Transcript Spinal Injury (II)

Spinal Injury
Dr Adrian Burger
Senior Registrar
Division of Emergency Medicine
UCT/US
25 May 2007
Objectives
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Anatomy
Stats
Clinical
Imaging
Summary
Anatomy 1
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Number of neurons in human spinal cord =
13,500,000
Length of human spinal cord = 45 cm
(male); 43 cm (female)
Length of human vertebral column = 70 cm
Length of cat spinal cord = 34 cm
Length of rabbit spinal cord = 18 cm
Weight of human spinal cord = 35 gm
Weight of rabbit spinal cord = 4 gm
Weight of rat spinal cord (400 gm body
weight) = 0.7 gm
Maximal Circumference of cervical
enlargement = 38 mm
Maximal Circumference of lumbar
enlargement = 35 mm
Pairs of Spinal Nerves = 31
Number of Spinal Cord segments = 318
cervical segments
12 thoracic segments
5 lumbar segments
5 sacral segments
1 coccygeal segment
Anatomy 2
Consequences
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Depends on
Complete/Incomplete
Level
Stabilised
Initial Management
Early Consequences
• Respiratory – apnoea, • C3-C5
hypoventilation • Intercostals
• Cardiac - neurogenic
shock triad
- autonomic
dysreflexia
- hypotension
• T1 –T4
• >T6
Later consequences
• Bowel reflex or non-reflex dysfunction
• Bladder retention
• Bed sores
• Contractions
Causes of death
• Dysrhythmias, apnoea
• Pneumonia
• VTE
• Sepsis
• CHD
Neurology
• Most frequent level of injury is C5,
then C4, C6, T12, C7, L1
• Overall about half are cervical injuries
• Incomplete quadraplegia (34.3%)
• Complete quadraplegia (22.1%)
• Complete paraplegia (25.1%)
• Incomplete paraplegia (17.5%)
Incomplete lesions
• Anterior cord syndrome
Corticospinal and spinothalamic pathways
Loss of motor, pain and temperature below the level of the injury
Preservation of position and vibration
Key is potential reversibility of a haematoma or fragment
• Central cord syndrome
Injury to the central portion of the spinal cord
Greater involvement of upper extremities than lower
Bowel or bladder control usually is preserved
Hyperextension injury of cervical spine with a narrow cord space
Can occur without fracture or ligamentous disruption
Incomplete lesions 2
• Brown-Séquard syndrome
Hemisection of the spinal cord, usually penetrating
trauma
Contralateral loss of pain and temperature
Ipsilateral loss of motor and posterior column functions
• Cauda equina syndrome
Injury to the lumbar, sacral, and coccygeal nerve roots
Motor and sensory loss in the lower extremities
Bowel and bladder dysfunction
Saddle anaesthesia
Sacral Sparing & Spinal Shock
• Preservation of any function of the sacral roots,
such as toe movement or perianal sensation
• Implies the chance of functional neurologic
recovery is good
• Spinal shock is a temporary concussive-like
condition in which cord-mediated reflexes, such
as the anal wink, are absent
• Spinal shock also may result in bradycardia and
hypotension. The extent of cord injury-and
prognosis-cannot be determined until these
reflexes return
Stats UK
Stats USA
• Vehicular crashes (50.4%)
• Falls (23.8%)
• Violence, primarily gunshot wounds
(11.2%)
• Sports (9.0%)
• Other (5.6%)
General Stats
• Average age 16-30
• Males 80%
• Life expectancy of someone with a SCI in Africa is 2-3
years
• 60 % of admitted patients have neurological deficits
• After the initial care require rehabilitation
• Average hospital stay for rehab of a paraplegic patient is
4 months, for quadriplegics 6 months
• Estimated that 2 000 SPINAL INJURIES are treated per
annum NATIONALLY in the public sector ie, 1:20 000 of
the population
Minister of Transport Jeff Radebe,
(MP)at the 2006
• Poor driver behaviour and attitude
95 % of crashes follow a traffic violation
• Our statistics reflect that 7 000 people
involved in crashes are left permanently
disabled every year.
At least 650 of these have SCI
South Africa MRC 1999
Cape Metropole 2000
Trauma Injuries, Red Cross Children's Hospital
1 April 1999 - 31 March 2000 (12 months)
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MVA
Pedestrian745
Passenger - Restrained 18 Passenger Unrestrained 106 Passenger - Bakkie/Minibus77 Cycle151 Motor
Cycle 2 Other - Boat, Train, Plane, Horse25
Total MVA 1125 (16%)
Assault
Blunt 126 Sharp25 Rape/Sexual 38 Human Bite 3 Other
33 Total Assault 2253
Burns
Flame 117 Fluid 497 Heat Contact 37 Electrical
13 Chemical 21 Explosion 10 Other 11 Total -706
Falls Off Ben 283 Stairs115 Attendants Arms 68 Playground
Equipment 252 Mobiles93 Other Heights 613 Other Level 1071
Total - Falls 2495 (35%)
Struck by/against objects 688 Caught between objects 212 Sharp
Instruments 250 Firearms42 Machinery9 Dogbite90 Other bite 7
Immersion/drowning Suffocation1 Food foreign body 33 Other
foreign body 351 Other cause549 Unknown290 Total 7075
X Ray or not?
