© ACS

Spine and Spinal Cord

Trauma
By : dr. ADRIAN KHU,SpOT
 © ACS

Objectives
 Describebasic spinal anatomy and
physiology.
 Evaluate for suspected spine injury.

 Indentify types of spinal injuries and x-ray

Features.
 Appropriately manage spinal injury.

 Detemine appropriate patient disposition.

 © ACS

Suspect Spinal Injury

 High-Speed Crash
 Unconscious patient
 Multiple injuries
 Neurologic deficit
 Spinal pain / tenderness
 © ACS

Spinal Injury
 ≥ 5% of Patients worsen neurologically at
hospital
 Protection — priority; detection—
secondary
 Spinal evaluation complicated by brain
injury
 Remove spine board as soon as possible
 © ACS

Cord injury Severity

 Complete : No motor or sensory
function↓ below injury level
 Incomplete :
• Any motor or sensory preservation ↓
injury level
• Sacral sparing may be only residual
function
 © ACS

Sensory Examination

Cervical Thoracic Lumbosacral

C-5 Deltoid T-4 Nipple L-4 Medial Leg
C-6 Thumb T-8 Xiphoid L-5 1st/2nd toes
C-7 Middle T-10 Umbilicus S-1 Lateral foot
finger T-12 Symphysis S-4 Perianal
C-8 Little finger
 © ACS

Motor Examination

Cervical / Thoracic Lumbosacral

C-5 Shoulder abduction L-2 Hip flexion
C-6 Wrist Extension L-3 Knee extension
C-7 Elbow extension L-4 Ankle dorsiflexion
C-8 Middle finger flexion L-5 Big toe extension
T-1 Little finger abduction S-1 Big toe / ankle
plantar flexion
 © ACS

Neurologic Assessment

Neurogenic Shock
 Hypotension associated with cervical /high

thoracic spine injury

 Bradycardia

 Treatment : Maintenance fluids, atropine

and occasionally vasopressors

 © ACS

Neurologic Assessment
Spinal “Shock”
 Neurologic Not hemodynamic phenomenon

 Occurs shortly after cord injury

 Flaccidity

 Loss of reflexes
 © ACS

Neurologic Assessment
Effect on Other Organ Systems
 Inadequate ventilation

 Abdominal evaluation compromised

 Occult compartment syndrome

 © ACS

Classifications of injury
Levels of injury
 Clinical exam

• Most caudal
• Normal bilaterally
• Motor / sensory function
 Bony : Site of vertebral column damage
 © ACS

Classification of Injury

Incomplete Complete
 Any sensation  No motor / sensory

 Position sense function

 Voluntary  No sacral sparing

movement in lower  May have reflexes

extremity
 Sacral sparing
 © ACS

Classifications of Injury

Spinal Cord Syndromes

 Central cord

 Anterior cord

 Brown - Sequard
 © ACS

Classification of Injury

Morphology
 Fracture or fracture / dislocation

 Spinal cord injury without radiographic

abnormality
 Penetrating
 © ACS

Classification of Injury

Morphology
 Consider unstable if :

• X-ray evidence of injury

• Neurologic deficit
• Severe pain on spine movement or
palpation
 © ACS

X-ray Guidelines
 Adequacy
 Alignment
 Bony abnormality
 Base of skull
 Cartilage , Contours
 Disc space
 Soft tissue
 © ACS

C-spine x-rays
 Crosstable lateral film exludes 85% of
fracture
 Additional 2 views exludes most fractures
 Also may require
• Swimmers view
• Ct scan for bony detail
• Flexion extension views
• MRI/CT myelogram
 © ACS

C – Spine X-rays
 10% of patients with a C-spine fracture
have a 2nd, associated noncontiguous
vertebral column fracture
 Indentify one abnormality ? Look for
another!
 Radiographic screening of entire spine
required in this instance
 © ACS

X –ray Guidelines
 Adequacy
 Alignment
 Bony abnormality
 Cartilage, Contours
 Disc Space
 Soft tissue
 © ACS

Screening for Spinal Injury

Conscious Patient
Presence of
paraplegia/quadriplegia

Presume spinal instability

Identify bony Early eurosurgical

fracture subluxation orthopedic consult
 © ACS

Screening for spinal injury

Alert,sober, neurologically normal patient :

① If no neck or spine ④ If still no pain or

pain or tenderness to tenderness with
palpation or voluntary voluntary moveme
movement ⑤ No further spine
② If no painful evaluation or c-spine
distracting injury x-ray necessary
③ Remove C-color
 © ACS

Screening for Spinal Injury

Alert, sober, neurologically normal patient :

 Neck or spine pain  If “ yes” to any

or tenderness to question
palpation or • Protect c-spine
voluntary • Obtain necessary
movement ? • x-ray exams
 After removal of c-
collar ?
 © ACS

Screening for Spinal Injury

Altered LOC
 Radiographic visualization of entire spine

 Plain films

 CT scan of suspicious areas

 © ACS

Screening for Spinal Injury

 Radiographic : Normal x-rays
 Clinical :
• Normal Neurologic exam and
• Absence of spinal pain/tenderness

Drugs,alcohol distracting
injuries may mask an injury
 © ACS

Management
Immobilization
 Entire Patient

 Proper padding

 Maintain until spine

injury excluded
 Avoid prolonged

use of backboard!
 © ACS

Medical Management
 Ensure adequate ventilation especially for
high level (c-4) quardriplegic
 Maintain blood pressure
 Atropine as needed for bradycardia
 Methylprednisolone
 © ACS

Medical Management
Intravenous Fluids
 Treat hypovolemia first

 Consider neurogenic shock

 Insert urinary catheter

 © ACS

Medical Management
Steroids
• IV Methylprednisolone
• Proven spinal cord injury
• Stars within 1 st 8 hours from injury only
• 30 mg/kg over 15 minutes
• 5.4 mg/kg over next 23 hours
Proven in blunt trauma only
 © ACS

Medical Management
Transfer
 Unstable fractures

 Neurologic deficit

Avoid delay
 Properly Immobilized

 Respiratory support as needed

 © ACS

Questions
 © ACS

Summary
 Treat life threatening injuries first
 Immobilize
 Appropriate spine films
 Document examination
 Neurosurgical/orthopedic consult
 Transfer unstable fracture /cord injury