spine trauma and management · treatment: bl 18g iv, 20mg ketamine iv, spine board, c-collar, he...

Spine Trauma and ManagementC PT SA MUEL ROC K ER, A PA - C

LC DR A RI DOUC ET TE , PA - C

DisclosuresCPT Rocker and LCDR Doucette have no financial interests to disclose with regard to this subject or the contents of the presentation.

Importance

• 3% of blunt trauma patients sustain a spinal column injury

• 1% sustain a spinal cord injury

Non-deployed:

• 1/5 spinal column injuries has involved the cord

• 1/2 of those are complete

Deployed:

Mechanisms of InjuryMechanical causes too numerous to list here, but may include• Rapid deceleration (e.g. MVC)

• Externally forced rotation (e.g. MVC, Machinery Acc)

• Blunt trauma (e.g. MV vs Ped, FFS)• Penetrating trauma (e.g. GSW, SW)

Mechanisms

Non-deployed:• 1/2 from Motor Vehicle Accidents

• Risk factors: Speeding, ETOH, Unrestrained• Rollover Cervical spine injury• Falls, sports, violence

Deployed:• 2/3 Explosive• 17% GSW• 3% Falls• 66% Blunt, 28% Penetrating, 5% Combined

Spinal Anatomy

A B RI EF REV I EW OF N ORMA L A N ATOMY:

3 3 B ON Y V ERTEB RAE:7 C ERVI C A L1 2 T HORAC I C5 LUMBA R5 SAC RA L (F US ED)4 COC C YG EA L (~ F US ED)

Cervical Spine: C1-C3

CraniocervicalLigaments: Internal

Cervical Spine Injuries

Atlanto -occipital dislocation

Atlanto -axial dislocation

C1 Burst (Jefferson)

C1 Posterior Arch

C2 Pedicle (Hangman’s)

C2 Odontoid

Atlanto-occipital dislocation

Atlanto-occipital dislocation

Basion-posterior axial line interval (BAI)& Basion-dental interval (BDI)

If either exceeds 12mm, suggests A-O dislocation

Atlanto-axial dislocation

C1 Burst “Jefferson” fracture

C1 Posterior Arch fracture

C2 Pedicle “Hangman’s” fracture

C2 Odontoid (“dens”) fracture

CraniocervicalLigaments: External

Flexion and Extension fractures

Anterior wedge - due forceful forward flexion. Typically stable

Flexion teardrop - also due to forceful forward flexion with compression. Unstable

Extension teardrop - severe abrupt extension avulses anterior corner of spine from rest of vertebral body. Unstable

Burst fracturesVertical compression due to axial loading

Stable vs unstable

Spinous process fractures

Clay shoveler’s fracture, stable

Laminar fractures

Typically associate with other fractures

The other fracture determines stability

Facet dislocations

Not necessarily a fracture, but…

Bilateral facet dislocation

Very unstable

Facet dislocations

Not necessarily a fracture, but…

Unilateral facet dislocation

Stable

General Vertebral Fracture Patterns

Anterior Wedge

Flexion or Extension teardrop

Spinous Process

Burst

Laminar

Facet

Ligamentous

Spinal Cord Injury With-Out Radiographic Abnormality (SCIWORA)

Thoracic Vertebrae

Anterior Middle Posterior

Thoracic Ligaments

Lumbar Vertebrae

Chance fracture

Spinal Cord: Nerve Roots

Spinal Cord: Protection

Spinal Cord: Blood Supply

Spinal Cord: Blood Supply

Mechanisms of Spinal Cord Injury

• Vertebral column injury may result in spinal cord injury through:

• Transection• Compression• Contusion• Vascular Compromise

TransectionPenetrating or blunt may transect all or part of the spinal cord

Either directly, or by displacing bony fragments into the spinal canal or through disk herniation

https://prod-images-static.radiopaedia.org/images/47636226/659df49efc3fea3fc2d05a9b526b6f_big_gallery.jpeghttps://www.researchgate.net/figure/MRI-sagittal-image-of-included-patient-with-complete-spinal-cord-transection-All_fig1_333294520

Compression

OsteoarthritisSpondylolysis spondylolisthesisDisc Herniation

Trauma:• Edema• Hematoma• Fracture fragments

https://www.merckmanuals.com/-/media/manual/professional/images/spinal_cord_compression_slide_high.jpg

Contusion

Bony dislocationsSubluxationsFracture fragments

https://radiopaedia.org/images/51203318

Vascular compromise

Causes ischemia

Suspected when discrepancy b/w clinically apparent neurologic deficit and the known level of spinal column injury

Important -Don’t miss

http://www.ajnr.org/content/36/5/825

3 general clinical categories:

1. Patients with complete spinal cord syndromes

2. Patients with an incomplete spinal cord injury

3. Patients with a spine fracture but normal neurological function

Thoracolumbar Spinal Trauma

BE.CONVDOCS.ORG/PARS_DOCS/REFS/113/112418/112418_HTML_4C6EB2ED.JPG

Thoracolumbar Spinal Trauma

https://asia-spinalinjury.org/wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf

Thoracolumbar Spinal Trauma

https://asia-spinalinjury.org/wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf

Spinal Shock◦ Transient◦ Decreased function ◦ Is complete when Bulbocavernosus reflex

returns

Neurogenic Shock◦ Circulatory collapse◦ Fluid resuscitation/pressers

Thoracolumbar Spinal Trauma -The Role 1

ATLS/TCCC - Address life threats first

High index of suspicion given MOI

Stabilize and Evacuate

Hemodynamic Goals for Evacuation

Thoracolumbar Spinal Trauma - The Role 2

ATLS/TCCC - Address life threats first

High index of suspicion given MOI

Plain Films Available

Stabilize and Monitor vs Evacuate

Hemodynamic Goals for Evacuation

HTTPS://MEDIA.DEFENSE.GOV/2017/MAY/19/2001749400/1088/820/0/170510-F-CH060-002.JPG

Thoracolumbar Spinal Trauma -The Role 2

Stable Patterns

◦ Wedge Fractures◦ Transverse Process Fractures

https://www.uptodate.com/contents/images/RADIOL/83217/MildcompressionL2.jpg

Thoracolumbar Spinal Trauma -The Role 2

https://www.uptodate.com/contents/images/RADIOL/83469/Xrayfraclumbartransproc.jpg

Thoracolumbar Spinal Trauma - The Role 2

Radiographic Findings

Stable Patterns

◦ Wedge Fractures◦ Transverse Process Fractures

HTTPS://WWW.UPTODATE.COM/CONTENTS/IMAGE?IMAGEKEY=RADIOL%2F83140&TOPICKEY=EM%2F357&SOURCE=SEE_LINK&SP=0&SEARCH=

Thoracolumbar Spinal Trauma -The Role 2

Radiographic Findings

Unstable Fracture Patterns◦ Burst Fracture◦ Shear Fractures◦ Translational distraction

https://www.uptodate.com/contents/images/RADIOL/83106/Verteburstfraclumbspine.jpg

Thoracolumbar Spinal Trauma -The Role 2

Flexion Distraction Fracture◦ Be concerned for intrabdominal

process◦ High Likelihood for permanent

neurological injury

https://www.uptodate.com/contents/images/RADIOL/60907/Chancefraclumbarspine.jpg

Thoracolumbar Spinal Trauma -The Role 2

Translational Spinal Fracture◦ Fracture dislocation◦ Shear Fracture

https://www.uptodate.com/contents/images/EM/61587/Thoraclmbrfraxdislctradg.jpg

Thoracolumbar Spinal Trauma - The Role 2When to EVAC to higher level of care

When to sit on a patient

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Thoracolumbar Spinal Trauma - Role 3

148 Beds (24 ICU Beds)

Up to 4 OR tables

Multiple specialties

CT Available

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Thoracolumbar Spinal Trauma -Role 3

Transverse Process Fracture

https://www.uptodate.com/contents/images/RADIOL/83470/CTtransverseprocessfrac.jpg

Thoracolumbar Spinal Trauma -Role 3

Burst Fracture

No MRI in Role 3

https://www.uptodate.com/contents/images/EM/104227/ThoraccvrtbrlfraxCTMRI.jpg

Thoracolumbar Spinal Trauma -Role 3CHANCE FRACTURE

http://boneandspine.com/wp-content/uploads/2011/01/chance-fracture-reconstructed.jpg

Thoracolumbar Spinal Trauma -Role 3WEDG E F RAC TURE

https://radiologyassistant.nl/assets/spine-injury-tlics-classification/a548ac011b1f9a_1.jpg

Thoracolumbar Spinal Trauma - Role 3

Management

Medical

Handling

NonOP vs OP◦ Blunt◦ Penetrating

HTTPS://WWW.ARMY.MIL/E2/C/IMAGES/2012/08/30/262219/ORIGINAL.JPG

Review questionsYou are the new role 1 PA. Shortly after you arrive 1st PLT Cco was hit with an IED. They are evacuating a 25YOM suffering a blast injury and was thrown 10 feet. The senior medic on the ground relays that the Pt is GCS 14 (1 off for confusion), BP of 90P, HR 110, resp 18. The pt has shrapnel wounds along the anterior BL LE that has achieved hemostasis with pressure dressings. Pt complains of excruciating LBP. The medic was concerned of ecchymoses and exquisite tenderness located at L3/4. But is otherwise neuro intact.|

Treatment: BL 18G IV, 20mg Ketamine IV, Spine Board, C-Collar,

He arrives to your aid station:

A - Patent

B- RR 20, 99 RA, Equal rise and fall of the chest, LCTAB

C - BP 100/60, HR 106. LE wounds hemostatic with pressure dressing

D - GCS 14 (1 off for confusion). Neuro Intact. Rectal tone was intact. Bogginess noted midline l spine around L3-4. TTP midline spine at that location.