• NEXUS
No midline cervical tenderness
No focal neurologic deficit
Normal alertness
No intoxication
No painful distracting injury
• CCS
• Any high-risk factor?(i.e., age
> 65, severe mechanism, or
focal neurologic signs)?
• Can the patient be assessed
safely for range of motion
(simple mechanism, sitting
position in the ED, ambulatory
at any time, delayed onset of
neck pain, or absence of
midline cervical spine
tenderness)?
• Can the patient actively rotate
the neck 45 degrees to the left
and the right?
Children
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Not validated in either study
Small numbers of children
Can’t assess under 2 years
Rare injury in children
High risk PMH
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Elderly
Rheumatoid arthritis
Down's syndrome
Osteoporosis
Metastatic cancer
Low Risk
• Simple rear end
• Sitting in ED
• Ambulatory at any time
• Delayed onset of neck pain
Which X Rays?
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3 View (LAT, AP, ODONTOID) in adults
2 View in children, ? 1 View
Sensitivity 90%
Add CT 99.9% sensitive
10% non-contiguous # incidence
Adjuvants
• Swimmers view
• CT scan
• MRI
• Flexion/Extension views
AP and LAT
• Evaluation
A Alignment
B Bones
C Cartilage
S Soft Tissue
AP & Odontoid
Measurements
On Lateral view
Soft Tissue
ADI
Swischuck’s Line
Mechanism of Injury
• Flexion type
Mechanisms of Injury
• Rotation/Flexion
• Lateral Flexion
Other mechanisms
• Axial Load
• Hyperextension
C5 on C6
L1 Compression Fracture
Lumbar Vertebral Body #
So why do we take “spinal
precautions”?
• Never can tell…
• Preserve intact cord
• Cost
Log Roll
Collar
It is AMUST to Suspect SCI!
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A = Airway
B = Breathing
C = Circulation
D = Disability
E = Exposure
• A = Altered mental state. Check
for drugs or alcohol.
• M = Mechanism. Does the
potential for injury exist?
• U = Underlying conditions. Are
high risk factors for fractures
present?
• S = Symptoms. Is pain,
paresthesia, or neurologic
compromise part of the picture?
• T = Timing. When did the
symptoms begin in relation to the
event?
Acute Treatment
• First treat life threatening conditions
• Then do no harm
• Spinal immobilise – 5% deteriorate
• A-B-C-D-E
• A-M-U-S-T
• Transport by air
Acute Medications
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O2
RSI – beware scoline
Crystalloids – judiciously
Atropine, pacemaker
Inotropes
Ganglioside GM-1, naloxone, CCB & glutamate
receptor antagonists
• And……..
Steroids?
• Definitely not for penetrating trauma!
• Blunt trauma?
• 1975 First National Acute Spinal Cord
Injury Study (NASCIS) established
• Followed by NASCIS 2 and NASCIS 3,
which was completed in 1998
• Bottom line……
Steroids
• Everyone wants to try and get just some
benefit…
• So it’s not advocated as a standard of care
but it is an option <8 hours
• Dosage 30mg/kg over 15 min +
5.4mg/kg/hour for 24 or 48 hours
Surgery
• Some unclear roles
• Some clear roles
anterior cord syndrome
thoracolumbar spine fracture/dislocation
Summary
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Suspect SCI and look for it
Spinal precautions in vast majority
Use and familiarize decision rules
Use your common sense
Examine your patient
Ask for help
References
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www.drivinghome.co.uk/html/cj_injury.shtml
http://www.worldortho.com/
http://www.playersfund.org.za/spineline/spineline.asp
http://www.emedicine.com/emerg/topic553.htm
http://www.doh.gov.za/mts/reports/spinal.html
http://quad.stormnet.co.za/info.htm
http://www.transport.gov.za/comm-centre/sp/2006/sp0907.html
American Academy of Emergency Medicine:
http://www.aaem.org/positionstatements/steroidsinacuteinjury.shtml
• American College of Surgeons: Advanced Trauma Life Support, 7th
ed. Chicago, 2004
• Canadian & American Spinal Research Organization
• Markovchick & Pons: Emergency Medicine Secrets 4E