RECENT BOARD GUIDELINES FOR MANAGEMENT OF SPINAL INJURY PATIENT.pptx

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1. Guidelines for Management of S pinal Injury patients - By team lister

2. I ntroduction Spine injury, with or without neurological deficits, must always be considered in patients with multiple injuries . Approximately 5% of patients with brain injury have an associated spinal injury, whereas 25% of patients with spinal injury have at least a mild brain injury. Approximately 55% of spinal injuries occur in the cervical region, 15% in the thoracic region, 15% at the thoracolumbar junction, and 15% in the lumbosacral area.

3. Up to 10% of patients with a cervical spine fracture have a second, noncontiguous vertebral column fracture. In patients with potential spine injuries, excessive manipulation and inadequate restriction of spinal motion can cause additional neurological damage and worsen the patient’s outcome . These complications are typically due to ischemia or progression of spinal cord edema, but they can also result from excessive movement of the spine.

4. If the patient’s spine is protected, evaluation of the spine and exclusion of spinal injury can be safely deferred, especially in the presence of systemic instability, such as hypotension and respiratory inadequacy . Presence of a spinal injury can be easily diagnosed in patients with neurological deficit, pain or tenderness along the spine, evidence of intoxication, or additional painful injuries. T he absence of pain or tenderness along the spine virtually excludes the presence of a significant spinal injury.

5. I n other patients, such as those who are comatose or have a depressed level of consciousness, the process of evaluating for spine injury is more complicated. In this case, the patient needs appropriate radiographic imaging to exclude a spinal injury. If the images are inconclusive, restrict motion of the spine until further testing can be performed.

6. The prolonged positioning of patients on a hard backboard and with a hard cervical collar (c-collar) can also be hazardous. As it causes severe discomfort in conscious patients, serious decubitus ulcers can form and respiratory compromise can result from prolonged use. long backboards should be used only during patient transportation, and every effort should be made to remove patients from spine boards as quickly as possible.

7. S pinal movement of any patient with a suspected spine injury is restricted above and below the suspected injury site until a fracture is excluded. This is accomplished simply by laying the patient supine without rotating or bending the spinal column on a firm surface with a properly sized and placed rigid cervical collar. Attempts to align the spine to aid restriction of motion on the backboard are not recommended if they cause pain. The logroll maneuver is performed to evaluate the patient’s spine and remove the long spine board while limiting spinal movement

8. Four-Person Logroll At least four people are needed for logrolling a patient to remove a spine board and/or examine the back. One person stands at the patient’s head to control the head and c-spine, and two are along the patient’s sides to control the body and extremities. As the patient is rolled, three people maintain alignment of the spine while the fourth person removes the board and examines the back. Once the board is removed, three people return the patient to the supine position while maintaining alignment of the spine.

9. ANATOMY OF THE SPINE The spinal column consists of 7 cervical, 12 thoracic, and 5 lumbar vertebrae, as well as the sacrum and coccyx. The typical vertebra consists of an anteriorly placed vertebral body, which forms part of the main weight-bearing column.

10. The vertebral bodies are separated by intervertebral disks that are held together anteriorly and posteriorly by the anterior and posterior longitudinal ligaments, respectively. Posterolaterally , two pedicles form the pillars on which the roof of the vertebral canal (i.e., the lamina) rests. The facet joints, interspinous ligaments, and paraspinal muscles all contribute to spine stability.

11. The cervical spine, because of its mobility and exposure, is the most vulnerable part of the spine to injury. The cervical canal is wide from the foramen magnum to just above the thoracic spine. A pproximately one-third of patients with upper cervical spine injuries (i.e., injury above C3) die at the scene from apnea caused by loss of central innervation of the phrenic nerves. Below the level of C3, the spinal canal diameter is much smaller relative to the spinal cord diameter, and vertebral column injuries are much more likely to cause spinal cord injuries.

12. Thoracic spine mobility is much more restricted than cervical spine mobility, and the thoracic spine has additional support from the rib cage. I ncidence of thoracic fractures is much lower. Most thoracic spine fractures are wedge compression fractures that are not associated with spinal cord injury. W hen a fracture-dislocation in the thoracic spine does occur, it almost always results in a complete spinal cord injury because of the relatively narrow thoracic canal. Most common region of injury is the thoracolumbar junction as it acts as a fulcrum between the inflexible thoracic region and the more mobile lumbar region.

13. Severity of Neurological Deficit Spinal cord injury can be categorized as: C omplete paraplegia (thoracic injury) or quadriplegia (cervical injury):- When a patient has no demonstrable sensory or motor function below a certain level, he or she is said to have a complete spinal cord injury. 2. Incomplete paraplegia (thoracic injury) or quadriplegia (cervical injury):- When a patient has some degree of motor or sensory function remains in this case, the prognosis for recovery is significantly better than that for complete spinal cord injury.

