Injury to Spinal Cord

Injuries to Spinal Column

General Overview 

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Spinal Cord Injury is damage to the spinal cord that results in a loss of function such as mobility or feeling. Frequent causes of damage are trauma and disease. Spinal Cord is the major bundle of nerves that carry impulses to/from the brain to the rest of the body. Spinal Cord is surrounded by rings of bone-vertebra. They function to protect the spinal cord.

Spinal Injuries ASIA IMPAIRMENT SCALE: A =Complete:

No motor or sensory function is

preserved

B =Incomplete:

Sensory but not motor function is

preserved

C =Incomplete:

Non-useful motor function is preserved below the neurological level

D =Incomplete:

Useful motor function is pre-served below the neurological level

E =Normal:

Motor and sensory func-tionare normal.

Incomplete Spinal Injuries CLINICAL SYNDROMES: Central Cord: greater motor deficit in the upper extremities

Brown-Sequard:

dissociated sensory loss,

ipsilateral paralysis

Anterior Cord:

paraplegia, quadriplegia

Incomplete Spinal Injuries CLINICAL SYNDROMES: Conus Medullaris:

saddle anesthesia, incontinence

(painless, symmetrical)

Cauda Equina: (painful, asymmetrical)

saddle anesthesia, incontinence

Causes Cause

Meaning

Trauma

Trauma means injury. Many people become injured through accidents. In these cases the skeletal, muscular or nervous systems may become damaged. Trauma usually happens after birth.

Illness

There are many illnesses that can cause damage to body systems that control movement and may lead to physically disabilities. Many illnesses are caused by a variety of bacteria and viruses. Some illnesses may be inherited and there are some illnesses for which scientists still don't know the cause.

Congenital

Something that is "congenital" means present when a person is born. In these cases, a person is born with a physical disability – doesn’t have to be genetic.

Genetic

Genetic means that something is inherited from a person’s parents. This means that one or both parents passed a gene that carried that disease or disability. Genetic disorders can sometimes be caused by a mutation of a gene. Scientist usually don't know why these mutations happen and when they can happen.

Spinal Injuries Injury level

Prognosis 

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Patients with a complete cord injury have a less than 5% chance of recovery. If complete paralysis persists at 72 hours after injury, recovery is essentially zero. The prognosis is much better for the incomplete cord syndromes. If some sensory function is preserved, the chance that the patient will eventually be able walk is greater than 50%. Ultimately, 90% of patients with SCI return to their homes and regain independence. In the early 1900s, the mortality rate 1 year after injury in patients with complete lesions approached 100%. Much of the improvement since then can be attributed to the introduction of antibiotics to treat pneumonia and urinary tract infection. Currently, the 5-year survival rate for patients with a traumatic quadriplegia exceeds 90%. The hospital mortality rate for isolated acute SCI is low.

Scale of Motor Strength in SCI 

The American Spinal Injury Association:    

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0 - No contraction or movement 1 - Minimal movement 2 - Active movement, but not against gravity 3 - Active movement against gravity 4 - Active movement against resistance 5 - Active movement against full resistance

Assessment of sensory function helps to identify the different pathways for light touch, proprioception, vibration, and pain. Use a pinprick to evaluate pain sensation.

Types of Spinal Cord Paralysis 

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Depending on the location and the extent of the injury different forms of paralysis can occur. Monoplegia- paralysis of one limb Diplegia- paralysis of both upper or lower limbs Paraplegia- paralysis of both lower limbs Hemiplegia- paralysis of upper limb, torso and lower leg on one side of the body Quadraplegia- paralysis of all four limbs

Spinal Cord Paralysis Levels C1-C3  All daily functions must be totally assisted  Breathing is dependant on a ventilator  Motorised wheelchair controlled by sip and puff or chin movements is required C4  Same as C1-C3 except breathing can be done without a ventilator C5  Good head, neck, shoulder movements, as well as elbow flexion  Electric wheelchair, or manual for short distances C6  Wrist extension movements are good  Assistance needed for dressing, and transitions from bed to chair and car may also need assistance C7-C8  All hand movements  Ability to dress, eat, drive, do transfers, and do upper body washes

Spinal Cord Paralysis Levels T1-T4 (paraplegia)  Normal communication skills  Help may only be needed for heavy household work or loading wheelchair into car T5-T9  Manual wheelchair for everyday living  Independent for personal care T10-L1  Partial paralysis of lower body L2-S5  Some knee, hip and foot movements with possible slow difficult walking with assistance or aids  Only heavy home maintenance and hard cleaning will need assistance

Signs and Symptoms of Spinal Cord Injury     

Pain Tenderness Painful Movement Deformity Soft Tissue Injury in area of spine (Bruise, Laceration, etc.)

