Spinal Injury - Kenyatta National Hospital
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Transcript Spinal Injury - Kenyatta National Hospital
Dr. Richard Bwana Ombachi
Lecturer and Consultant Spine & Orthopaedic
surgeon
Introduction
Spine -Vertebral Column/Nervous Tissue
5% worsen in the hospital
Protection is priority –Diagnosis a secondary priority
Treat the spine of an alive patient – Identify live
threatening conditions
Effects of spinal injury
Inadequate ventilation
Compromised abdominal evaluation
Mask compartment syndrome
Patient Referral
Trauma
Vertebral Column Trauma and
Nervous Tissue Trauma
Somatic Nervous System
Spinal Cord tracts
Nerve roots / Nerves
Autonomic Nervous System
sympathetic
Spinal Injuries Devastating effect
Protection primary priority
Management starts at the scene of the accident
Spinal Cord Injury
Primary Injury- physical injury by mechanical forces
Contusion
Compression
Stretch
Laceration –
penetrating foreign bodies,
missiles,
fragments or displaced bone
Secondary Injury
Additional neural tissue damage from biologic response
Changes local blood flow
Tissue oedema
Metabolite concetration lethal to the neural tissues leading to
further injury
Statistics
Aetiology
RTA 45% ( motor cycle accidends )
Falls 20%
Sports 15 %
Assault 15%
Gender ratio M: F
4:1
Neurologic Injury
Cervical 40%
Thoracolumbar 20%
PRINCIPLES OF MANAGEMENT
Suspect Spinal Injuries and Protect further injury
Immobilize the spine
Assess the patient (ATLS Protocal)
Manage live threatening conditions while caring for
spine
Image patient to identify the injuries
Manage/Reffer injuries as appropriate
Suspect Spinal Injuries
History of transient neurological symptoms
Neck pain or back pain
Multiply Injured patient
An inconsolable child
Inability to assess pain because of a secondary distracting injury or intoxication
Head injury or severe facial or scalp lacerations or neck injuries
Trauma +Unconscious : assume spinal injury until proven otherwise
Abnormal neurological finding
Diaphragmatic breathing
Physical signs of spinal trauma (e.g., ecchymosis and abrasions, step deformity,
gap deformity.
hypotension, hypothermia, and bradycardia- upper thoracic/ cervical injuries
neurogenic shock
Penile erection and incontinence of the bowel or bladder suggest a significant
spinal injury
Tale Tell Signs on Examination
Patient should be log rolled by at least 4 people for back
examination
leakage of CSF or blood behind the tympanic
membrane- a skull fracture.
paraplegia/ quadriplegia
Painful spinous process
Palpable defects ( gaps or steps) indicate disruption of
the supporting ligamentous complex.
Scalp wounds, neck injuries, seat belt marks etc.
Diaphragmatic Breathing
Immobilize the Spine
Protection Priority
Neck immobilization firm collar + head strapped to
bolsters/ sand bags on either side to the board
Immobilize in neutral position don’t correct
deformities- ? AS, ? RS children, ? Spondylosis
Children - board should have a depression to
accomodate big head – avoid flexing neck.
Patients should not be kept on the board longer than
two hours as pressure sores start to develope two hours
on the board (Spine board transporting tool)
NEUROLOGICAL EXAMINATION
Done to determine level and severity of injury.
Sensation to light touch and pain should be
documented comparing each spinal level and side
Motor examination using MRC grading.
Deep tendon reflexes and pathological reflexes also
should be checked.
Motor and sensory evaluation of the rectum and
perirectal area is mandatory (complete/incomplete
Injuries)
Asia Chart
ASIA Chart.pdf
Spinal Shock
Spinal dysfunction based on physiological rather than
structural disruption.
Recognized by return of the reflexes caudal to the level
of injury usually 24 -48 hours (BCR or the anal wink)
Neurogenic Shock
Injuries above T6 disrupt the sympathetic nervous
system to the heart and the vascular system –
Neurogenic shock
Sympathetic disruption leads to uncounterted vagal
action leading to Bradycardia, Hypotension,
Vasodilatation
Maintain Mean Preasure above 70mmHg
Do not over infuse pt use ionotropic drugs
Vertebral Column Examination
Done in Secondary Survey
Use log rolling technique
Detect
Bruises/ Lacerations
Swellings / Bogginess
Step or Gap Deformity
Tenderness
Remove spine board at this stage if not referring
Radiological Imaging Indications
No x-rays if
No neurological deficit
Conscious
Cooperative
Able to concentrate
If no neck or back tenderness
Altered sensorium, then
X-ray the whole spine
Pain or tenderness, no neurological deficit
Xray affected areas consider flex-ext
X-rays
AABBCCDs
Adequacy, Alignment, Bony
abnormality, Base of Skull, Cartilage, contours, Disc
space, Soft tissues
- Cross-Table Lateral: 85% sensitive
-AP + Lat 92 % sensitivity -excludes most fractures
-Swimmer’s for C7-T1
- Open mouth view upper cervical
-Obliques not necessary in trauma
-CXR / Abd Xrays not adequate for evaluation spine
CT SCAN / MRI
CT Scan
Clearance in patients with questionable or inadequate
plain radiographs
Assess occipitocervical and cervicothoracic junctions
MRI
Spinal cord injury – disruptions, oedema, haematomas
Intervertebral disc disruption
Posterior ligamentous disruption
Canal compromise and neural tissue compression
Summary of Management
High Index of Suscipicion
Immobilize the spine to protect spine (Protection Priority)
Examine for Spinal and none spinal injuries.
Neurological Examination +Vertebral Examination
Institute rescuscitation as condition demands giving preference to life threatening
conditions While taking care of the spine.
Do not over infuse the patient with neurogenic shock- use ionotropic agents as indicated
Image the spine to identify and confirm suspected injuries. (Maintain Spine Board untill
imaging is complete)
Remove Spine Board within two hours to avoid decibitus ulcers
Pressure sore management
Bladder management
Respiratory system management
GIT
Psychological support
Definative stabilization according to the injury
Steroids in some centres