Management of Spinal Trauma

Dr Nola McPherson

SCGH Registrar Education

April 2014

Spinal anatomy

Evaluating a patient with suspected spinal injury

Broad management principles of spinal injury

Hypovolaemic vs neurogenic vs spinal shock

Overview

Anatomy

Location of Spinal Injuries

55% in cervical region (mobile & exposed)

15% in thoracic region (less mobile & protected)

15% in thoracolumbar region (fulcrum)

15% in lumbosacral region

Anatomy

Upper cervical region is wide from foramen magnum to lower part C3

- 1/3 die at scene from apnoea

- those that survive are usually neurologically intact when reach hospital

Anatomy

Below C3, diameter of spinal canal is smaller

- vertebral column injuries more likely to produce spinal cord injuries

Anatomy

Most thoracic spine fractures are wedge compression fractures without SC injury

If fracture-dislocation in thoracic spine region

– almost always complete spinal cord injury because narrow thoracic canal

Anatomy

Thoracolumbar junction

- inflexible thoracic spine meets strong lumbar spine making it vulnerable to injury

Anatomy

Multiple ascending and descending tracts in the spinal cord (not going to cover all of these today!)

THREE are easily clinically assessable

lateral corticospinal tract (descending tract)

spinothalamic tract (ascending)

dorsal columns (ascending)

Anatomy

Corticospinal tract – controls motor power on SAME sideSpinothalamic tract – transmits pain & temp sensation from OPPOSITE sideDorsal columns – carries position sense (proprioception), vibration sense and some light touch sensation from SAME side

Anatomy

Sensory Examination Dermatomes

Motor Examination Myotomes

Spinal Injury: Classification

Spinal cord injury may be categorised as:

Incomplete quadraplegia (incomplete cervical injury)

Complete quadraplegia

Incomplete paraplegia (incomplete thoracic injury)

Complete paraplegia

QUIZ– location of lesions and clinical presentations

COMPLETE Neurology

Total flaccid paralysis

Total anaesthesia

Total analgesia

No tendon reflexes

MUST WAIT UNTIL SPINAL SHOCK RESOLVED to diagnose

INCOMPLETE Neurology

Partial paralysis

Altered sensation (light touch or pin prick)

Sacral sparing

BETTER prognosis, may recover

Spinal Cord Syndromes

Different patterns of neurologic injury with the following syndromes:

Central Cord Syndrome

Anterior Cord Syndrome

Posterior Cord Syndrome

Inferior Cord Syndrome

Transverse Cord Syndrome

Brown-Sequard Syndrome

Cauda Equina Syndrome

Syringomyelia

Spinal Injury: Morphology

Spinal injuries can be described as:

1. Fractures

2. Fracture – dislocations

3. Spinal cord injury without radiographic abnormalities

4. Penetrating injuries

These injuries can be further categorized as stable or

unstable

Spinal Injury: Signs and Symptoms

Pain (and bony tenderness on examination)

Tingling, numbness and weakness in peripheries

Loss of sensation or paralysis below level of injury

Impaired breathing – C3/4/5 (diaphragm)

Incontinence

Priapism

Spinal Trauma: Primary Survey

Activate trauma team, triage to trauma bay

Move patient off spinal board as soon as clinically safe to do so

Airway maintenance with C spine immobilisation - definitive airway early if respiratory compromise

(injury higher than C6 need intubation and ventilation) - maintain hard collar, sandbag/bolsters and tape

Breathing and Ventilation - 15L /min oxygen (NRB) + ventilatory support

- monitor RR, respiratory effort, cough

Circulation with haemorrhage control

- if hypotension – hypovolaemic vs neurogenic shock

- assume hypovolaemia 1st : search for source blood loss + replace fluids

- if SC injury: guide fluid replacement with CVP monitoring (controversial)

- inotropes may be required - before IDC – perform rectal examination and assess rectal sphincter tone and sensation

Spinal Trauma: Primary Survey

Disability

- GCS /pupils/BSL

- look for paralysis/paresis/priapism/ anal sphincter

tone/bulbocavernosus reflex

Exposure/Environment

– keep warm (blankets, bair hugger, fluid warmer)

peripherally vasodilated, unable to regulate temp if injury above T4

Spinal Trauma: Primary Survey

Adjuncts to Primary Survey

Full non invasive monitoring (consider invasive later)

ECG

Trauma Xray series – lateral cervical spine, chest, pelvis

Bedside FAST scan (?sources of bleeding)

NGT

IDC

Focused AMPLE Hx

Ask

mechanism?

does your neck or back hurt?

can you feel me touching your fingers and toes?

can you move your hands and feet?