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Paralysis Paresthesias Paresis (weakness) Shock Priapism

Complete and Incomplete Spinal Cord Syndromes can be classified into either complete or incomplete categories  Complete – characterized as complete loss of motor and sensory function below the level of the traumatic lesion

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Incomplete – characterized by variable neurological findings with partial loss of sensory and/or motor function below the lesion

Spinal Shock  

An immediate loss of reflex function, called areflexia, below the level of injury Signs:  

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Slow heart rate Low blood pressure Flaccid paralysis of skeletal muscles Loss of somatic sensations Urinary bladder dysfunction

Spinal shock may begin within an hour after injury and last from several minutes to several months, after which reflex activity gradually returns

Central Cord Syndrome   

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Usually involves a cervical lesion May result from cervical hyperextension causing ischemic injury to the central part of the cord Motor weakness is more present in the upper limbs then the lower limbs Patient is more likely to lose pain and temperature sensation than proprioception Patient may complain of a burning feeling in the upper limbs More commonly seen in older patients with cervical arthritis or narrowing of the spinal cord

Brown-Sequard Syndrome      

Results from an injury to only half of the spinal cord and is most noticed in the cervical region Often caused by spinal cord tumours, trauma, or inflammation Motor loss is evident on the same side as the injury to the spinal cord Sensory loss is evident on the opposite side of the injury location (pain and temperature loss) Bowel and bladder functions are usually normal Person is normally able to walk although some bracing or stability devices may be required

Anterior Spinal Cord Syndrome   

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Usually results from compression of the artery that runs along the front of the spinal cord Compression of SC may be from bone fragments or a large disc herniation Patients with anterior spinal cord syndrome have a variable amount of motor function below the level of injury Sensation to pain and temperature are lost while sensitivity to vibration and proprioception are preserved

Hyperflexion

Hyperextension

Hyperotation

Axial Loading

Axial Distraction

Sudden/Extreme Lateral Bending 

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Excessive/abnormal lateral movement of the spine Can affect any portion of the spine Example: T-bone MVAs

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Spinal Column Injury 

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Bony spinal injuries may or may not be associated with spinal cord injury These bony injuries include:   

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Compression fractures of the vertebrae Comminuted fractures of the vertebrae Subluxation (partial dislocation) of the vertebrae

Other injuries may include:  

Sprains- over-stretching or tearing of ligaments Strains- over-stretching or tearing of the muscles 25

Spinal Column Injury Atlanto-occipital dislocation 

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Power’s ratio=BC/OA 5mm

Spinal Column Injury Atlas (C1) fractures  

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Described as Jefferson # Axial load Usually no neurological deficit 1/3 have C2 # Usually stable

Spinal Column Injury Axis (C2) # 

Includes Hangman’s # and Odontoid process #

HANGMAN’S #  Bilateral # of the isthmus of the pedicles of C2 with anterior sublaxation of C2-C3  Hyperextention and axial loading  Usually stable

Spinal Column Injury Axis (C2) # 

Includes Hangman’s # and Odontoid process #

Odontoid #  Flexion injury  15% of all cervical injuries  II unstable,I & III stable

I

II

III

Spinal Column Injury Subaxial (C3-C7) # Whiplash injury:  Traumatic injury to the soft tissue in the cervical region  Hyperflexion, hyperextention  No fractures or dislocations  Most common automobile injury  Recover 3-6 months

Spinal Column Injury Subaxial (C3-C7) # Vertical compression injury:  Loss of normal cervical lordosis  Burst #  Compression of spinal cord  Unstable  Requires decompression and fusion

Spinal Column Injury Subaxial (C3-C7) # Compression flexion injury (teardrop #)  Classical diving injury  Posterior elements involved in >50%  Displacement of inferior margin of the body  Unstable  Requires stabilization

Spinal Column Injury Subaxial (C3-C7) # flexion distraction injury (locked facet)  >50% displacement  Unstable  Requires reduction and stabilization

Spinal Column Injury Subaxial (C3-C7) # extention injury (# posterior elements)  # lamina, pedicles or spinous process  With or without ligamentous injury  Usually stable

Spinal Column Injury Thoracic and lumbar #

Stability (three column model of Denis)  Injury affecting two or more column is unstable

