The fact that most of the pathological changes in neural tissue occur during the period from injury to treatment, especially due to instability, shows the importance of immobilization of the mobile spine during this period.
Vertebral injury may not always be associated with spinal cord injury. However, it should be kept in mind that the risk of spinal cord injury is always present. Immobilization of the patient with spinal trauma should be maintained until direct radiographs are taken and it is shown that there is no fracture or fracture-slip. Immobilization should be provided to correct systemic causes such as hypotension and respiratory failure first and investigations for spinal cord and spine trauma can be delayed.
Contents
II. Anamnesis
It is very important to know the neurologic picture of the patient before the injury. It is important to describe the trauma in detail in order to understand the underlying mechanisms and to think about potential injuries. In a patient with an injury above the clavicle or head trauma, if he/she is unconscious, it is treated as if he/she has cervical spine trauma. Spinal cord and spine injuries may be seen together in patients who have been involved in motor vehicle accidents.
III. Evaluation
A. General
The patient with suspected spinal trauma should be examined in a neutral position and the spinal system should not be moved. The patient should be immobilized from the scene to the emergency room. This can be achieved with a semi-rigid cervical collar or by fixing the patient's head on a hard surface such as a spine board or a door. The aim is to ensure complete immobilization. Movement of the chest, pelvis and lower extremities should also be prevented to protect not only the head and neck but also the thoracic and lumbar segments of the spine. The conscious patient with complete loss of motor power usually easily identifies pain at the level of injury (as there is sensory loss below this level). When palpating the spine carefully, the patient may scream and grimace because of the pain. It should be remembered that paralysis and loss of sensation may mask abdominal and lower extremity injuries.
When evaluating unconscious patients, it should be remembered that cervical injury is seen in 5-10% of cases in falls or motor vehicle accidents. Some of the following clinical findings should suggest that the spinal cord is injured at the cervical level in an unconscious patient:
- General areflexia, especially flaccid rectal sphincter.
- Diaphragmatic respiration.
- Flexion of the elbow, but not extension.
- No movement with painful stimulus, but grimaces.
- Bradycardia and hypotension, especially in the absence of hypovolemia.
- Spontaneous erection is not very common, but is characteristic.
All information obtained from the neurologic examination should be written in detail on the patient card so that any subsequent changes can be easily identified. In the paralyzed patient, movements and sensations below the level of injury are important and may affect the prognosis. Early consultation with a neurosurgeon is essential in such patients.
B. Evaluation of the spinal system
Spinal injuries are usually associated with local tenderness and less commonly palpable deformity. A careful examination should be performed from the occipital to the sacrum in the supine patient. The patient should be moved as little and carefully as possible during the examination. Four assistants are needed to achieve this. The first one holds the patient's neck and head in such a way as not to allow movement, the second holds the pelvis and buttocks, and the third holds the legs. The last assistant holds the lower spinal board steady while watching the procedure.
The examining physician should assess the patient for pain, tenderness and deformity. Pain may be localized at the lesion level or radiate to the arms or legs. Other diagnostic symptoms and signs include more prominent spinous processes, local tenderness, pain with movement, edema, ecchymosis, visible deformity and muscle contractions.
C. Neurologic evaluation in spinal cord injuries
The patient should be carefully examined for muscle tone and strength, sensory changes, reflex changes and autonomic dysfunction. Autonomic dysfunction may be manifested by bladder and rectal sphincter control deficits and priapism. Only three of the many tracts within the spinal cord can be clinically evaluated.
Any of the tracts can be injured on one side of the spinal cord or on both sides. The corticospinal tract is posterolateral to the spinal cord, controls motor strength on the same side of the body and can be tested by voluntary muscle contractions or involuntary responses to painful stimuli. The spinothalamic tract is anterolateral to the spinal cord. It transmits pain and heat sensations from the opposite side of the body. It can be tested with a needle or painful stimuli. The posterior column carries proprioceptive information on the same side of the body. It can be tested by finger and thumb position sensation or vibration examination.
