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Spinal Injury Dr Adrian Burger Senior Registrar Division of Emergency Medicine UCT/US 25 May 2007 Objectives • • • • • Anatomy Stats Clinical Imaging Summary Anatomy 1 • • • • • 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 • • • • • 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) • • • • • • 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 • • • • Not validated in either study Small numbers of children Can’t assess under 2 years Rare injury in children High risk PMH • • • • • 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? • • • • • 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! • • • • • 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 • • • • • • 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 • • • • • • 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 • • • • • • • • 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