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Spinal injury gihs
- 1. SPINAL CORD INJURY MRS.D.LALITHAMANI M.SC NURSING LECTURER GANGA COLLEGE OF NURSING COIMBATORE
- 3. Outline • Goal of spine trauma care • Pre-hospital management • Clinical and neurologic assessment • Acute spinal cord injury – Term, type and clinical characteristic • Common cervical spine fracture and dislocation
- 4. Goal of spine trauma care • Protect further injury during evaluation and management • Identify spine injury or document absence of spine injury • Optimize conditions for maximal neurologic recovery
- 5. Goal of spine trauma care • Maintain or restore spinal alignment • Minimize loss of spinal mobility • Obtain healed & stable spine • Facilitate rehabilitation
- 6. Suspected Spinal Injury • High speed crash • Unconscious • Multiple injuries • Neurological deficit • Spinal pain/tenderness
- 7. Pre-hospital management • Protect spine at all times during the management of patients with multiple injuries • Up to 15% of spinal injuries have a second (possibly non adjacent) fracture elsewhere in the spine • Ideally, whole spine should be immobilized in neutral position on a firm surface
- 8. • PROTECTION PRIORITY • Detection Secondary “Log-rolling”
- 9. Pre-hospital management • Cervical spine immobilization • Transportation of spinal cord-injured patients
- 10. Cervical spine immobilization • “Safe assumptions” – Head injury and unconscious – Multiple trauma – Fall – Severely injured worker – Unstable spinal column • Hard backboard, rigid cervical collar and lateral support (sand bag) • Neutral position
- 12. Transportation of spinal cord-injured patients • Emergency Medical Systems (EMS) • Paramedical staff • Primary trauma center • Spinal injury center
- 13. Clinical assessment • Advance Trauma Life Support (ATLS) guidelines • Primary and secondary surveys • Adequate airway and ventilation are the most important factors • Supplemental oxygenation • Early intubation is critical to limit secondary injury from hypoxia
- 14. Physical examination • Information • Mechanism – ↑energy, ↓energy • Direction of Impact • Associated Injuries
- 15. Is the patient awake or “unexaminable”? • What’s the difference ? – Awake • ask/answer question • pain/tenderness • motor/sensory exam – Not awake • you can ask (but they won’t answer) • can’t assess tenderness • no motor/sensory exam
- 16. Physical examination • Inspection and palpation – Occiput to Coccyx – Soft tissue swelling and bruising – Point of spinal tenderness – Gap or Step-off – Spasm of associated muscles • Neurological assessment – Motor, sensation and reflexes – PR • Do not forget the cranial nerve (C0-C1 injury)
- 17. Neurogenic Shock • Temporary loss of autonomic function of the cord at the level of injury – results from cervical or high thoracic injury • Presentation – Flaccid paralysis distal to injury site – Loss of autonomic function • hypotension • vasodilatation • loss of bladder and bowel control • loss of thermoregulation • warm, pink, dry below injury site • bradycardia
- 18. 18 Neurogenic Hypovolemic Etiology Loss of sympathetic outflow Loss of blood volume Blood pressure Hypotension Hypotension Heart rate Bradycardia Tachycardia Skin temperature Warm Cold Urine output Normal Low Comparison of neurogenic and hypovolemic shock
- 19. Definitions of terms • Neurologic level – Most caudal segment with normal sensory and motor function both sides • Skeletal level – Radiographic level of greatest vertebral damage • Complete injury – Absence of sensory and motor function in the lowest sacral segment • Incomplete injury – Partial preservation of sensory and/or motor function below the neurologic level
- 20. Neurologic assessment • Spinal shock – Bulbocavernosus reflex • Complete VS incomplete cord injury – spinal shock – Sacral sparing • Voluntary anal sphincter control • Toe flexor • Perianal sensation • Anal wink reflex
- 21. Neurologic assessment • American Spinal Injury Association grade – Grade A – E • American Spinal Injury Association score – Motor score (total = 100 points) • Key muscles : 10 muscles – Sensory score (total = 112 points) • Key sensory points : 28 dermatomes
- 24. Incomplete cord injury • Anterior cord syndrome • Brown-Sequard syndrome • Central cord syndrome