In complete spinal cord lacerations, there is no motor or sensory function. There is almost no chance of recovery of this loss of function. Incomplete spinal cord lesions, on the other hand, may improve. It is therefore very important to perform a detailed motor and sensory examination.
The ability to distinguish between superficial or deep pain indicates incomplete lesion and preservation of the lateral column. Since the sense of light touch is transmitted through the posterior and both lateral columns, it may be the only sensory modality preserved even if all other senses are absent. The best indication that some function may return in spinal cord injury is what we call “sacral sparing”. Detection of this is evidence of an incomplete injury. Sensory and reflex examinations of the anus, perineum and scrotum should be performed to assess this.
D. Neurogenic and spinal shock
Neurogenic shock develops as a result of slowed conduction in the descending sympathetic pathways in the spinal cord. Neurogenic shock ends with loss of vasomotor tone and sympathetic innervation of the heart. If this condition persists, blood pools in the intravascular space as a result of dilatation of the vessels of the organs and lower extremities, resulting in hypotension. Since cardiac sympathetic tone is lost, the patient may be tachycardic or bradycardic. Therefore, the hypotension seen in neurogenic shock is not due to true hypovolemia. Attempting to correct blood pressure with fluid infusion alone in this situation will lead to fluid overload. Blood pressure can only be raised by careful use of vasopressors. In case of bradycardia, atropine should be used.
Spinal shock refers to the neurologic picture immediately after spinal cord injury. There is a complete loss of function even if the entire spinal cord is not injured. This will cause a complete loss of muscle tone and reflexes instead of the expected spasticity, hyperactive reflexes and Babinski's sign. After days and weeks, the spinal shock disappears and function begins to return.
E. Effects on other organs
In spinal cord injuries at the lower cervical or upper thoracic level, hypoventilation develops due to paralysis of the intercostal muscles. In upper or middle cervical level spinal cord injury, there will be diaphragmatic paralysis due to involvement of C3-C5 spinal cord segments. In both cases, the use of auxiliary respiratory muscles and abdominal breathing will be seen.
F. Direct radiography
Lateral cervical radiographs should be obtained in all patients with head trauma and suspected injury above the clavicle. Thoracic and lumbar spine radiographs should be obtained in patients with a history of trauma to the trunk. Cervical Spine: Lateral cervical radiographs should be obtained after stabilization of vital signs. The skull base, all seven cervical vertebrae and the first thoracic vertebra must be seen. If the seven cervical vertebrae are not visible, the swimmer's position can be tried during the radiograph or if it is known that there is no fracture in the arm and shoulder, the shoulder can be pulled down by holding both hands.
After obtaining an adequate film, the physician can obtain a chest radiograph and an open-mouth dens radiograph. AP and oblique cervical radiographs and other direct radiographs may be ordered later if necessary. If these radiographs are normal but there is a history of cervical trauma, further technical investigations should be performed, remembering that direct radiographs may miss 5-15% of fractures.
Computed tomography (CT) shows bone fragments in the spinal canal. Functional cervical radiographs (lateral flexion and extension) are dangerous and, if done, should be performed under the supervision of a physician and under the control of a scope.
Thoracic and lumbar spine: AP radiographs are standard at these levels. The power of portable radiology machines in emergency departments is not sufficient to show the bony structure in lateral views. Oblique thoracic radiographs are often unhelpful. If necessary, lateral and oblique films of the lumbar region are obtained.
IV. Types of spine injuries
Cervical direct radiographs provide the following examinations for suspected fractures and fracture-slip in the spinal system:
a. Anteroposterior diameter of the spinal canal
b. Contour and plane of the vertebrae
c. Bone fragments displaced into the canal
d. Simple or common fractures of the lamina, pedicle or neural arches
e. Increase in soft tissue distance An AP radiograph alone is sufficient for the initial evaluation of suspected thoracic and/or lumbar injury. This can give the following information:
f. Bilateral symmetry of the pedicles
g. Height of the intervertebral disc space
h. Whether the spinous processes are in the midline
ı. Contours of the vertebrae
1. Spine plane
1. Cervical spine injuries
Injuries to the cervical spine occur as a result of one or a combination of the following mechanisms
- axial loading
- flexion
- extension,
- rotation
- lateral bending
- distraction
Injuries to this region result in unstable fractures, fracture-slips and/or spinal cord injuries.
