Assessment of Spinal Injury

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Assessment of Spinal Injury
Stephen Schutts, Master Sergeant, WA ANG National
Registry Emergency Medical Technician -
Paramedic 1
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Objectives

• Identify the anatomical levels of the spine.
• Understand the function of the spinal
  cord/column.
• View Types and Mechanisms of injury that can
  cause spine injury.
• Discuss the difference between Spinal Column
  Injury vs Spinal Cord Injury.
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Objectives

• Overview of Spinal Regions and Injuries
• Step by step view of the EMS Spinal
  Immobilization Assessment Protocol
• Discuss Common Treatment/Management Mistakes
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Introduction

• Spinal injuries are devastating
• Improper management can have horrible and
  permanent results
• Appropriate use of spinal immobilization can mean
  the difference between a patient who fully
  recovers and one who must spent the rest of
  his/her life paralyzed
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Mechanism based assessment (the current method)

• Low-speed fender bender
• An elderly man trips over a lamp cord and falls
• When in doubt back board em
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• Are all 8 patients assumed to have spinal
  injuries?
• Does this man have a spinal injury? Do all such
  falls cause spinal injuries?
• Not necessarily, apply EMS Spinal Immobilization.

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Anatomy Physiology- General Structure Function

• Spinal Column
• Made up of 26 vertebrae stacked on top of one
  another
• Divided into 5 areas cervical, thoracic, lumbar,
  sacral, and coccyx
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Anatomy Physiology-Long Bone

• Think of the Spinal Column as on Long Bone
  with Joints at each end
• The Cervical spine makes up one joint
• The Hip makes up the other
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Anatomy Physiology- Cervical Spine (7)

• Joint at the superior end of the spinal Long
  Bone
• Very flexible
• Allows flexion, extension, and rotation of the
  head
• The head acts as a weighted lever during
  acceleration/ deceleration
• Common site of spinal injuries
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C-1 Atlas
C-2 Axis

• C-1 supports the full weight of the head
• C-1 and C-2 allow head rotation and fine flexion
  and extension
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Anatomy Physiology- Thoracic Spine (12)

• Much less flexible than C-Spine
• Stabilized by rib cage (especially down to T-10)
• Spinal canal narrow through T-Spine
• Spinal cord tightly fitted into narrow space
• Spinal cord ends about T-12 or L-1
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Anatomy Physiology- Lumbosacral Spine

• 5 Lumbar vertebrae plus sacrum and coccyx
• More flexible than T-spine
• More room in spinal canal
• Spinal cord ends about T-12 or L-1
• flexible nerve roots (Cauda equina) flow through
  LS spine
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Anatomy Physiology- Spinal Cord

• Bundles of nerve fibers originating in the brain
• Bundles or tracts travel in right and left pairs
• Spinal Tract pairs crossover midline at various
  specific levels
• always in specific anatomical areas
• understanding of the structure of these tracts
  helps in assessing spinal cord injuries
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Mechanism of Injury

• Physical manner and forces involved in producing
  injuries or potential injuries
• Valuable tool in determining if the a particular
  set of circumstances could have caused a spinal
  injury
• Mechanisms likely to produce spinal injuries
  occur in MVAs, falls, violence, and sports
  (including diving accidents)
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Hyperflexion
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Hyperextension
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Hyperotation
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Axial Loading
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Axial Distraction
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Sudden/Extreme Lateral Bending

• Excessive/abnormal lateral movement of the spine
• Can affect any portion of the spine
• Example T-bone MVAs
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Spinal Column Injury

• Bony spinal injuries may or may not be associated
  with spinal cord injury
• These bony injuries include
• Compression fractures of the vertebrae
• Comminuted fractures of the vertebrae
• Subluxation (partial dislocation) of the
  vertebrae
• Other injuries may include
• Sprains- over-stretching or tearing of ligaments
• Strains- over-stretching or tearing of the
  muscles
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Spinal Cord Injury

• Cutting, compression, or stretching of the spinal
  cord
• Causing loss of distal function, sensation, or
  motion
• Caused by
• Unstable or sharp bony fragments pushing on the
  cord, or
• Pressure from bone fragments or swelling that
  interrupts the blood supply to the cord causing
  ischemia
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Primary Spinal Cord Injury

• Immediate and irreversible loss of sensation and
  motion
• Cutting, compression, or stretching of the spinal
  cord
• Occurs at the time of impact/injury
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Secondary Spinal Cord Injury

• Injury Delayed
• Occurs later due to swelling, ischemia, or
  movement of sharp or unstable bone fragments
• May be avoided if spine immobilized during
  extrication, packaging, treatment, and transport
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Incomplete Spinal Cord Injury

• Complete injury to specific spinal tracts with
  reduced function distally
• Other tracts continue to function normally with
  distal function intact
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Spinal Region Overview

• Cervical Spine Injuries
• Thoracic Spine Injuries
• Lumbosacral Spine Injuries
• Spinal Injury Summary
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Cervical Spine Injuries

• C-spine very flexible
• Most frequently injured area of spine
• Most injuries at C-5/C-6 level
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Thoracic Spine Injuries

• T-spine less flexible
• Narrow spinal canal
• Cord injury occurs with minimal displacement
• Common mechanisms
• Any cord damage usually complete at this level
• Most T-spine injuries occur at T-9/T-10
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Lumbosacral Spine Injuries

• LS spine flexible nerve roots in roomy spinal
  canal
• May have bony injury w/o cord or nerve root
  damage
• Secondary injury still possible
• Neurological injury rare w/ isolated sacral
  injuries
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Assessment Overview

• Decision to apply spinal immobilization in past
  based was solely on mechanism of injury
• Utilize EMS Spinal Immobilization Algorithm to
  determine when spinal immobilization is NOT
  needed
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Spinal Immobilization Algorithm

• Patient Mentation
• Decreased Level of Consciousness?
• No Yes ----------------------------Immobiliz
  e
• ETOH/Drug Impairment?
• No Yes
  ----------------------------Immobilize
• Subjective Assessment
• Cervical/Thoracic/Lumbar Spinal pain?
• No Yes
  ----------------------------Immobilize
• Numbness/Tingling/Burning/Weakness?
• No Yes -----------------------------Immobili
  ze
• Objective Assessment
• Cervical/Thoracic/Lumbar Deformity or
  Tenderness?
• No Yes -----------------------------Immobili
  ze
• Other Severe Injury?
• No Yes -----------------------------Immobili
  ze
• Other Severe Injury?
• No Yes -----------------------------Immobil
  ize
• Pain w/Cervical Range of Motion?
• No Yes -----------------------------Immobili
  ze

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Principles of Treatment

• Protect spinal cord from secondary injury
• We have little or no effect on primary injury
• Focus on prevention of secondary injury
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Complete Spinal Immobilization

• Must act as if whole spine unstable
• Immobilize entire spine
• To do this we must immobilize the head, neck,
  shoulders/chest, and pelvis /hips
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Common Treatment/Management Mistakes

• Improperly sized C-Collar
• Spine not supported due to improper positioning
  on backboard
• Inadequate strapping allows excessive movement
• Movement possible due to little or no padding to
  shim the body
• C-spine movement by inadequate or improperly
  applied head immobilization device
• C-spine hyperextension due to improperly applied
  C-collar or head immobilization device
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Common Treatment/Management Mistakes (cont.)

• Readjusting torso straps after immobilization of
  the head, causing misalignment of the spine
• Securing head to backboard prior to securing
  shoulders, torso, hips, and legs
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Any Questions???