- 25. Anterior cord syndrome • Loss of motor, pain and temperature • Preserved propioception and deep touch
- 26. Brown-Sequard syndrome • Loss of ipsilateral motor and propioception • Loss of contralateral pain and temperature
- 27. Central cord syndrome • Weakness : – upper > lower • Variable sensory loss • Sacral sparing
- 28. The Canadian C-spine Rule for alert and stable trauma patients where cervical spine injury is a concern. • Any high-risk factor that mandates radiography? • Age>65yrs or • Dangerous mechanism or • Paresthesia in extremities Any low-risk factor that allows safe assessment of range of motion? • Simple rear-end MVC, or • Sitting position in ER, or • Ambulatory at any time, or • Delayed onset of neck pain, or • Absence of midline C-spine tenderness Able to actively rotate neck? • 45 degrees left and right No Radiography Radiography NO YES ABLE YES NO UNABLE
- 29. Cervical Spine Imaging Options – Plain films • AP, lateral and open mouth view – Optional: Oblique and Swimmer’s – CT • Better for occult fractures – MRI • Very good for spinal cord, soft tissue and ligamentous injuries – Flexion-Extension Plain Films • to determine stability
- 30. Radiolographic evaluation X-ray Guidelines (cervical) AABBCDS • Adequacy, Alignment • Bone abnormality, Base of skull • Cartilage • Disc space • Soft tissue
- 31. Adequacy • Must visualize entire C-spine • A film that does not show the upper border of T1 is inadequate • Caudal traction on the arms may help • If can not, get swimmer’s view or CT
- 32. Alignment • The anterior vertebral line, posterior vertebral line, and spinolaminar line should have a smooth curve with no steps or discontinuities • Malalignment of the posterior vertebral bodies is more significant than that anteriorly, which may be due to rotation • A step-off of >3.5mm is significant anywhere
- 33. Lateral Cervical Spine X-Ray • Anterior subluxation of one vertebra on another indicates facet dislocation – < 50% of the width of a vertebral body unilateral facet dislocation – > 50% bilateral facet dislocation
- 34. Bones
- 35. Disc • Disc Spaces – Should be uniform • Assess spaces between the spinous processes
- 36. Soft tissue • Nasopharyngeal space (C1) – 10 mm (adult) • Retropharyngeal space (C2- C4) – 5-7 mm • Retrotracheal space (C5-C7) – 14 mm (children) – 22 mm (adults)
- 37. AP C-spine Films • Spinous processes should line up • Disc space should be uniform • Vertebral body height should be uniform. Check for oblique fractures.
- 38. Open mouth view • Adequacy: all of the: all of the dens and lateraldens and lateral borders of C1 & C2borders of C1 & C2 • Alignment: lateral: lateral masses of C1 andmasses of C1 and C2C2 • Bone: Inspect dens for lucent fracture lines
- 39. CT Scan • Thin cut CT scan should be used to evaluate abnormal, suspicious or poorly visualized areas on plain film • The combination of plain film and directed CT scan provides a false negative rate of less than 0.1%
- 40. MRI • Ideally all patients with abnormal neurological examination should be evaluated with MRI scan
- 41. Management of SCI • Primary Goal – Prevent secondary injury • Immobilization of the spine begins in the initial assessment – Treat the spine as a long bone • Secure joint above and below – Caution with “partial” spine splinting
- 42. Management of SCI • Spinal motion restriction: immobilization devices • ABCs – Increase FiO2 – Assist ventilations as needed with c-spine control – Indications for intubation : • Acute respiratory failure • GCS <9 • Increased RR with hypoxia • PCO2 > 50 • VC < 10 mL/kg – IV Access & fluids titrated to BP ~ 90-100 mmHg
- 43. Management of SCI • Look for other injuries: “Life over Limb” • Transport to appropriate SCI center once stabilized • Consider high dose methylprednisolone – Controversial as recent evidence questions benefit – Must be started < 8 hours of injury – Do not use for penetrating trauma – 30 mg/kg bolus over 15 minute – After bolus: infusion 5.4mg/kg IV for 23 hours
- 44. Principle of treatment • Spinal alignment – deformity/subluxation/dislocation reduction • Spinal column stability – unstable stabilization • Neurological status – neurological deficit decompression
- 45. THANK YOU