Spinal Trauma: Secondary Survey

Assess full spine

A. Log roll and palpate spine/paraspinal region

look for deformity/ crepitus/pain/contusions/ lacs/penetrating wounds

B. Assess for pain, paralysis and paraesthesia

locationneurological level

Spinal Trauma: Secondary Survey

Spinal Trauma: Secondary Survey

Test sensation

Test motor function

Test deep tendon reflexes

DOCUMENT carefully and REPEAT

Head to toe examination – assess for associated injuries

Adjuncts to Secondary Survey

Advanced spinal imaging

- CT scan (defines bony injury)

- MRI scan (defines neurological injury)

Consider CVP monitoring

Disposition

EARLY discussion with spinal specialists

- best imaging technique based on suspected injury

- management options - ?steriods – give or not give

Transfer to spinal unit

Examination For SC Level

Sensory Examination

Best Motor Examination:

TABLE 1: Determining the level of Quadraplegia

TABLE 2: Determining the level of Paraplegia

Table 1: Examination For SC Level

Action Nerve Root Level

Raises elbow to shoulder level Deltoid, C5

Flexes forearm Biceps, C6

Extends forearm Triceps, C7

Flexes wrist and fingers C8

Spreads fingers T1

Table 2: Examination For SC Level

Action Nerve Root Level

Flexes hip Iliopsoas, L2

Extends knee Quadriceps L3-4

Flexes Knee Hamstrings L4-5, S1

Dorsiflexes big toe Extensor hallucis longus, L5

Plantar flexes ankle Gastrocnemius, S1

Phases of Injury

Primary spinal cord Injury

– initial trauma direct injury to SC due to fractures, dislocations, haematomas, soft tissue swelling

Secondary spinal cord injury (later)

– due to ongoing mechanical instability or insults secondary to hypoxia and hypotension

Spinal Trauma: Management Principles

1. Immobiisation

2. Intravenous fluids

3. Medications

4. Early advise, prompt referral/transfer

ED acute care priority: avoid secondary spinal injury

Spinal Trauma: Management Principles

Immobilisation: protect from further spinal injury

cervical collar

long spinal board, bolsters and tape

remove from spinal board as soon as possible(ideally < 2hours, BEWARE pressure pts &

decubitus ulcers)

logroll maintaining neutral alignment of entire spine

(four or more helpers required with av 70kg patient)

After arriving at ED, at least 5% with spinal injury experience new symptoms or worsening of preexisting symptoms as a result of –

secondary spinal injury (ischaemia & progression of spinal cord

oedema)

poor immobilisation technique

Spinal Trauma: Management Principles

Fluid resuscitation• Maintenance fluids only unless shock

• If shocked – establish if hypovolaemic OR neurogenic

Insert IDC (during primary survey)• Monitor urinary output

• Prevent bladder distension

Insert NGT • Prevent gastric distension (+/- paralytic ileus)

• Prevent aspiration (sphincter paralysis)

Spinal Trauma: Management Principles

Medications Corticosteriods - insufficient evidence for routine use

Aimed at reducing extent of permanent paralysis

Most trials have used high dose methylprednisolone

Improved motor neurological outcome up to one year post injury if given within eight hours of injury

Given as bolus dose and then IV infusion for 24-48 hours

- 24 hour IVI if treatment commenced within 3 hours of injury

- 48 hours IVI if treatment commenced within 3-8 hours of injury

Spinal Trauma: Management Principles

Early studies (NASCIS I & II)* showed no increased complications or mortality if 24 or 48 hour IVI

More recent larger studies have raised concerns about increased risk of sepsis due to immunosuppressive effects

CI: heavily contaminated open injuries, other heavily contaminated injuries eg perforated bowel, sepsis

Consult with spinal specialist (use or not to use??)

