Spinal Cord/column Injuries
Para441 Neurological Injuries
Dr Oteir, PhD
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Key things
 How many vertebrae?
 How many peripheral nerves?
– 8, 12, 5, 5, 1
 Myotomes
 Dermatomes
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Motor and sensory tracts
 Pain and temperature interpretation (Spinothalamic).
– Painful stimuli enter the sensory nerve root in the dorsal horn.
– Crosses to the opposite side of the cord
– Ascends to the contralateral parietal lobe
 Both motor and pain pathways  anterio-lateral cord
– anterior spinal artery flow compromise!!.
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Spinal reflexes
 Rapid and protective motor response to painful stimuli
 Before interpreting the stimulus as pain
 Results in muscle jerk
 Muscle jerk but not pain?!
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Spinal Cord Injuries
 3%-25% of spinal cord injuries occur during
– field stabilization
– transit to the hospital, or
– early in the course of therapy
 As many as 10% of patients w/ cervical spinal cord injury are
initially neurologically intact
 Assume a cervical spine injury
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multisystem trauma
altered LOC
blunt injury above the clavicle
Remember CCR and NEXUS?
t: @alaa_oteir
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Spinal Cord Injuries
 Emphasis first is on preventing injury, then secondly, to prevent
extension of injury
 When to suspect?
– Young
– Elderly
– Mechanism of injury
 SCI can be
– complete
– Incomplete
– bony or ligamentous
t: @alaa_oteir
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Spinal Cord Injury Pathophysiology
 Hemorrhages are seen in the central gray matter
 Zone of hemorrhage, edema & necrosis spreads from
central area to involve up to the entire diameter of the
cord w/i 6-24 hrs
 Damage to the gray  an interruption of nerve
conduction in the fiber tract,
– isolates the region of the body below the level of injury
from cerebral control
t: @alaa_oteir
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Pathophysiology
 Progressive loss of function for 1st 24hrs related to
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associated secondary injury
Edema
disc compression
Hematoma
hypoperfusion to the spinal cord
 As edema subsides & circulation is reestablished, function may improve
slightly
 Spinal Shock
– State of transient physiological reflex depression of cord function below
level of injury with associated loss of sensorimotor function
• duration is variable
t: @alaa_oteir
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Neurogenic Shock
 Results from impairment of descending sympathetic
pathways in the spinal cord causing loss of vasomotor
tone & sympathetic innervation of the heart
– Causing vasodilation of visceral & LE vessels, pooling of
blood (hypotension)
– Loss of cardiac sympathetic tone (bradycardia)
– Vasopressors are often needed to restore blood pressure
 Triad of hypotension, bradycardia, hypothermia
t: @alaa_oteir
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Spinal Cord Injury
*suspect in all patients that suffer blunt trauma*
Common types:
-Whiplash; soft tissue injury of spine
-Incomplete injury; some preserved sensory-motor
function
-complete injury; total loss of movement & sensation below
the lesion
-sacral sparing; preservation of some sensory perception in
perianal region and/or voluntary contraction of rectal
sphincter
t: @alaa_oteir
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Spinal Cord Injury
 Bony vs Ligamentous
– Most injuries do not involve the cord itself.
– Both types of injuries require stabilization
– Unable to clear c-spine with distracting injuries, altered LOC and pain in
neck region.
• Re-immobilize patients for transfer if C-Collar removed without the
above criteria.
 Complete vs. Incomplete
– Complete SCI; ?
– Incomplete SCI; ?
