Spinal trauma and its management

Early diagnosis of injury, preservation of spinal cord function, maintenance and restoration of spinal alignment and stability are the key to successful management.
Evaluation for spinal injury is indicated if focal pain, neurological examination, or mechanism of injury is suggestive.Cervical spine injuries are common in RTA, falls or other injuries in which; flexion-extension forces are exerted.

1. Initial Support

Airway: Airway must be cleared of any obstruction e.g. foreign body or vomitus. Endotracheal intubation is necessary. If gag reflex is absent Associated cervical spine injury should be excluded in the patients with head injury before endotracheal itubation with the help of cervical spine radiographs.  In situations where this is not possible, two-person intubation should be performed, with the second individual securing patient’s neck by axial traction to avoid extension of neck during intubation
Breathing:

  • Examination of chest for injuries to ribs and sternum.
  • Look for Pneumothorax and Haemothorax and manage accordingly.
  • Assisted ventilation if adequate air exchange is not clearly taking place.

Circulation: I/V access should be established and at the same time, blood sample sent for CBC and Electrolytes in unconscious patients and where necessary, blood grouping and cross matching should be done.
Hypovolaemia should be corrected in acute stage with Ringer Lactate until blood is arranged.  Patients identified to be in spinal shock (after exclusion of haemorrhagic shock) will be treated aggressively with fluid resuscitation, monitoring of CVP and urine output.  Severe bradycardia will be treated with atropine until the pulse is > 60/min.  Hypotension will be treated with dopamine infusion titrated to a systolic BP > 100 mmHg.

2. Initial Assessment

Focused history:

  • Mechanism of injury.
  • History suggestive of loss of consciousness.
  • History of transient deficit in function.

Examination:
Examination may reveal tenderness over the spinous processes, paraspinal swelling or a gap between the spinous processes, indicating rupture of interspinous ligaments.  Neurogenic paradoxical ventilation (indrawing of the chest on inspiration due to absent intercostal function) may occur with cervical cord damage.  Bilateral absence of limb reflexes in flaccid limbs unresponsive to painful stimuli indicates spinal cord damage (unless death is imminent from severe head injury).  Painless urinary retention or priapism may also occur.
Detailed neurological evaluation assessment of motor and sensory function and deep tender reflexes should be documented including sphincter tone, cremasteric and bulbocavernous reflexes.

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3. Radiological Evaluation

  • AP, lateral and open mouth views for cervical spine.
  • Thoracic & lumbar spine – AP , lateral views.

Additional views such as oblique, flexion/extension, swimmer’s view, etc. may be required in individual patients.  Visualization of the entire cervical spine including the C1-T1 interspace is required.  Failure to visualize the entire C-spine will mandate additional studies such as a Swimmer’s view or CT scan.
Indications for Spinal Radiographs:

  • Patients with a mechanism of injury suggestive of possible spinal injury.
  • Multiple trauma patients with alteration in consciousness (e.g. head injury, intoxication, mental confusion, or painful, distracting injuries).
  • Patients with post-traumatic neck pain or tenderness.
  • Patients presenting with neurologic deficits consistent with a spinal cord injury.

Unstable patients should not be taken from the resuscitation area for radiographs. Patients with normal spinal radiographs but persistent neck pain or unexplained neurologic deficits should have CT scan or MRI.

4. Treatment

  • Once a patient is discovered to have a spinal cord injury, the Department of Neurosurgery should be notified immediately.
  • Prevention of secondary injury is paramount for spinal cord injuries.  Consequently, hypoxia, hypotension, fever and hypoglycemia should be treated aggressively.
  • Strict immobilization of the spine will be maintained until definitive care for the injury can be provided.  Initially, with cervical collar and long backboard and referred to Neurosurgery Deptt.
  • All patients with spinal cord injury presented within 8 hrs after injury will receive Inj. Methylprednisolone (30-mg/kg I/V bolus over one hour, followed by 5.4 mg/kg/hr I/V infusion over the next 23 hours.)
  • Patients with bowel and bladder dysfunction associated with spine injury may require Nasogastric Decompression, urinary catheter placement, and laxatives.

Conversely, patients who present with normal mental status, a low-grade mechanism of injury, and absence of distracting injuries, neurologic deficit, neck pain or tenderness may be “cleared” clinically by the following process:

  1. Establish a normal neurologic exam, including mental status.
  2. Confirm that the patient does not have neurologic symptoms such as paraesthesias or weakness and does not have pain in the spinal area.
  3. Remove the cervical immobilization device and palpate along the spinous processes to elicit tenderness or step-off.
  4. Have the patient actively flex and rotate his/her neck with instructions to stop immediately should any pain or paraesthesias develop.

Any positive findings during this examination will require that the spine be re-immobilized and radiographs obtained.  If all findings are negative, the spine may be cleared clinically.

 

 

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