Spinal injuries: Recognition and Therapy

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Spinal injuries Recognition and Therapy
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The Spinal Column
C-Spine 7 vertebrae (44)
Thoracic Spine 12 vertebrae (41)
Lumbar Spine 5 vertebrae
(15)
Sacral Spine 5 vertebrae
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Cervical Spine
The most vulnerable and most common site of
injury. Data from the UK (1993-95) 44 of all
spine trauma occurs at the cervical level
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Incidence of SCI

• 20-40 cases per million per year
• US data 10 000 cases per year
• Of these 10 000 cases
• 40 are complete
• No sensory or motor function below the lesion
• 4 000 cases per year of tetra/paraplegia

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Incidence of SCI cont.

• Disease of the young male
• 85 male
• Age usually between 15-35 years
• Mechanisms of injury (UK vs. Can)
• MVA 36 / 36
• Sport 20 / 14
• Domestic/Work 37 / 44
• Assault 6.5 / 6

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Alpine skiing, snowboarding and spinal trauma

• 10 year review at a US resort- 41 patients with
  spinal fracture/dislocation.
• 12 cervical-25 associated with neurological
  problems
• 25 thoracic-4 neurological problems
• 20 lumbar injuries-no neurological problems

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Mechanism of injury

• Cervical spine related to landing on the head
  with flexion-hyperextension (whiplash-type)
  mechanism
• Thoracic injuries were compression injuries due
  to fall directly onto upper or lower back-more
  likely snowboarders landing uncontrolled
• Lumbar injuries similar

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INCIDENCE

• 1 significant injury once every 100 000 skier
  days
• Permanent neurological injury much rarer once
  every 9 million skier days
• Reference Floyd T,Arch Orthop Trauma
  Surg,2001121433-6

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Cost of Spinal Cord Injury

• Lifetime direct medical costs range between 325
  000 - 1 350 000
• Varies according to age at injury as well as
  severity of injury
• High quadriplegics account for over 80 of
  expenditures
• 7.7 Billion per year in USA

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Spinal Injuries

• The devastating effects on the patient, as well
  as the burdensome effect on health care dollars
  has created an urgency for a cure.
• WHAT CAN BE DONE?

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Spinal Injuries

• The patient with potential spine injury.
• Injury prevention
• Pre-hospital care
• Emergency triage
• Surgical Management
• Medical Management
• Rehabilitation

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SCI pre-hospital care

• We are instructed to maintain potential SCI
  patients in a Neutral position for fear of
  worsening the initial injury
• Cervical Hard collar is North American Standard
  of Care.

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Identifying the SCI patient

• Emergency medical personnel are usually the first
  on the scene.
• Who should be placed in spinal precautions?

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Who should get spinal precautions?

• Stroh Braude (Ann Emerg Med June 2001)
• Retrospective chart review
• Fresno County EMS Spine protocol
• 861 patients discharged from hospital with SCI
  from 1990-96
• 504 patients brought by EMS
• 495 were in Spinal precautions
• What about the 9 patients that werent?

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Pre-hospital immobilization

• An interesting point
• Do ANY patients with suspected SCI need
  immobilization?
• (Hauswald Acad Emerg Med Mar 1998)

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Out of Hospital spinal immobilization its effect
on neurologic injury

• 5 year retrospective chart review
• Effect of emergent immobilization on neurologic
  outcome, comparing two different University
  hospitals
• University of Malaya, Malaysia
• 120 patients
• University of New Mexico
• 334 patients

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Who Cares?

• Malaysia
• Similar hospital
• Similar Staff
• NO SPINAL PRECAUTIONS

• New Mexico
• Universal precautions

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Who Cares?

• Malaysia
• Similar hospital
• Similar Staff
• NO SPINAL PRECAUTIONS
• Less neurologic disability in malaysian patients
  at discharge

• New Mexico
• Universal precautions

Out of hospital immobilization has little effect
on outcome
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Of course we cant!

• A retrospective study has many significant
  pitfalls but it suggests a few things
• Spinal cord injury is primarily the result of the
  initial impact.
• Secondary damage may be caused by swelling,
  ischemia etc, but NOT necessarily by unrestricted
  movement post injury
• There may be unrecognized morbidities associated
  with spinal immobilization.

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Morbidity associated with Spinal immobilization

• Several studies have questioned the wisdom of
  routine spinal immobilization
• Pain and discomfort
• Respiratory compromise
• Increased intracranial pressure

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Identifying potential SCI Clearing the Spines

• There is no easy solution.
• We must recognize that MANY people will be
  immobilized in the hopes of preventing further
  injury to those patients with true spinal injury.
• Efforts must be made to clear low risk patients
  quickly and efficiently.