More research needed

Analgesia

* National Acute Spinal Cord Injury Study I & II

Spinal Trauma: Management Principles

Transfer

Promptly after consultation with spinal specialist

If injury above C6 (can result in partial or complete loss of respiratory function) – intubate before transfer

Secondary Complications

Consider

DVT/PE

Pressure sores

Respiratory complications eg pneumonia

UTIs

Muscle length changes

Psychological problems

Hypovolaemic vs Neurogenic Shock

Hypovolaemic Shock Neurogenic Shock

Increase HR Decreased HR

Decreased BP Decreased BP

Cool extremities Warm extremities

American Spinal Injury Association (ASIA) Classification

Allows classification of spinal cord injury (standardizing terminology worldwide)

Based on

- severity of neurological deficit A=complete to E=normal

- neurological level most caudal segment with normal function

Neurogenic Shock

Neurogenic Shock

Mechanism

impairment of descending sympathetic pathways in the cervical or upper thoracic spinal cord (usually above T6)

Loss of sympathetic vasomotor tone

- peripheral vasodilation (visceral and lower extremity b/v) pooling of blood

HYPOTENSION

Neurogenic Shock

Loss of sympathetic innervation to heart (usually lesion above T1)

bradycardia (or at least failure of tachycardic response to hypovolaemia)

Neurogenic Shock

Management:

1. Hypotension1. crystalloid (250mL boluses) and IVI – may not improve BP despite massive infusion

(beware fluid overload and pulmonary oedema)

2. vasopressors eg noradrenaline, dopamine- after trial of volume replacement

Maintain organ perfusion: mentation, UO>0.5mL/kg/hr, MAP >65mmHg, warm peripheries

Consider CVP monitoring

Neurogenic Shock

2. Bradycardia1. atropine (0.6mg IV boluses, up to max 3mg)

2. avoid overzealous vagal stimulation with suction/NGT and ETT placement

Spinal Shock

Spinal Shock= transient loss of muscle tone and loss of reflexes

(flaccid areflexia) below the level of spinal cord injury

Not true shock

Spinal cord (temporarily) nonfunctional but not destroyed

No ANS or somatic reflexesFirst to return is bulbocavernosus and Babinski reflexes

Duration variable (hours to weeks)

Resolves with improvement in soft tissue swelling

Take Home Messages

Over half of spinal cord injuries occur in the cervical spine region (most vulnerable and mobile region)

C spine immobilisation in trauma = spinal board (initially), hard collar, sandbags/bolster and tape

Consider early intubation and ventilation with injuries higher than C6 (altered LOC, regurgitation, cervical haematomas) – hypoxaemia is late sign of deterioration

Follow ATLS ‘A B C D E’ algorithm in spinal trauma – aim is to limit secondary spinal cord injury

Take Home Messages

Neurogenic shock is a triad of hypotension, bradycardia and peripheral vasodilation

In trauma patients, neurogenic shock is a diagnosis of exclusion

Watch over zealous fluid treatment – if hypotension not improving with fluid resuscitation, consider neurogenic shock

EARLY discussion with spinal specialist the use of noradrenaline (for hypotension) and steroids (remains controversial) in spinal trauma

Question and discussion time

Thank you

References

Fildes J, et al. Advanced Trauma Life Support Student Course Manual (9th edition), American College of Surgeons 2012.

Image of Vertebral Column taken from: http://upload.wikimedia.org/wikipedia/commons/5/54/ Gray_111_-_Vertebral_column-coloured.png

Image of Major Tracts in Spinal Cord taken from:http://www.dontbeasalmon.net/archives/2012/01/week-222-spinal.html

References

Image of Dermatomes taken from:http://commons.wikimedia.org/wiki/File:Dermatomes_and_cutaneous_nerves_-_anterior.svg

Image of Myotomes taken from: https://www.pinterest.com/pin/174162710563226309/

Image of Tetraplegia/paraplegia spinal levels taken from: http://quizlet.com/23549824/spinal-cord-injury-med-surg- exam-2-flash-cards/

References

Trauma Spinal Injury taken from: https://www.lifeinthefastlane.com/trauma-tribulation-016/

ASIA Impairment Scale taken from: http://www.asia-spinalinjury.org/elearning/ ISNCSCI_ASIA_ISCOS_low.pdf

BrackenMB.Steroidsforacutespinalcordinjury.CochraneDatabaseofSystematicReviews2012,Issue1.Art.No.:CD001046. DOI: 10.1002/14651858.CD001046.pub2.

References

Cameron P, Jelinek G, Kelly AM, Murray L, Brown A. Textbook of Adult Emergency Medicine. 3rd Edition. Churchill Livingston Elsevier 2009.