E-Placed in “blizzard blanket”

Do you evac patient or sit on patient if this is your only patient?

Your EMEDS is located approx. 26 km away (40 min drive) air or ground evac?

Its been two hours since the pt was evaced from POI on a spine board. What should you do?

What should you ensure about his blood pressure?

Review questionsThe Role 1 PA relays that the Pt is GCS 14 (1 off for confusion), BP of 100/60, HR 110, resp 18. The pt has shrapnel wounds along the anterior BL LE that has achieved hemostasis with pressure dressings. Pt complains of excruciating LBP. The PA was concerned of ecchymoses and exquisite tenderness located at L3/4 and paresthesia's noted in the L3 distribution of the left side. But is otherwise neuro intact.

Treatment: BL 18G IV, 25mg Ketamine IV, Spine Board, C-Collar, Blizzard blanket

He arrives to your role 2:

A - Patent

B- RR 26, 90 RA, Equal rise and fall of the chest, decreased lung sounds left side. JVD noted.

C - BP 100/60, HR 115. LE wounds hemostatic with pressure dressing

D - GCS 14 (1 off for confusion). CN II-XII grossly intact, EOMI sans diplopia Neuro intact.. Rectal tone was intact. Bogginess noted midline l spine around L3-4. TTP midline spine at that location.

E-Placed in “blizzard blanket” What do you want to do next to address low SPO2?

After Pt is stabilized?

Review questionsYOU S HOOT A C HEST X RAY ,C , T, L S P I N E PELV I C F I L MS

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Review questions

C-Spine and T spine films are clear. You notice this on L Spine films

What are you concerned of?

Do you Evac?

Should you consult a Neurosurgeon?

HTTP://WWW.IJOONLINE.COM/ARTICLES/2015/49/4/IMAGES/INDIANJORTHOP_2015_49_4_471_159680_U6.JPG

Review questions

WHAT I F YOU P I C K ED UP ON THI S ?

WHAT A RE YOU WORRI ED A B OUT ?

WHO EL S E S HOUL D I N VOLV E I N THE PAT I EN T ’S C A RE?

WOUL D YOU F I N D A N YTHI N G ON FA ST EX A M?

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Bibliography

Cervical Spine Collar Clearance in the Obtunded Adult Blunt Trauma Patient - Practice Management Guideline. https://www.east.org/education/practice-management-guidelines/cervical-spine-collar-clearance-in-the-obtunded-adult-blunt-trauma-patient. Accessed 27 Dec. 2019.

Cervical Spine Injuries Following Trauma - Practice Management Guideline. https://www.east.org/education/practice-management-guidelines/cervical-spine-injuries-following-trauma. Accessed 27 Dec. 2019.

Eisen, Andrew. “Anatomy and Localization of Spinal Cord Disorders.” UpToDate, edited by TW Post, UpToDate Inc, https://www.uptodate.com/contents/anatomy-and-localization-of-spinal-cord-disorders. Accessed 26 Dec. 2019.

Hansebout, Robert, and Edward Kachur. “Acute Traumatic Spinal Cord Injury.” UpToDate, edited by TW Post, UpToDate Inc, https://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury. Accessed 26 Dec. 2019.

Hoffman, J. R., et al. “Validity of a Set of Clinical Criteria to Rule out Injury to the Cervical Spine in Patients with Blun t Trauma. National Emergency X-Radiography Utilization Study Group.” The New England Journal of Medicine, vol. 343, no. 2, July 2000, pp. 94-99, doi:10.1056/NEJM200007133430203.

Kaji, Amy. “Evaluation and Initial Management of Cervical Spinal Column Injuries in Adults.” UpToDate, edited by TW Post, UpToDate Inc, https://www.uptodate.com/contents/evaluation-and-initial-management-of-cervical-spinal-column-injuries-in-adults. Accessed 26 Dec. 2019.

Kaji, Amy, and Robert Hockberger. “Spinal Column Injuries in Adults: Definitions, Mechanisms, and Radiographs.” UpToDate, edited by TW Post, UpToDate Inc, https://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions-mechanisms-and-radiographs. Accessed 26 Dec. 2019.

Netter, Frank H. Atlas of Human Anatomy. Philadelphia, PA: Saunders/Elsevier, 2006. Print.

Stiell, I. G., et al. “The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients.” JAMA, vol. 286, no. 15, Oct. 2001, pp. 1841-48, doi:10.1001/jama.286.15.1841.

Weingart, Scott. “Cervical Spine Injuries in the ED.” EMCrit Project, 25 Dec. 2011, https://emcrit.org/emcrit/cervical-spine-injuries-i/.

CDR Chris Neal, Col Randall McCafferty, LTC Brett Freedman, MAJ Melvin Helgson. “Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery in the Deployed Setting” 05 Aug 2015, https://jts.amedd.army.mil/assets/docs/cpgs/JTS_Clinical_Practice_Guidelines_(CPGs)/Spinal_Injury_-_Cervical_and_Thoracolumbar_Aug_2016_ID15.pdf

Questions?