Spinal Injury Sayun - PowerPoint Presentation

Slide1

Spinal Injury

Sayun

Sumethvanich

M.D.

Slide2

Spinal injury

Stable injury

: vertebral component will not be displace by normal movement

Unstable injury

: there is significant risk of displacement and damage neural tissue

Slide3

Outline

Goal of spine trauma care

Pre-hospital management

Clinical and neurologic assessment

Acute spinal cord injury

Term, type and clinical characteristic

Common thoracolumbar spine fracture and dislocation

Slide4

Goal of spine trauma care

Protect further injury during evaluation and management

Detect spine injury or absence of spine injury

Protection

Priority

Detection

Secondary

Slide5

Maintain or restore spinal alignment

Minimize loss of spinal mobilityObtain healed & stable spine

Optimize conditions for maximal neurologic recovery

Facilitate rehabilitation

Slide6

Suspected Spinal Injury

High energy trauma

Sudden deceleration (traffic accident, fall)

Unconscious

Multiple injuries

Neurological deficit

Spinal pain/tenderness

Slide7

Pre-hospital management

Protect spine at all times during the management of patients with multiple injuries.

Up to 5% of spinal injuries have a second, possibly non adjacent, fracture elsewhere in the spine

Whole spine should be immobilized in neutral position on a firm surface.

Can be done manually or with a combination of semi-rigid cervical collar, side head supports, long spine board and strapping.

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Cervical spine immobilization

Hard backboard, rigid cervical collar and lateral support (sand bag)

Neutral position

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Transportation of spinal cord-injured patients

Rigid cervical collar

Log-rolling

Rigid transportation board

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Initial immobilization of C-spine with a hard-collar is a priority

Long spine boards are valuable primarily for extrication from vehicles

Rapid evacuation to a level 1 trauma center

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Clinical and neurologic assessment

Advance Trauma Life Support (ATLS) guidelines

Primary and secondary surveys

Adequate airway and ventilation are the most important factors

Supplemental oxygenation

Early intubation is critical to limit secondary injury from hypoxia

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Spine evaluation concurrent with resuscitative measure

Assessment of gross neurological function

Diagnosis of

severy

unstable injury

Analysis of hemodynamic parameters :

neurogenic shock

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Neurogenic shock

Secondary to spinal cord injuries of the cervical or high thoracic region

Loss of

symphathetic

imput

– vasodilation, decrease cardiac output and venous return

Diagnosishypotension with bradycardiawarm extremities (loss of peripheral vasoconstriction)motor and sensory deficits

Slide15

In the multiply

-

injured patient,

hypotension

had

blood

loss as the etiology rather than

neurogenic causes

Treatment

Adequate airway and ventilation

Most

patients

with

neurogenic

shock

will

respond

to

restoration

of

intravascular

volume

alone

Administration of vasoconstrictors will improve peripheral vascular tone

Dopamine may be utilized first

Slide16

Physical examination

Inspection and palpation

Occiput to Coccyx

Soft tissue swelling and bruising

Point of spinal tenderness

Gap or Step-off

Spasm of associated muscles

Neurological assessment

Motor, sensation and reflexesSacral sparing - PR

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Neurological assessment

Sensory

Dermatome

Pain &

tempature

Positional sense

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Motor power

Campbell, 12

th

edition

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Grading Scale of motor power: 0-5

0: total paralysis

1: palpable or visible contraction

2: active movement; gravity eliminated

3: active movement: against gravity

4: active movement: against some resistance

5: active movement: against full resistance

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Neurological assessment: RectalTone: the presence of rectal tone

Perianal sensation

Incomplete cord

A voluntary contraction of the sphincter

Bulbocavernosus reflex:

Positive: the presence of this reflex implies the lack of

supraspinal

input to the sacral outflow and is suggestive of a complete spinal injury

Negative: spinal shock

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Acute spinal cord injury

Spinal shock

Functional classification

Anatomical classification

Slide22

Spinal shock

The loss of spinal

sensation, reflex with motor paralysis

after injury of the spinal cord

This commonly resolves in 48 hours

Complete & Incomplete spinal cord injury -

Bulbocavernosus reflex

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TreatmentPatient's neck and back is immobilized

Airway is maintained so patient can breath normal

Continue intravenous fluid and volume injected as necessary to maintain normal blood pressure

Nasal oxygen is provided to maintain normal blood oxygenation

Intravenous corticosteroid -

controvercy

Slide24

Functional classification

American Spinal Injury Association (ASIA) score

Slide25

ASIA Impairment ScaleA = Complete

:

No motor or sensory function is preserved

below the level of injury (including the anal area)

B = Incomplete

:

Sensory

but not motor function is preserved below the neurological level and includes the sacral segments

C = Incomplete: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade < 3D = Incomplete: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or moreE = Normal

: Motor and sensory function are normal

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Anatomical classification

Complete Spinal cord injury

No sensation / motor below injury

Poor prognosis - chance to recover < 5 %

May be involuntary movement

Incomplete Spinal cord injury

Spare sensation / motor below injury

Better prognosis than complete injury

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Type of Spinal cord injury

Brown-

Sequard

syndrome

Hemicord

Ipsilateral motor weakness

Contralateral loss of pain & temp

Good prognosis

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Anterior cord syndromeAnterior 2/3

Motor weakness, loss of pain & temp below injury level

Poor prognosis

Posterior cord syndrome

Posterior column

Loss of

propioceptive

, vibratory, but spare sensory and motor function

Prognosis : Fair

Slide29

Central cord syndrome

Central area

Old age – degenerative cervical spondylosis

Hyperextension injury

Motor weakness :

arm,hand

> leg

Sensory : spare

Prognosis : Fair

Slide30

Common thoracolumbar spine fracture and dislocation

Thoracic vertebrae

Rib bearing vertebrae

Designed to remain stiff and straight

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Lumbar vertebraeWeight bearing vertebrae

Lamina, facets and

spinoligamentous

complex are major parts of posterior elements

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Three column concept

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1. Wedge compression fracturesIsolated failure of the anterior column

Forward flexion

Neurological deficit are rare

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2. Burst fractureThe anterior and middle columns fail because of a compressive load, but no loss of integrity of the posterior elements

The posterior column is disrupted – unstable burst fracture

Maybe neurological deficit

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3. Flexion-Distraction injuryThe anterior column fails in compression

The middle and posterior columns fail in tension

Unstable

4. Chance fracture

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5. Translational injuryFracture-dislocation

Totally disruption and one part of the spinal canal has been displaced in the transverse plane

Slide37

TLIC score

≤ 3 =

nonoperative

treatment

score of ≥ 5 = operative treatment;

score of 4 = either

nonoperative

or operative treatment

Slide38

Nurse care plan

Immediate care

Assessment – vital sign, neurological function

Ventilation

Hemodynamic parameter

Stabilization

Pain control

Pshycological

supportRehabilitation – multidisciplinary approachPrevent complication

Slide39

Thank you