 30

what is unique about the prognosis for sacrocaudal injury / tail pull injury?

Answer 30

if tail and perineal sensation is present, MOST improve within 2 weeks from the injury.
most have return of urinary function and tail function.

Even without intact pain perception, 50% regain urinary function.