C1 (atlas) fractures: Atlas fractures are mostly anterior or posterior edge fractures (Jefferson fracture). The mechanism of CI fracture is usually axial loading. This fracture is best seen on an open-mouth radiograph, but can be seen as a lamina fracture on a lateral radiograph. These fractures are associated with C2 fractures in 1/3 of cases. Spinal cord injury is usually not associated.
Immobilization should be started with a semi-rigid cervical collar.
C1 subluxation: This lesion can be recognized on open mouth dens radiographs. The odontoid is not equidistant from both lateral masses of C1. Because the C1 ring is rotated around its axis relative to the odontoid. This condition is mostly seen in children.
Torticollis, or turning the head in one direction, is noticeable. It is important not to try to return the head to its normal position. C2 odontoid dislocation: In blows to C2, the odontoid may slip posteriorly into the spinal canal. Dens subluxation is seen as a result of injury of the transverse ligament adhering to the odontoid and C1 forearm. There may be no damage to the bone; the diagnosis is made if there is a distance of more than 3 mm between the C1 forearm and the odontoid.
As described in Steel's rule of three, dislocation can occur without spinal cord injury. At the level of the atlas, l/3 of the spinal canal is occupied by the odontoid, l/3 by the intermediate space and l/3 by the spinal cord. Therefore, the space behind the odontoid tolerates slippage. However, sudden head movements can injure the spinal cord.
C2 odontoid fractures: Three types of odontoid fractures can be distinguished. These can be very difficult to detect on routine radiographs. If suspected, tomograms or CT should be obtained.
- Type I: Odontoid tip fracture and is mostly stable.
- Type II: Occurs at the base of the odontoid and is usually anstable. It is important to remember that the epiphysis can be seen in children up to 6 years of age and this is not a fracture.
- Type III Odontoid fracture extending to the vertebral body
Patients with type 1 fractures can be treated with a semirigid collar.
C2 posterior element fractures: “Hangman or ace fractures” involve the posterior elements of C2. The mechanism of this injury is extension-distraction or extension-axial compression. This is an unstable fracture. In these cases, cervical traction has no place if the mechanism is secondary to distraction. These patients should be sent to centers where definitive treatment with extemal immobilization can be performed.
Fractures and fracture-dislocations between C2-C7: Fractures and/or fracture-dislocations at this level may show various combinations. In stable fractures, the mechanism of injury is usually flexion-axial loading, extension-axial loading or flexion-rotation.
In traumas at this level, if the distance between the pharynx and the anterior/inferior border of C3, which is normally less than 5 mm, is increased on lateral radiographs, it should be considered as indirect evidence of vertebral fracture.
Children normally have a prevertebral width of 2/3 of the C2 vertebral width. This distance changes during breathing. When the presence of hematoma is suspected in a child, it should be remembered that this distance will increase with crying and breathing. All patients with unstable fractures at this level should be referred to a hospital for definitive treatment. Typically, these patients may have one or more of the following features:
(1) Outgoing fracture with separation of all rear and front elements
(2) Fracture with displacement of the superior vertebra over the inferior vertebra by more than 3.0 mm
(3) Fractured facet joint locking with more than il degrees of angulation between two vertebrae: An unstable vertebral injury, especially when bilateral. In unilateral facet joint locking, there is a displacement of 25% and in bilateral facet joint locking there is a displacement of more than 50%. The absence of alignment of the spinous processes in the midline on AP radiograph should raise suspicion.
2. Cervical spinal cord injury
A separate bone fragment on the upper surface of the vertebra indicates an extensional type of injury. This is usually stable and does not affect the spinal cord. In the classic teardrop fracture, a separate bone fragment is seen at the anteroinferior margin of the vertebra. Displacement of posterior fragments from the vertebral body or the disc into the spinal canal suggests slippage.