t: @alaa_oteir
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Spinal Cord Syndromes
Central cord syndrome
•Damage to corticospinal
tract
•Commonly seen with
hyperextension/flexion
•Disproportionately greater
power loss in upper
extremities than in lower
extremities
•Have sacral sparing
t: @alaa_oteir
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Spinal Cord Syndromes
 Anterior Cord Syndrome
– Complete motor paralysis with loss of pain/temperature
(proprioception/vibration preserved)
– Usually seen in flexion injuries
– Often associated with burst fractures with fragment
retropulsion into canal
– Caused by compression of anterior spinal artery resulting in
anterior cord ischemia or direct compression of anterior
cord
– Hyperesthesia below lesion
t: @alaa_oteir
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t: @alaa_oteir
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2. Brown Squared
Syndrome
•Hemitransection
of cord
•Ipsilateral motor
loss & loss of
position sense
•Contralateral
dissociated
sensory loss of
pain &
temperature
•Begins 1-2 levels
below the level of
injury
t: @alaa_oteir
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Spinal Fractures
 Mechanisms of Injury
– Axial loading (most common injury is compression to T12-L1)
– Extremes of flexion, hyperextension, and hyperrotation
– Excessive lateral bending
– Distraction
 Any injury above the clavicle  search for a cervical spine injury
 May need to maintain c-spine immobilization until able to properly clear
spine
t: @alaa_oteir
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Jefferson Fractures
•Fracture of C1 ring from axial loading
•Unilateral or bilateral fracture of
anterior and posterior arches of C1
•**unstable fracture
t: @alaa_oteir
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C 2 Fractures
•1/3 of cervical
spine fractures at
C2
•60% of C2 fractures
are odontoid fractures;
other’s are Hangman’s
fracture (extends
through pedicles of C2)
•Odontoid fractures
•Type I – avulsion of the
tip of dens
•Type II – base of dens;
most common
•Type III – fracture line
extends into body of axis
t: @alaa_oteir
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C3 – C7 fractures
½ of fractures occur at C6-C7
Most common subluxation is at C5-C6
t: @alaa_oteir
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Types of Fractures
 Anterior wedge compression fracture – loss of body height at
anterior portion of body
 Burst fracture – compression fracture extending to posterior third
of vertebral body
 Chance fracture – splitting injury which begins posterior and
proceeds inferiorly through the vertebral body; seatbelt injuries
 Fracture-dislocation – uncommon; but usually cause complete
deficits due to narrow canal
t: @alaa_oteir
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Spine Fracture Management
 ABC’s
 Spine immobilization
 Alleviate pain & muscle spasm
 **Avoid secondary injury
– Prevent decubitus ulcers
 Definitive treatment:
– de-compressive laminectomy
– fusion
– instrumentation
t: @alaa_oteir
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Anterior Wedge Fracture
t: @alaa_oteir
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Thoracic Spine Transverse Process
Fracture
t: @alaa_oteir
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Chance fracture (posterior)
t: @alaa_oteir
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Burst Fractures
t: @alaa_oteir
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Spinal Cord Assessment
 Assessment after ABC’s & life-threatening injuries addressed
 External Exam; check for
– Deformity
– Line of demarcation
 Motor Exam
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Strength
Reflexes
Range of motion
Motor nerve function
t: @alaa_oteir
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VS alterations w/ Spinal Injuries
 Heart rate
– ↓ rate may indicate neurogenic shock, drugs (use vasopressors)
– May not see ↑ HR w/ shock
 Respiratory rate
– Denervation of respiratory muscles
• C4 and above – no respiration
• C5-6-7 – phrenic nerve
• T1-T6 – intercostal innervation
 Blood pressure
– Low blood pressure may indicate neurogenic shock or
hypovolemia
 Temperature; Loss of regulating ability
t: @alaa_oteir
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Spinal Cord Management
 Have high index of suspicion
 Assess the need for immobilization
– Immobilize the spine if necessary
 Tight glucose control
 Complication of SCI
– Cardiovascular complications
• Dysregulation with vasodilatation due to loss of sympathetic tone
– Respiratory complications
• Phrenic nerve dysfunction if injury above C4
• Intercostal nerve dysfunction if injury below C4
– Musculoskeletal complications
• Need to treat spasticity
t: @alaa_oteir
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Further avoidance of complications
 Assess abdomen for distension
 Optimize venous return by turning pt slowly
 Perform passive ROM all extremities every 2-4 hrs
 Avoid hypotension
– Use dopamine, dobutamine, neosynephrine
 Note:
– **hypotension is not always caused by hypovolemia in trauma patients;
skin is warm, flushed, and dry in neurogenic shock (this is not the case
in hypovolemic shock)
t: @alaa_oteir
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Transport Issues with SCI
 Patients with cervical cord level injury are at risk for CO2 retention;
– Monitor ETCO2, depth and rate of breathing.
 Hypotension due to Neurogenic Shock
– Injury above T6
 Patients are at high risk for hypothermia due to poikilothermic
– Lesions above T1
 Immobilize any patient not meeting clearance criteria
 Reassess patients’ motor and sensory levels after each transfer
or move i.e. ER bed to EMS cot. Chart it!
 Watch for skin breakdown if patient has been on long spine
board for extended period.
t: @alaa_oteir
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Other Pre-transport Considerations
 Assess ability to maintain airway & clear secretions
– Cough ability, presence of gag reflex
 Assess pateint’s need for hemodynamic stability
 Bowel/bladder assessment
 Other considerations
– Excessive patient movement during transport
– Length of transport
t: @alaa_oteir
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THANK YOU
t: @alaa_oteir
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