th year medical student Tim Gardner Orthopaedic Registrar For IT Text in blue indicates a question for students to answer Information regarding how the question will work eg free text of multiple choice is listed in the notes section of the slide ID: 1037482
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1. Spinal injuriesKatherine Flack – 4th year medical student Tim Gardner – Orthopaedic Registrar
2. For ITText in blue indicates a question for students to answer Information regarding how the question will work (eg free text of multiple choice) is listed in the notes section of the slide References are also in the notes sectionSlides titled navigation is how the navigation pane should appear on the side
3. Navigation Anatomy revision Overview of spinal fractures Denis classification Common types Compression fracture case Situation and background Assessment Overview of compression fractures Traumatic spinal cord injury (TSCI) case Situation and backgroundC-spine immobilisation AssessmentManagement 1Management 2 Summary of TSCI ASIA chart Patterns of injuries Management 3
4. Navigation part 2Back pain PresentationRed flags Differentials Summary
5. Spinal column anatomy 33 bones separated by intervertebral discs
6. Structure of vertebrae Anterior ventral body – weight bearing Posterior vertebral arch – multiple bony prominences which enable the attachments for muscles and ligaments
7. Denis classification of spinal fractures The Denis Classification of spinal fractures divides the spine into 3 columns the anterior, middle and posterior Anterior column – anterior longitudinal ligament and anterior half of vertebral body Middle column – posterior half of vertebral body and posterior longitudinal ligament Posterior column – pedicles, facet joints and supraspinous ligamentsIf 2 or more of these columns are injured the spine is described as unstable
8. Compression Chance (flexion/distraction) Burst Anterior part of vertebra breaks but the posterior aspect remains intact therefore only loses height anteriorly.Commonly occurs in patients with osteoporosis.Usually stable Vertebra loses height on both anterior and posterior aspects. Usual cause is falling from height and landing on feet. Occurs when vertebrae are suddenly pulled away from each other in a flexion-distraction mechanism. Associated with high rates of mechanical instabilities and gastrointestinal injuries. Most common types of spinal fractures Click on the boxes to find out more about type of spine of spinal fracture
9. Compression fracture case
10. Situation and background Mary is a 75 year old lady who lives alone in a bungalow. She has a PMHx of acid reflux, osteoporosis, type 2 diabetes.Whilst out gardening she slipped on the steps outside.What are you worried about when an elderly patient presents with a fall?Fracture Head injury Collapse due to underlying cause – eg stroke, MI, hypoglycaemia, rupture abdominal aortic anerusym
11. Assessment When she arrives in A&E she is sent for an urgent x-ray which confirms your suspicions of a compression fracture. Select which aspect of her past medical history is most likely to have contributed to her injury?Acid reflux Female Osteoporosis Type 2 diabetes Age
12. Compression fracture Compression fractures are common in individuals with osteoporosis.Diagnosis is done using lateral x-rays.On x-ray there is a loss of anterior, middle or posterior vertebral height by 20%. This shows the typical ‘wedge’ shape.Treatment – observations and pain management mostly
13. Traumatic spinal injury case
14. Situation and background You are an FY1 working in A&E. Greg (age 35) has arrived to ARI by helicopter after being involved in a serious high speed head-on collision whilst driving. He has been initially managed by trauma doctors at the scene and has a cervical collar and ‘blocks and board’ in place. He is able to talk and his main complaint to you is pain in neck and tingling in arms.
15. C-spine immobilsation This is how Greg arrives to you What is the main indication in this case to use a c-spine immobilisation collar and blocks? Paresthesia in extremities Car collision mechanism
16. Assessment for cervical spine injury NICE recommend using the indications given in the Canadian C-spine rule to determine whether to maintain full in-line immobilisation. Using the Canadian-C spine rule Greg is deemed to be high risk (due to dangerous mechanism).Therefore you should maintain full in-line spinal immobilisation.This is also used to determine if radiography should be used, in this case the answer is yes.
