Spinal Trauma

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Cervical spine (C-spine) injuries are present in around 1-2% of all blunt trauma patients and 5-10% of patients with head trauma. It is important to maintain C-spine precautions, document a complete neurologic exam, and assess the respiratory status frequently since high spinal injuries can impair breathing.

Evaluation

The patient may be cleared clinically if there is no C-spine pain, a full range of motion, no tenderness to palpation, no intoxication or altered mental status, no distracting injury, and no neurologic deficits. In all other cases, C-spine x-rays must be obtained and the full cervical spine seen, including C7-T1. In patients with a fracture on plain films or those with a neurologic deficit, neurosurgery should be called immediately. Extensive diagnostic investigations, including CT or MRI, may be required.

Spinal Cord Injury (SCI) Syndromes

Anterior Cord Syndrome

Compression of the cord or spinal artery occlusion results in loss of all motor and sensory function below the lesion other than position sense which is preserved.

Posterior Cord Syndrome

Rarely traumatic; usually related to vitamin deficiencies and infections (e.g., syphilis); results in loss of position and vibratory sense.

Central Cord Syndrome

Typically seen in elderly patients following hyperextension injuries to the neck, often without x-ray abnormality; weakness in hands, arms greater than legs; with loss of pain and temperature sensation.

Brown-Sequard Syndrome

Hemisection of the cord producing ipsilateral paralysis and loss of proprioception below the injury, with contralateral loss of pain and temperature; typically results from penetrating trauma.

SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) Syndrome

Typically seen in pediatric trauma; neurologic deficits may be subtle, transient, and/or delayed (mean 1.2 days); MRI is normal in up to 50%, with atrophy of cord evident 1-3 months post-injury; the vast majority (83%) involve the cervical cord.

Complete Cord Injury

Flaccid below injury level and distal areflexia; vasomotor instability from loss of sympathetic vascular tone results in peripheral vasodilation with hypotension, warm/dry extremities and paradoxical bradycardia; decreased anal tone on rectal exam; and priapism.

Spinal Shock

In contrast, is defined as a temporary loss of spinal reflex activity below a total or near-total SCI.

Management

There are three priorities in the care of patients with potential SCI:

1. Airway management involves in-line stabilization (not traction), cricoid pressure, and rapid sequence intubation (RSI) for patients unable to ventilate adequately or protect their airway. Fluid resuscitation also is important; obvious bleeding must be controlled and occult hemorrhage ruled out.

2. Patients must have constant full spine immobilization, including C-spine stabilization with a hard collar and sandbags or other similar devices to prevent further spinal injury.

3. Aside from fluid resuscitation and oxygenation, neurogenic shock usually responds to low-dose Dopamine at 2.5-10 ^g/kg/min. However, in the trauma patient, this diagnosis should be one of exclusion. Closed SCIs with neurologic deficits should be treated with IV high-dose Methpredni-solone, 30 mg/kg IV bolus followed by an infusion at 5.4 mg/kg/h for 24 hours, which may improve neurologic recovery.

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