SPINAL

CORD

INJURIES

David Garvey, PhD, MD, FACEP

International Trauma Conference 2016

SCI Spinal Cord Injuries

DISCLOSURE

I have no actual or potential

conflict of interest in relation

to this program/presentation.

SCI Spinal Cord Injuries

OUTLINE

Statistics

Anatomy

Traumatic Causes

Pathophysiology

What’s What?

Backboards and

Collars

SCI Statistics

12-20K SCIs per year

Societal cost is astronomical

Males ages 15-35 account for >50%

Male to female ratio is approx. 4:1

>10% occur in patients over age 60

<10% occur in patients under age 15

ANATOMY Spinal Column

ANATOMY Spinal Cord in Situ

A

P

ANATOMY Spinal Cord

Dorsal (Posterior)

Ventral (Anterior)

Spinal Nerves

Dermatomes Myotomes

C6

Sympathetic Outflow

ANATOMY Spinal Tracts

Dorsal Column

ANATOMY Spinal Tracts

Dorsal Column

SCI Traumatic Causes

MVCs – 40-50%

Falls / Work-Related – 30%

Violent Crimes – 15%

Sports-Related – 10%

• Hyperextension

• Hyperflexion

• Compression

• Rotation

• Lateral Stress

• Distraction

SCI Pathophysiology

Laceration

Compression

Distraction

Ischemia

SCIWORA – injury not seen on plain films or CT,

but identified on MRI

What’s What ?

Stable versus Unstable Spinal Injuries

Complete versus Incomplete Cord Injuries

Neurogenic versus Spinal Shock

Safe / “Cleared” versus Unsafe Spine

What’s What ?

STABLE VERSUS UNSTABLE INJURIES

What’s What ?

STABLE VERSUS UNSTABLE INJURIES

Number of columns affected (1C/2T&L)

C and L spine – mobile, T- fixed

Amount of compression (25%C/50%T&L)

Amount of subluxation

Unstable C-spine Injuries

C1 burst (Jefferson)

Bilateral facet

Odontoid (II/III)

C2 posterior elements

Teardrop

Mnemonic:

*Jefferson Bit Off The Hangman’s Tit

What’s What ?

COMPLETE VERSUS INCOMPLETE CORD INJURIES

Complete • Tetraplegia

• Paraplegia

Incomplete • Central Cord

• Brown Sequard

• Anterior Cord

Complete versus Incomplete Cord Injuries

Tetraplegia

Tetraplegia (Quadraplegia)

Paraplegia

Cauda Equina

Syndrome

ASIA Classification

Sensory: C4-clavicles to

sternal angle, C6-thumb,

T4/5-nipples, T10-umbilicus,

S4/5-perianal

Motor: C3,4,5-diaphram,

C6-wrist, S2,3,4-rectal tone

Autonomic: significant

dysfunction with lesions

above T5/6

Complete

(not a true SCI)

High C

Incomplete Cord Syndromes

Central Cord Brown Sequard Anterior Cord

• Hyperextension

• Cervical cord

• Distal > Proximal

• Upper > Lower

• Elderly (but all ages)

• Dysesthesias

• Hemisection of cord

• Hemiplegia

• Penetrating trauma

• Ipsilateral paralysis

• Ipsilateral proprio

• Contra pain & temp

• Anterior spinal artery

• Anter cord compression

(e.g. ruptured disc)

• Complete motor loss

• Incomplete sensory loss

• Touch and proprio intact

What’s What ?

NEUROGENIC VERSUS SPINAL SHOCK

Neurogenic Shock • Vasodilation • Bradycardia • Hypotension

Spinal Shock

• Temporary loss of all neurological activity

below the level of the cord injury, includes

reflexes (e.g. bulbocavernosus reflex)

What’s What ?

SAFE “CLEARED” VERSUS UNSAFE C-SPINE

Initial Assessment • ABCDE

• D (Neuro) - LOC (AVPU/GCS), Motor

• Question - “Any numbness/weakness?”

* ANY NEUROLOGIC COMPLAINT must raise suspicion for SCI

(e.g. paresthesias, dysesthesias, weakness, numbness, etc.)

with or without physical findings, even if transitory

How do we assess the C-spine? • Spine Assessment Protocol

C-Spine Rules

NEXUS (Low Risk Criteria)

• No Midline Tenderness

• No Altered Mental Status or Intoxication

• No Neurological Deficits (Signs or Symptoms)

• No Distracting Injuries

CCR (High Risk)

• Age > 65

• Dangerous Mechanism*

• Paresthesias in the Extremities

CCR Dangerous Mechanism

Fall from height >3 ft or 5 stairs

Axial load to head (e.g. diving)

High speed MVC (>60 mph), rollover

or ejection

Collision involving an ATV or bicycle

Hit (rear-ended) by a bus, truck or high-

speed vehicle or pushed into oncoming

traffic

SCI Prehospital / ED Treatment

Immobilization (C-collar / Backboard)

Oxygenation / Ventilation

Fluids / Pressors

Steroids

Hypothermia

To Board or Not To Board?

Cons

Pros

• Airway concerns

• Breathing compromise

• Skin ischemia

• Increased ICP

• Patient discomfort

(pain and agitation)

May “potentially”

prevent secondary

SCI in a patient

with a spinal injury

QUESTIONS? _________________________

According to recommendations from several organizations (e.g. NAEMSP, ACS-COT, PTLS-Executive Committee, etc.) concerning the use of full spinal immobilization (C-collar and backboard) in trauma patients, which of the following situations is full spinal immobilization considered appropriate:

A. Penetrating trauma to the neck, chest or back

B. All major trauma patients regardless of the

circumstances

C. Blunt trauma and altered level of consciousness

D. High risk mechanism of injury, no neurologic

findings or c/o’s, GCS 15 and no intoxication