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