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Spinal injury

• To identify the 10 000 people each year with
  spinal injury, emergency physicians will screen
  approximately 800 000 patients with spinal
  radiography.

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Canadian C-spine rules (JAMA Oct 17 2001)

• Brought to fruition by same group who developed
  the Ottawa Ankle rules
• Prospective cohort study, patients evaluated for
  20 standardized clinical findings PRIOR to
  radiography
• Hx of blunt trauma to head/neck, hemodynamically
  stable, with GCS 15

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Canadian C-spine rules

• 8924 patients enrolled
• 151 patients had important c-spine injury (1.7)
• Derived Decision rule as follows

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Canada Rules

• 1) Any High risk factor that mandates
  radiography?
• Agegt65, dangerous mechanism, paresthesias
• 2) Any low risk factors that allow safe
  assessment of range of motion
• Simple rear end MVC, sitting position in ER,
  Ambulatory at any time, delayed onset of neck
  pain, absence of midline tenderness
• 3) Able to rotate neck?
• 45 degrees left and right

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Canadian C-spine rules

• 100 sensitivity
• 42.5 specificity
• Potential radiography order rate 58.2
• Unfortunately, these rules do not apply to
  critically injured patients

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Calgary EMS-exclusion

• lt 16 years
• No potential back injury
• GCS lt15,hemodynamically unstable
• gt8 hours after incident
• Acute paralysis

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EMS Mandatory Imm.

• Mechanism of injury-fall gt 5 stairs.gt100km/hr,
  collisions between pedestrian ,death of another
  individual
• Language barrier
• Distracting injuries-fractures,burns,degloving
  injuries
• Intoxiction
• Midline tenderness
• Neurological deficit

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Head Injury

• In a patient with a head injury assume spinal
  cord injury until proven otherwise. 25-50 of
  patients with head injury have spine injury.

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C-spine radiography

• Bare Minimum
• Cross table lateral
• Anteroposterior view
• Open mouth odontiod
• If adequate views NOT attainable, patient
  requires CT scan reconstructions of disputed areas

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Lateral c-spine view
Lateral views have a sensitivity of approx 80 to
identify c-spine fractures
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• Disruption of all spinal lines with obvious
  anterior dislocation

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Vertebral Burst fractures
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Paediatrics

• Assume cervical spine injuries with multiple
  injuries
• Falls less then 5 feet rarely cause spinal
  injuries
• On backboard remember large occiput-might need to
  prop shoulders up
• Size of collar

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Examination of neck and spine

• Anterior landmarks
• Hyoid cartilage C3
• Thyroid cartilage C4-5
• Cricoid C6
• Posterior landmarks
• Occiput
• Mastoid
• Cervical processes C2 C7
• Facet joints 2.5 cm lateral

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• Soft tissue-
• anterior Sternocleidomastoid muscle.
• Posterior-Trapezius muscle Paravertebral muscles

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Range of motion

• Flexion/extension
• Rotation
• Lateral bending

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Neurological

• C4-collarbone
• C5-lateral upper arm, Biceps
• C6 Thumb index finger. Wrist extension
• C7-middlefingerWrist flexion
• C8-ring and little finger, Finger flexion
• T1-inside of upper arm, Finger abduction
• T4-nipple line
• T10-umbilicus
• L1-L3-Groin to knee
• L4-Inside of calf
• L5 Top of foot, Extension of big toe
• S1 Baby toe and back of calf

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Case Report

• 15 yr snowboarder -7 metre jump. Landed semi
  flexed on buttocks and back. Immediate lower back
  pain but no other symptoms. On admission to
  hospital tender over lower cervical, lower
  thoracic and lumbar spine. Complete neurological
  exam was normal He had 9 vertebral fractures
  compression C5,C7.ant wedge T10-L3,burst L5.
  Full recovery at 6mnths .
• Is he snowboarding again??????

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Other neck injuries in athletes

• Cervical sprain/strain. Localized
  tightness/tenderness one side of neck. Decreases
  ROM. 12-24 hours after injury
• Cervical facet syndrome. Joint capsule and
  ligaments are stretched. Immediate pain, radiates
  to back, arm and shoulder, decreased ROM as well
  as headaches. Immediate after accident
• Cervical radiculopathy. Pinching of nerve due to
  disc herniation or nerve trapped. Forced
  hyperextension or axial loads. Pain radiates from
  neck to extremity Relief by holding hand up.