17. How do you initially manage the patient?Take a thorough history Give pain medication <C>ABCDE approach CT scan
18. <C>ABCDE CCatastrophic bleeding / Cervical SpinePelvic binder in place, abdomen hard. Neck ImmobilisationAAirwayThere is no airway obstruction, airway patentBBreathing O2 sats at 92 and clear lung sounds. Equal chest expansion, no flail chestCCirculation Blood pressure is 95/60, weak pulse in peripheries. HR 110 bpm, cool peripherallyDDisability Pupil responses equal and reactive, numbness and weakness in right armEExposure/everything else Glucose levels normal, multiple grazes and abdominal bruising but no other major external injuries
19. Next management Thinking about each component of the <C>ABCDE approach, list how you would now like to manage Greg?When answering a complex question like this it can be helpful to group into the C ABCDE order. Catastrophic bleedingIV accessBloods – group and save (pink tube), FBC, U+E, CoagUrgent CT scan request – ‘camp bastion protocol’ – Head, neck, chest, abdomen, pelvis at leastAirways + breathing Oxygen15L high flow non-rebreathe mask CirculationIV fluid resuscitation – start with IV Crystalloid but consider early switch to blood Disability Covered by CT scan Neurological exam Everything else Pain relief – likely IV OpioidInvolve seniors and other specialities – Should have a trauma call but just in case, make sure everyone is here! (orthopaedics, general surgery, anaesthetics, radiology)Update family
20. Images to be included on page when answers appear from the previous slide
21. CT scan After the initial handover and <C>ABCDE, Greg is sent for a full CT scan.Findings – C5/6 Facet joint dislocationFree fluid in abdominal cavity, suspicious of splenic ruptureNo pelvic fractureNo pneumothorax, no rib fracturesNo intracerebral injuriesNo other bony injuries
22. Traumatic spinal cord injury (TSCI)More common in males.Most are due to preventable causes such as RTA, sport injuries or falls. Can be classified as complete or incomplete (AOSpine Injury Classification System).Complete – damage affects the whole spinal cord width which causes complete loss of sensation and paralysis below the level of injury. Incomplete – damage only affects part of the spinal cord, hence only partially implicating sensation or movement below the level of injury.
23. Pathophysiology of TSCI Primary injury – the direct trauma from injury mechanism causes damage to spinal cord.Secondary injury – result of injuries to surrounding structures causing compression on the spinal cord often from haematoma.
24. Spinal surgeon The spinal orthopaedic surgeon is sent to review Greg.First she goes through the ASIA chart to determine the level of severity of neurological deficit.
25. ASIA chart Developed as a universal classification tool for spinal cord injuries. Grades A: complete no sensory or motor function preserved B: sensory incomplete sensory but not motor function is preserved C: motor incomplete less than half of key muscle functions below the lesion have a muscle grade of >/= 3D: motor incomplete half or more key muscles functions below the lesion having a muscle grade >/= 3 E: normalFor more in depth classification look up the ASIA Impairment Scale (AIS).
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27. Greg’s neurological injuries Greg has these findings on neurological examination especially:Anal tone normal Weakness to wrist extension bilaterally Numbness and tingling in thumb bilaterally At which spinal level do these injuries correspond to?C2/3C3/4C5/6C6/7
28. ASIA Impairment Scale (AIS)Based off of Greg’s injuries and ASIA chart, what AIS grade do you give him?ABCDEHe has an incomplete TSCI as the damage only affects part of the spinal cord, hence only partially implicating sensation or movement below the level of injury. He is not paralysed below the level of injury indicating it is not a complete TSCI.
29. Patterns of injuriesTetraplegia – impairment of function in arms, trunk, legs and pelvic organs. Paraplegia – impairment of function in trunk, legs and pelvic organs. Arm function is preserved.
30. Management Spinal column injuries can be managed non-operative or operative.There are 2 absolute indications for surgical management of TSCI - Progressive neurological deficit Dislocation type injury to spinal column What will the spinal surgeon’s decision be regarding Greg’s management? - Operate
31. Rehab After stabilization of his major bleeding, he then has successful spinal surgery and Greg is now in rehab. Which members of the multi-disciplinary team may be involved in his care?Medical teamNursesPhysiotherapy Speech and language Occupational therapy Psychologist
32. Approach to back pain history taking
33. Back pain presentation John is a 55 year old man who presents to his GP with back pain.
34. Using a systematic approach, which questions would you initially like to ask regarding the pain?Using SOCRATES Site Onset Character Radiating pain Associated symptoms Time/duration Excerbating/relieving factors Severity
35. Back pain presentation John replies with these answers - Pain is in lower back It came on approximately a week ago after lifting a heavy box in work Pain is dull and does not radiate Regular ibuprofen helps a bit Rates the pain an 7/10 and was at it’s worst the day after lifting the box
36. Back pain red flagsWhich red flags questions should you ask to rule out a more serious cause of the back pain? Cauda equina red flags Bilateral sciatica Bilateral motor weakness of legs Difficulty initiating micturition Faecal incontinence Saddle anesthesia Decreased anal tone Erectile dysfunction Other red flagsNight pain Stiffness in morning Major trauma Gradual onset Weight loss Fever History of cancer
37. Differentials of back pain There are many differentials of back pain, try list as many as you can
38. Differentials of back pain Back pain Mechanical Muscle of ligament sprain Herniated disc Scoliosis Degenerative changes Spinal fracture Cauda equina Spinal stenosis Ankylosing spondylitis Spinal infection Non-spinal related Eg Ruptured aortic aneurysms, pyelonephritis + more Cancer
39. John says he is not affected by any of those symptoms. He has a normal PR exam, and no altered perineal sensation. He went to pass urine before coming into the clinic room. You are confident this is likely a mechanical cause and prescribe simple analgesia to John with a worsening statement given.
40. Summary Be aware of risk factors for compression fractures.Recognise the signs of spinal cord injury and gain confidence using the ASIA chart.Recognise red flag symptoms in back pain which may require urgent investigation.