Spinal Trauma

Samuel Kim, M.D., M.Div.

September 12, 2006

Introduction • 40 y.o. male falls off a 12 foot high roof and lands on his back – Not able to feel or move his lower extremities – C-collared, boarded and sent to the nearest trauma center – 10 mg Morphine given en route

Introduction • Initial trauma survey: – Airway: intact – Breathing: clear b/l, equal, no crepitus – Circulation: BP160/90, 2+ pulses x 4 – Disability: no sensation or motor below umbilicus – Exposure

MRI

Introduction • • • • Pt suffered a burst fracture of T7 and T8 No change in condition over next several days Eventually sent to rehabilitation Poor prognosis: permanent paraplegia

Statistics • • • 10,000 - 20,000 spinal cord injuries per year Incidence – ~ 82% occur in men – ~ 61% occur in 16-30 y.o.

Common causes – MVC (48%) – Falls (21%) – Penetrating injuries (15%) – Sports injuries (14%)

Statistics • • • 40% of trauma patients with neuro deficits will have temporary or permanent SCI Many more vertebral injuries that do not result in cord injury Most commonly injured vertebrae – C5-C7 – C1-C2 – T12-L2

Statistics • Average cost of caring for permanent paraplegics and quadriplegics – Over five billion dollars per year • • Not all are Christopher Reeves Costs ultimately paid by tax payers

Introduction • As first responders: – Can play a significant role in minimizing secondary spinal cord injuries

Anatomy • • 33 Vertebrae Spine supported by pelvis

• Cervical Spine – 7 vertebrae – Very flexible – C1: atlas – C2: axis Anatomy

Anatomy • Thoracic Spine – 12 vertebrae – Ribs connected to spine – Provides rigid framework of thorax

Anatomy • • • Lumbar Spine – 5 vertebrae – Largest vertebral bodies – Carries most of the body’s weight Sacrum – 5 fused vertebrae Coccyx – 4 fused vertebrae – “Tailbone”

Spinal Cord • • 31 pairs – Cervical 1-8 – Thoracic 1-12 – Lumbar 1-5 – Sacral 1-5 – Coccygeal 1 Carry both sensation and motor function

Dermatome • • Specific area in which the spinal nerve controls Useful in assessment of specific level of SCI

Dermatome • • C 3, 4 – Motor: shoulder shrug – Sensory: top of shoulder C 5, 6 – Motor: elbow flexion – Sensory: thumb

Dermatome • • • • C 7 – Motor: elbow, wrist, finger extension – Sensory: middle finger C8, T 1 – Motor: finger abduction & adduction – Sensory: little finger T4 – Motor/sensory: level of nipple T 10 – Motor/sensory: level of umbilicus

Dermatome • • • L 1, 2 – Motor: hip flexion – Sensory: inguinal crease L 3, 4 – Motor: quadriceps – Sensory: medial thigh, calf L 5 – Motor: great toe, foot dorsiflexion – Sensory: lateral calf

Dermatome • • S 1 – Motor: knee flexion – Sensory: lateral foot S 4 – Motor: anal sphincter tone – Sensory: perianal

Assessment of Spinal Injury • Consider Mechanism of Injury – High speed MVA – Fall from significant height – Stabbing – Gun shot – Sports injury • Football

Assessment of Spinal Injury • • • • • Airway Breathing Circulation Disability Exposure

Neurologic Status • Check level of consciousness.

– Cooperative?

– Intoxicated?

– Able to communicate?

– Recall the events?

Assessment of Function & Sensation • • • Palpate over spinous processes Motor function – Arm and leg movements Sensation – Position – Pain

Spinal Cord Injuries • • Direct traumatic injury – Stab – Gunshot Excessive Movement – Acceleration – Deceleration – Deformation

Spinal Cord Injuries • Directional Forces – Flexion – Extension – Rotational – Lateral bending – Vertical compression – Distraction

Compression Fracture

Wedge Compression Fracture • Flexion injury

Burst Fracture • Another flexion injury with posterior involvement

Chance Fracture • • • Flexion-distraction injury Typically seatbelt injury in high speed MVA Involves: – Spinous process – Lamina – Transverse processes – Pedicles – Vertebral body

Chance Fracture

Chance Fracture

Primary Injury

• Occurs at the time of injury – May result in • Cord compression • Direct cord injury • Interruption in cord blood supply • Not much can be done

Secondary Injury

• • Occurs after initial injury – May result from • Dwelling/inflammation • Ischemia • Movement of body fragments First responders can play a significant role in reducing these injuries!

Cord Transection • Complete – Cord functions below transection are permanently lost – Results in quadriplegia or paraplegia

Complete Cord Transection

Complete Cord Transection

Cord Transection • Incomplete – Some cord mediated functions remain intact – Potential for recovery of function – Brown-Sequard Syndrome – Anterior Cord Syndrome – Central Cord Syndrome – Posterior Cord Syndrome

Brown Sequard Syndrome • • Injury to one side of the cord Often due to penetrating injury or vertebral dislocation • Complete damage to all spinal tracts on affected side • Good prognosis for recovery

Brown Sequard Syndrome • Exam Findings – Ipsilateral loss of motor function motion, position, vibration, and light touch – Contralateral loss of sensation to pain and temperature

Brown Sequard Syndrome

Anterior Cord Syndrome • Exam Findings – Variable loss of motor function and sensitivity to pinprick and temperature – Loss of motor function and sensation to pain, temperature and light touch – Proprioception (position sense) and vibration preserved

Anterior Cord Syndrome

Central Cord Syndrome • Usually occurs with a hyperextension of the cervical region • Weakness or paresthesias in upper extremities but normal strength in lower extremities • Varying degree of bladder dysfunction

Central Cord Syndrome

Posterior Cord Syndrome • • • Good muscle strength Normal pain and temperature sensation Difficulty in coordinating limb movements

Posterior Cord Syndrome

Cauda Equina Syndrome • • • Injury to nerves within the spinal cord as they exit the lumbar and sacral regions – Usually fractures below L2 Flaccid-type paralysis of lower body Bladder and bowel impairment

Pictures

Neurogenic Shock • • • • • From physiologic and anatomic transection or near-transection of the spinal cord Leads to flaccid paralysis Hypotension due to vasomotor instability Patients will be warm No tachycardia

Spinal Shock • Caused by severe trauma to the spinal cord – Flaccid quadriplegia with areflexia – Need 24-48 hours before determining long term prognosis – May spontaneously resolve

Management • Primary Goal – Prevent secondary injury – Prevent secondary injury – Prevent secondary injury

Management Goal • Neutral positioning of head and neck in in line position – Maximizes cord space – Most stable position for spinal column • • Rigid collar Long board

Padding • • • Maintains anatomical position Limits movement on board Fill all the voids – Pillows, blankets, towels

Securing to the Board • Straps or tape – Torso first – Then legs and feet – Head

Helmets • Remove only for emergency access to airway and ventilation • Otherwise, leave in place

Conclusion • • • ABCs Mechanism of Injury Prevent Secondary Injuries