Spinal Column Injury Thoracic and lumbar #

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Compression # Burst # Chance # (seat belt) Flexion distraction Fracture dislocation

Spinal Cord Injury 

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Cutting, compression, or stretching of the spinal cord Causing loss of distal function, sensation, or motion Caused by: 

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Unstable or sharp bony fragments pushing on the cord, or Pressure from bone fragments or swelling that interrupts the blood supply to the cord causing ischemia 38

Primary Spinal Cord Injury 

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Immediate and irreversible loss of sensation and motion Cutting, compression, or stretching of the spinal cord Occurs at the time of impact/injury

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Secondary Spinal Cord Injury 

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Injury Delayed Occurs later due to swelling, ischemia, or movement of sharp or unstable bone fragments May be avoided if spine immobilized during extrication, packaging, treatment, and transport

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Incomplete Spinal Cord Injury 

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Complete injury to specific spinal tracts with reduced function distally Other tracts continue to function normally with distal function intact

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Spinal Region Overview 

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Cervical Spine Injuries Thoracic Spine Injuries Lumbosacral Spine Injuries Spinal Injury Summary

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Cervical Spine Injuries 

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C-spine very flexible Most frequently injured area of spine Most injuries at C-5/C-6 level

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Thoracic Spine Injuries 

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T-spine less flexible Narrow spinal canal Cord injury occurs with minimal displacement Common mechanisms Any cord damage usually complete at this level Most T-spine injuries occur at T-9/T-10 44

Lumbosacral Spine Injuries 

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LS spine flexible nerve roots in roomy spinal canal May have bony injury w/o cord or nerve root damage Secondary injury still possible Neurological injury rare w/ isolated sacral injuries

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General Management Guidelines     

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Strict spine precautions (immobilization) Emergency resuscitation (ABC..) Comprehensive approach Neurological and Radiological assesment. Always expect multiple trauma (neuroexam, chest, abdomin,muskuloskeletal…) Differentiate hggic from neurogenic shock

General Management Guidelines External vs Internal stabilization

Assessment Overview 

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Decision to apply spinal immobilization in past based was solely on mechanism of injury Utilize EMS Spinal Immobilization Algorithm to determine when spinal immobilization is NOT needed

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Spinal Immobilization Algorithm Patient Mentation:

Decreased Level of Consciousness? No

Yes ----------------------------Immobilize

ETOH/Drug Impairment? No

Yes ----------------------------Immobilize

Subjective Assessment: Cervical/Thoracic/Lumbar Spinal pain? No

Yes ----------------------------Immobilize

Numbness/Tingling/Burning/Weakness? No

Yes -----------------------------Immobilize

Objective Assessment: Cervical/Thoracic/Lumbar Deformity or Tenderness? No

Yes -----------------------------Immobilize

Other Severe Injury? No

Yes -----------------------------Immobilize

Other Severe Injury? No

Yes -----------------------------Immobilize

Pain w/Cervical Range of Motion? No

Yes -----------------------------Immobilize

MAY TREAT/TRANSPORT WITHOUT SPINAL PRECAUTIONS

Principles of Treatment 

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Protect spinal cord from secondary injury We have little or no effect on primary injury Focus on prevention of secondary injury

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Complete Spinal Immobilization 

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Must act as if whole spine unstable Immobilize entire spine To do this we must immobilize the head, neck, shoulders/chest, and pelvis /hips

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General Assessment 

Scene Size Up

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Initial Assessment 

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Including manual stabilization/immobilization of the c-spine

Focused History and Physical Exam - Trauma 

Reevaluate Mechanism of Injury (MOI)

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Suspected Spinal Injury Protocol

Positive MOI - Forces or impact suggest a potential spinal injury 

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High Speed MVC Falls Greater than 3x pt.’s body height Axial Loading Violent situations near the spine  Stabbing  Gun shots  etc.

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Sports Injuries Other High Impact Situations Consideration to special pt. Population  pediatrics  geriatrics  history of Down’s  spino bifoda  etc.

