SPINE - NON TRAUMA + TRAUMA
GENERAL SPINE TRAUMA
PromptSpine injury - Key examination features
ResponseBreathing – spinal cord injury involving diaphragm, need for respiratory support
Haemodynamics – neurogenic shock, need for vasopressors
Motor assessment – assess for presence and level of spinal cord injury
Sensory assessment – assess for level
Reflexes – lost distally in complete spinal cord injury
Respiratory status (accept oxygenation or ventilation or testing (spirometry, FEV1) → respiratory insufficiency secondary to loss of diaphragmatic innervation)
Neurologic status - * - conscious state, signs of anterior or posterior cerebral ischaemia carotid or vertebral dissection
Neurologic status - UL neurologic exam weakness from cord injury/haematoma
Cardiovascular status – risk of neurogenic shock – hypotension with vasodilation
Priapism – evidence of major cord injury
Bulbocavernosus reflex – absence suggests spinal shock. Presence allows classification of cord injury severity (ie ASIA status – complete vs incomplete)
Haemodynamics – neurogenic shock, need for vasopressors
Motor assessment – assess for presence and level of spinal cord injury
Sensory assessment – assess for level
Reflexes – lost distally in complete spinal cord injury
Respiratory status (accept oxygenation or ventilation or testing (spirometry, FEV1) → respiratory insufficiency secondary to loss of diaphragmatic innervation)
Neurologic status - * - conscious state, signs of anterior or posterior cerebral ischaemia carotid or vertebral dissection
Neurologic status - UL neurologic exam weakness from cord injury/haematoma
Cardiovascular status – risk of neurogenic shock – hypotension with vasodilation
Priapism – evidence of major cord injury
Bulbocavernosus reflex – absence suggests spinal shock. Presence allows classification of cord injury severity (ie ASIA status – complete vs incomplete)
PromptMyotomes
= Easy question to write/mark or MCQ. Need to know
= Easy question to write/mark or MCQ. Need to know
ResponseBelow from answers - Every text seems a little different if they include 1 or 2 levels
Elbow flexion C5 (+/-C6)
Elbow extension C7 (+/-C8)
Wrist extension C6/7
Finger abduction T1
Elbow extensors – C7
Knee extensors – L 3
Ankle plantar flexors: - S1
Elbow flexion C5 (+/-C6)
Elbow extension C7 (+/-C8)
Wrist extension C6/7
Finger abduction T1
Elbow extensors – C7
Knee extensors – L 3
Ankle plantar flexors: - S1
PromptList options for C spine immobilisation (With normal neurology)
ResponseRigid Collar - Hard collar / Philadelphia / Miami J
Soft collar
Foam head blocks or sandbags to sides of head
Head tape
Laying patient flat on bed, head mid-line
Vacuum mattress
Manual in line stabilisation
Soft collar
Foam head blocks or sandbags to sides of head
Head tape
Laying patient flat on bed, head mid-line
Vacuum mattress
Manual in line stabilisation
PromptList complications of C spine immobilisation
ResponseRaised ICP
Reduced access to the neck
Pain and discomfort - pressure areas
Airway compromise added difficulty with airway interventions
Aspiration risk
Impaired ventilation
Impaired head movement
Potential worsening of spinal cord injury
Unnecessary distraction from important resuscitation issues
Unnecessary additional radiology esp in children
Requirement for log-rolling, increased nursing requirements, staff distraction from other duties
Reduced access to the neck
Pain and discomfort - pressure areas
Airway compromise added difficulty with airway interventions
Aspiration risk
Impaired ventilation
Impaired head movement
Potential worsening of spinal cord injury
Unnecessary distraction from important resuscitation issues
Unnecessary additional radiology esp in children
Requirement for log-rolling, increased nursing requirements, staff distraction from other duties
PromptManagement of agitated patient non compliant with spinal precautions
ResponseFamily support, Remove noise stimulus
Analgesia- IV paracetamol, small doses morphine
Call radiology for urgent report re Cspine
Remove cervical collar, sand bag instead
Light chemical sedation- need to mention risks to airway, aspiration
Intubation
Analgesia- IV paracetamol, small doses morphine
Call radiology for urgent report re Cspine
Remove cervical collar, sand bag instead
Light chemical sedation- need to mention risks to airway, aspiration
Intubation
PromptList unstable C spine fracture patterns
ResponseAtlantoaxial dislocation or dissociation
Jeffersons # (Burst C1)
Hangmans # (Bilateral pedicle C2)
Type 2 or 3 Odontoid Process #
Tear drop fracture
Bilateral facet joint dislocation
Jeffersons # (Burst C1)
Hangmans # (Bilateral pedicle C2)
Type 2 or 3 Odontoid Process #
Tear drop fracture
Bilateral facet joint dislocation
PromptC5 injury - Management priorities
ResponseManage ventilatory failure - (Control of airway with intubation using MILS as ventilatory failure likely given phrenic nerve involvement at this spinal level)
BP management - high risk of hypotension from neurogenic shock
initially iv fluids +/- pressors
Assess and manage concurrent injuries (eg chest, abdo, pelvis, limb fractures)
Temperature control
Methylprednisolone controversial- discuss with local spinal team
Refer to spinal team for definitive management once other injuries excluded
BP management - high risk of hypotension from neurogenic shock
initially iv fluids +/- pressors
- consider concurrent hypovolaemia from bleeding and Ix as required
Assess and manage concurrent injuries (eg chest, abdo, pelvis, limb fractures)
Temperature control
Methylprednisolone controversial- discuss with local spinal team
Refer to spinal team for definitive management once other injuries excluded