Spinal and Spinal Cord Injuries

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For patients presenting after significant fall (> 12ft), deceleration injuries, blunt trauma to head, neck, or back, assume cord injury. Spinal immobilization such as spinal collar and transportation via spine board is to be undertaken until spinal injury can be ruled out. Sometimes vertebral injuries can be sustained without spinal cord injury, and a normal neurologic exam does not rule out spinal injury. Sometimes the spinal cord can be injured despite normal C-spine x-ray (SCIWORA = spinal cord injury without radiologic abnormality). The injuries can include complete/incomplete transection, cord edema, and spinal shock.

Any spinal cord injury below T10 à beware Cauda Equina Syndrome! Symptoms include incontinence, anterior thigh pain, quadriceps weakness, abnormal sacral sensation, decreased rectal tone, and variable reflexes.

History:

·      Mechanism of injury

·      Previous deficits

·      Neck pain, weakness/paralysis, paresthesia

Physical exam:

·      Vital signs

·      Abdominal: ecchymosis, tenderness

·      Complete neurological examination, including mental status

·      Spine:

o   Front—palpate C-spine while maintaining neutral position

o   Back—log roll to palpate T and L-spine and assess rectal tone

o   When palpating, assess for tenderness, muscle spasm, bony deformities, step-off, and spinous process mal-alignment.

·      Extremities: capillary return, suspect thoracolumbar injury with calcaneal fractures (e.g. patient falling from height landing on his/her feet).

Investigation:

·      Blood work: CBC, electrolytes, creatinine, glucose, coagulation profile, cross and type, and toxicology screen.

·      Imaging

o   C-spine x-ray series (AP, lateral, odontoid)

o   Thoracolumbar x-ray series (AP, lateral) if any of the following is present:

§  C-spine injury

§  Unconscious patient (and probable mechanism of injury)

§  Patients with neurological symptoms or findings

§  Patients with palpable deformities when log rolled

§  Patients with back pain

§  Patients with bilateral calcaneal fractures (concurrent burst fractures of the thoracic or lumbar spine T11~L2 will be find in 10%)

o   Consider CT for subtle bone injuries

o   Consider MRI for soft tissue injuries

C-Spine can be cleared when:

·      Oriented to person, place, time, and event

·      No intoxication

·      No posterior midline cervical tenderness

·      No focal neurological deficits

·      No painful distracting injuries (so that patient neglects to recognize pain from neck).

Management of cord injury

·      Immobilize

·      DRABC

·      Treat neurogenic/spinal shock (maintain systolic BP > 100)

·      NG tube and Foley catheter

·      High dose steroids (methylprednisolone 30mg/kg bolus, then 5.4mg/kg/h drip within 6~8 h after injury) is controversial and recently has less support

·      Complete imaging of spine and consult spine service if available

·      Continually assess high cord injuries as edema can travel up cord

·      If there is cervical cord injury, watch out for respiratory insufficiency

o   Low cervical transection (C5~T1) produces abdominal breathing (phrenic innervation of diaphragm still intact).

o   High cervical injury (C4 and above) may require intubation and ventilation

·      Supportive treatment: warm blanket, Trendelenburg position (the body is laid supine with the feet higher than the head by 15-30 degrees), volume infusion, consider vasopressors.