Week 6 - B - Regional Adult Trauma (1) - Spinal injuries (cervical, thoracolumbar), spinal cord injuries and myotomes Flashcards
When do cervical spine fractures tend to occur?
They tend to occur in high energy injuries eg road traffic accidents or falling from a height and may be associated with head injury
Potentially dangerous unstable fractures may be missed in the unconscious or confused patient What may this result in regarding cervical spine fractures?
This may result in spinal cord injury
One should have a low threshold for C‐spine immobilization with a hard collar and sand bags or blocks on a spinal board in any high energy injury or head injury (ABCD – Airway with C‐spine control).
What are the criteria that must be satisfied to clinically clear the c-spine?
In order to clinically clear a c-spine following trauma, ALL of the following criteria must be satisfied:
- * No history of loss of consciousness
- * GCS 15 with no alcohol intoxication
- * No significant distracting injury ((such as head injury, chest trauma or other fractures including more distal spinal fractures))
- * No neurological symptoms in the upper or lower limb
- * No midline tenderness on palpation of the c-spine
- * N pain on gentle active neck movement
If there is any doubt over any of the criteria to clinically clear the c-spine, what happens to the hard collar that has been inserted for C-spine immobilization? What investigations are carried out once in hospital?
If there is any doubt over any of these criteria, the c-spine cannot be clinically cleared and the collar must stay in situ.
Further imaging in the form of X‐Rays (AP & lateral views +/‐ odontoid peg open mouth view) or CT scan of the c‐spine is required so that a c-spine injury can be radologically cleared.
High c-spine fractures or dislocations may be fatal especially if above which level?
High c‐spine fractures or dislocations may be fatal especially if above C3 (above phrenic nerve - C3,4,5 - which supplies the diaphragm).
How may stable and unstable c-spine injuries be treated?
More stable c‐spine injuries can be treated in a firm cervical collar.
Unstable injuries may require immobilization in a “halo vest” which is a type of external fixator with 4 pins into the skull.
- (broken neck Vinny Paz in Bleed for this (miles teller actor))
The majority of thoracolumbar spine fractures occur due to motor vehicle accidents or falls from a height. What type of thoracolumbar fractures occur in the elderly due to oestoporosis?
Wedge fractures
What is the management of a wedge fracture? What drug can increase the risk?
Symptomatic management
Steroids can causes osteoporosis increasing the risk of wedge fractures
Whilst osteoporotic low energy fractures tend to be compression / wedge fractures which are relatively stable, younger patients with higher energy injuries tend to have what type of thoracolumbar fractures?
Younger patients tend to have Burst fractures - a type of compression fracture related to high-energy axial loading spinal trauma that results in disruption of the posterior vertebral body cortex or
Chance-flexion distraction fracture - excessive flexion of the spine
What is an example of a cause of a CHance fracture? What sign may be seen one examination?
The cause is classically a head-on motor vehicle collision
Symptoms may include abdominal bruising (seat belt sign)
What are the indications for surgery in thoracolumbar spinal fractures?
Indications for surgery include:
Presence of neurological deficit especially if progressive or very unstable injury
Unstable injury pattern with substantial loss of vertebral height,
displacement or involvement of the posterior ligamentous structures.
The spinal cord or nerve roots can be damaged from contusion, compression, stretch or laceration.
What is spinal shock and what are the features?
Spinal shock is a physiologic response to injury with complete loss of sensation and motor function and loss of reflexes below the level of the injury.
* Anaesthesia, areflex flaccid paralysis of all segements and muscles innervated below the level of the injury
How long does it usually take for spinal shock to resolve?
Can take up to 24 hours for spinal shock to resolve
The bulbocavernous reflex is absent in spinal shock and its return signals the end of spinal shock. What is the bulbocavernous reflex?
This is when there is the reflex contraction of the anal sphincter with either a squeeze of the glans pens, tapping the mons pubis or pull of the urethral catheter
Neurogenic shock occurs secondary to temporary shutdown of sympathetic outflow from the cord What is the range of this sympathetic outflow?
T1 to L2
Neuorgenic shock is usually due to injury in the cervical or upper thoracic cord What does this lead to? Spinal shock can take up to 24 hours to resolve, how long does neurogenic shock take?
Leads to hypotension and bradycardia which usually resolves within 24-48hours
In a male, what may occur due to unopposed parasympathetic stimulation in neurgoenic shock?
Priapsim may occur - patient is erect for hours
Neurogenic shock must be differentiated from other forms of shock (hypovolaemic shock is much more common in trauma cases and should respond to fluid replacement therapy). How is neurgoenic shock treated?
Give IV fluids
* Also give atropine for slowed heart rate
* Vasopressors eg adrenaline for vasoconstriction
* Give dopamine or other inotropic drugs to increase heart contraction
Spinal cord comrpession can be * Acute or chronic * Complete or incomplete
What is the commonest cause of spinal cord compression? How does complete cord compression or transection present?
Commonest cause of spinal cord compression is malignant compression of the spinal cord
Complete cord compression presents as spinal shock initially with flacccid areflex paralysis
* Bilateral paralysis below the level of compression
* Bilateral loss of sensation below the level of compression
What signifies the ending of the spinal shock - ie what other symptoms may start? What reflex can be checked for?
End of spinal shock are when the features of an upper motor neurone lesions kick in
* ie stops being flaccid areflex paralysis and hyperreflexia and spasticity bein
Can check for bulbocavernosus reflex - when this returns, spinal shock has ended
Spinal cord injuries can be classified as complete or incomplete: Complete spinal cord injury results in no sensory or voluntary motor function below the level of the injury (reflexes should return).
What is the prognosis of a complete spinal cord injury?
Very poor prognosis
Incomplete cord injuries include * Central cord syndrome * Anterior cord syndrome * Posterior cord syndrome * Brown-sequard syndrome
Central cord syndrome is the most common incomplete cord injury pattern
What is central cord syndrome and what does it result in?
Central cord syndrome is when there is damage to the centre area of the spinal cord resulting in loss of movement and loss of certain sensation in mainly the arms (but not the legs)
What is the main cause of central cord syndrome? Why is it that the lower limbs are less/not affected in central cord syndrome?
The main cause of central cord syndrome is usually due to hyperextension of the neck in an individual with osteoarthritis (cervical spondylosis in the neck) - can occur in younger patients
The lower limb fibres are arranged on the outside of the spinal cord compared to the upper limb fibres which are arranged nearer the centrre of the cord
What defects does a patient with central cord syndrome present with?
Patients upper limbs and axial skeleton tend to be far greater affected than the less/non affacted lower limbs
Patients usually presents with loss of pain and temp, as well as weakness in the upper limbs and chest bilaterally
Almost cape-like spinothalamic and corticopsinal loss