High Risk MOIs Axial load (i.e., diving injury, spearing tackle)  High speed motorized vehicle crashes or rollover  Falls greater than standing height The presence of one of these MOIs does not always require treatment, but providers should be more suspicious of spinal injury, and immobilize if they are at all worried about the possibility of spinal injury 

Other High Risk Factors Associated with Spinal Injury 

Trisomy 21 (Down Syndrome, mongolism) 

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Age Greater than 55 

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Risk of degenerative arthritis of cervical spine

Degenerative Bone Disease (including ostegenesis imperfecta, or “fragile bones”) 

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Risk of Atlanto-Axial Instability (AAI)

Risk of “pathological” (disease-related) fractures

Spinal Tumors 

Risk of “pathological” (disease-related) fractures

Negative MOI 

Forces or impact involved does not suggest a potential spinal injury 

Dropping rock on foot

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Twisting ankle while running

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Isolated soft tissue injury

Uncertain MOI 

Unclear or uncertainty regarding the impact or forces 

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Trip and fall hitting head Fall from 2-4 feet Low speed MVC with minor damage

MOI, cont. When using the Suspected Spinal Injury protocol, a positive mechanism of injury is not considered means to necessitate full immobilization … BUT… should be used as a historical component that may heighten a provider’s suspicion for a spinal cord injury.

Current Practice Widespread spinal immobilization of all adult and pediatric trauma patients.

Spinal Immobilization Education  Identify

All Patients at Risk for Spinal Injury based on Mechanism of Injury and Patient Assessment  Shift

from current thinking of immobilization based on mechanism of injury alone.

Major Trauma Protocol  All

Adult and Pediatric Trauma Patients who meet the Major Trauma Protocols (T 6–7)  Certain Adult and Pediatric Patients with Blunt Head and Neck Trauma i.e. Based on Mechanism of Injury (T 8)

Consider Spinal Immobilization

Not Meeting Major Trauma Protocol but patient has one or more:  Altered

Mental Status  Patient Complaint of Neck Pain  Weakness, Tingling or Numbness  Pain on Palpation of Posterior Midline Neck

Consider Spinal Immobilization  High

Risk Patients

 Not

Meeting Major Trauma Protocol but patient

has one or more:  Altered

Mental Status  Evidence of Intoxication  Distracting Injury  Inability to Communicate 

Acute Stress Reaction

 Elderly 

Age Greater than 65 years

What is an Altered Level of Consciousness?   

Verbal or less on the AVPU Scale Glascow Coma Scale of 14 or Less Short Term Memory Deficit

 Patients A

who have either

What is Intoxication?

History of Recent Alcohol Ingestion or Ingestion of Other Intoxicants  Evidence of Intoxication on Physical Examination

What is a Distracting Painful Injury?? 

Painful Injury or Serious Illness that would Mask the Symptoms Associated with Spinal Cord Injury

Distracting Injury or Circumstances 

Painful Injury    

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Obvious Deformity Significant Bleeding Impaled Object Any painful injury that may distract the patient’s attention from another, potentially more serious (cervical spine) injury

Inability to Communicate Clearly (small child, confused or intoxicated adult) Emotional Distress Presence or Exacerbation of Existing Medical Conditions

Fundamental Principle  Patient

Communication

 Patients

with Communication Difficulties  Acute Stress Reaction

What is Acute Stress Reaction? A

“fight or flight” response that can override any pain from an injury

Key Point  If

there is ANY DOUBT, then SUSPECT that a SPINE INJURY is Present and Treat Accordingly

Termination of Immobilization Once spinal immobilization has been initiated, it must be completed. An extrication or cervical collar starts the immobilization process Manual Stabilization does NOT start the immobilization process

Documentation  Negligence  Either

an omission or a commission of an

act Documentation

of rationale to

 Immobilize

 Not

Immobilize

Routine Prehospital Care Documentation  Mechanism

Of Injury  Patient Chief Complaint  Physical Examination Finding  Initial

Assessment  Rapid Trauma Examination  Detailed Trauma Examination

Documentation of Rationale to Not Immobilize  Mechanism

Of Injury is Minor

 Physical

Examination (Positives)  Physical Examination (Negatives)  Absence

of signs of spine injury  Absence of distracting injury  Patient

was not one of the identified high risk patients

New NYS BLS Protocol Suspected Spinal Injury (not meeting major trauma criteria)

First, do no harm 

Good Medical Care requires good clinical judgment; this can not be defined or legislated, but must be employed.

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When in doubt, decide in favor of the patient and immobilize the spine.

Common Treatment/Management Mistakes     

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Improperly sized C-Collar Spine not supported due to improper positioning on backboard Inadequate strapping allows excessive movement Movement possible due to little or no padding to shim the body C-spine movement by inadequate or improperly applied head immobilization device C-spine hyperextension due to improperly applied C-collar or head immobilization device 80

Common Treatment/Management Mistakes (cont.) 

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Readjusting torso straps after immobilization of the head, causing misalignment of the spine Securing head to backboard prior to securing shoulders, torso, hips, and legs

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Any Questions???