14. Signs of an incomplete injury include any sensation (including position sense) or voluntary movement in the lower extremities, voluntary anal sphincter contraction, and voluntary toe flexion

15. Anterior cord syndrome This results from injury to the motor and sensory pathways in the anterior part of the cord. It is characterized by paraplegia and a bilateral loss of pain and temperature sensation. sensation from the intact dorsal column (i.e., position, vibration, and deep pressure sense) is preserved. This syndrome has the poorest prognosis of the incomplete injuries and occurs most commonly following cord ischemia.

16. Central cord syndrome It is characterized by a disproportionately greater loss of motor strength in the upper extremities than in the lower extremities, with varying degrees of sensory loss. This syndrome typically occurs after a hyperextension injury in a patient with preexisting cervical canal stenosis. The mechanism is commonly that of a forward fall resulting in a facial impact. These injuries are frequently found in patients, especially the elderly, who have underlying spinal stenosis and suffer a ground-level fall. It can occur with or without cervical spine fracture or dislocation.

17. Brown- Séquard syndrome It results from hemisection of the cord, usually due to a penetrating trauma. T he syndrome consists of ipsilateral motor loss ( corticospinal tract) and loss of position sense (dorsal column), associated with contralateral loss of pain and temperature sensation. Even when the syndrome is caused by a direct penetrating injury to the cord, some recovery is usually achieved.

18. Thoracolumbar injury classification and severity score (TLICS) The Spine Trauma Group has developed a classification system and an injury severity score which may facilitate communication between physicians and serve as a guideline for treating these injuries . The classification system is based on:- the morphology of the injury integrity of the posterior ligamentous complex neurological status of the patient.

19. Guidelines for screening the patient with suspected spinal injury. General management of spine and spinal cord trauma includes restricting spinal motion, intravenous fluids, medications. Because trauma patients can have unrecognized spinal injuries, be sure to restrict spinal motion until they can undergo appropriate clinical examination and imaging .

20. CERVICAL SPINE Patients who are awake, alert, sober, and neurologically normal, with no neck pain, midline tenderness, or a distracting injury, are extremely unlikely to have an acute c-spine fracture or instability. With the patient in a supine position, remove the c-collar and palpate the spine. If there is no significant tenderness, ask the patient to voluntarily move his or her neck from side to side and flex and extend his or her neck. Patient’s neck movement should never be forced.

21. C-spine films should be assessed for : • bony deformity/fracture of the vertebral body or processes • loss of alignment of the posterior aspect of the vertebral bodies (anterior extent of the vertebral canal) • increased distance between the spinous processes at one level • narrowing of the vertebral canal • increased prevertebral soft-tissue space.

22. In locations with available technology, the primary screening modality is multidetector CT (MDCT) from the occiput to T1 with sagittal and coronal reconstructions. Where this technology is not available, plain radiographic films from the occiput to T1, including lateral, anteroposterior (AP), and open-mouth odontoid views should be obtained.

23. Patients with neck pain and normal radiography should be evaluated by magnetic resonance imaging (MRI) or flexion-extension x-ray films. Flexion-extension x-rays of the cervical spine can detect occult instability or determine the stability of a known fracture.

24. MRI may be the most sensitive tool for identifying soft tissue injury if performed within 72 hours of injury. In the presence of neurological deficits, MRI is recommended to detect any soft-tissue compressive lesion that cannot be detected with plain films or CT, such as a spinal epidural hematoma or traumatic herniated disk. MRI may also detect spinal cord contusions or disruption, as well as paraspinal ligamentous and soft-tissue injury. MRI is frequently not feasible in patients with hemodynamic instability.

25. Thoracolumbar spinal injuries The presence of paraplegia or a level of sensory loss on the chest or abdomen is presumptive evidence of spinal instability. Patients who have spine pain or tenderness on palpation, neurological deficits, an altered level of consciousness, or significant mechanism of injury should undergo screening. Trauma patients who require emergency surgery before a complete workup of the spine can be accomplished should be transported carefully, assuming that an unstable spine injury is present. T he c-collar is left in place and the patient is log rolled to and from the operating table.

26. Where available, MDCT scanning of the thoracic and lumbar spine can be used as the initial screening modality. If MDCT is unavailable, obtain AP and lateral plain radiographs. On the AP views, observe the vertical alignment of the pedicles and distance between the pedicles of each vertebra. Unstable fractures commonly cause widening of the interpedicular distance. The lateral films detect subluxations, compression fractures, and Chance fractures.

27. CT scanning is particularly useful for detecting fractures of the posterior elements (pedicles, lamina, and spinous processes) and determining the degree of canal compromise caused by burst fractures. Sagittal and coronal reconstruction of axial CT images should be performed.

28. General management Spinal Motion Restriction Intravenous Fluids Medications

29. Steroid Use in Patients With Acute Spinal Cord Injury In 2017, AOSpine practice guideline suggested that 24-hour infusion of high-dose MPSS should be provided in patients with SCI within 8 hours as a treatment option without presenting any new evidence .  Steroid treatment in the early hours after the injury is aimed at reducing the extent of permanent paralysis during the rest of the patient's life . The use of corticosteroids can inhibit the immune reactivity in the site of traumatic injury, resulting in a pressure decrease on the neuronal axons and augments nerve regeneration and re-myelination.