3. Thoracic fractures (T1-T1O)
Fractures in this area are usually the result of hyperflexion, leading to wedge-type collapse fractures of one or more vertebrae. The collapse is usually very small, with the anterior half of the vertebra collapsed by only 25% compared to the posterior half. Fractures in this area are stable due to the stability of the thorax. In kyphosis greater than 30 degrees, internal stabilization is necessary to prevent further deformity. At this level, the spinal cord almost completely fills the spinal canal. Therefore, spinal cord injuries are complete at this level.
Spinal cord injury is often present if the deformity is associated with rotation.
4. Thoracolumbar fractures (T11-L1)
These fractures often occur with a combination of acute hyperflexion and rotation and are anstable. Since the spinal cord ends at this level and the cauda fibers begin, bladder and bowel symptoms and various degrees of loss of movement and sensation in the lower extremities may occur.
5. Lumbar fractures
Sudden hyperflexion at this level causes rupture of the posterior elements, resulting in an unstable spine injury. Clinical findings are similar to those seen in previous fractures.
6. Open injuries
The most common injuries are those caused by firearms or sharp objects. If the bullet passes through the spinal canal, there is complete neurological loss. The physician should check for CSF from the wound. Hemopneumothorax, acute abdomen or large vessel injuries may be associated with open spinal trauma and should be considered in treatment planning.
V. Treatment
Immobilization The patient must be transferred from the accident scene to the hospital after immobilization. While the patient is immobilized, he/she should be positioned lying on his/her back in a neutral position and should be prevented from turning or bending movements. Skin areas in contact with the hard floor should be protected with small pillows. It should be kept in mind that skin changes will begin after 2 hours in areas that are not protected from pressure. The most commonly damaged areas in this situation are the occiput and sacrum.
Maintaining adequate spinal immobilization requires special attention in restless and strong patients. This restlessness may be due to pain, confusion due to hypoxia or hypotension, alcohol or drugs, or simply a personality disorder. The physician should identify and treat the cause by careful history and examination. Sedatives or tranquilizers such as chlorpromazine may be used if necessary.
Intravenous fluids: Hypovolemic shock can be distinguished from neurogenic shock by the appearance of tachycardia followed by bradycardia. If blood pressure does not rise despite adequate fluid administration, vasopressors should be used.
Excessive fluid administration causes pulmonary edema in patients with spinal cord injury. A urinary catheter should be placed to measure the amount of urine output and bladder distension should be prevented.
Medications that can be given: Restriction of fluid intake also prevents the use of diuretics. The value of steroids is still controversial. However, they are used in the early stages of spinal cord injuries. They should be used especially in incomplete injuries. The management protocol can be structured with neurosurgical consultation.
Transfer: Patients with unstable fractures or neurological deficits should be transferred to centers where definitive treatment can be performed. The most important feature to remember during transfer is that respiratory function may be partially or completely lost in high cervical trauma.
Approach to Spinal Trauma (SCI)
Spinal cord injuries (SCI) are traumas that can impair spinal cord function. Although spinal column injuries do not cause damage to the spinal cord, if there is an instability, it is possible that this condition may cause future spinal cord dysfunction.
The most common cause of spinal cord injury is mechanical trauma, but the spinal cord can also be damaged by tumors, MS, vascular lesions, epidural hematoma, abscess, disc, polio, etc. Our topic will include mechanical trauma. It is a mistake to think of the spinal cord as an organ with only motor and sensory functions, as it also includes the very important autonomic system.
The clinical picture in SCI depends on the type and level of trauma. In complete lesions, all functions below the level of the lesion are lost, whereas partial lesions, which have a better prognosis, have become more common with the awareness of emergency trauma teams.
SCI Statistics
The number of SCI patients in the US is around 450 thousand. The SCI incidence rate is 32 per 1 million population. The rate of people who have SCI but die at the scene is 20 per 1 million. When these figures are applied to our country, it means that 3-4 thousand spinal traumas occur annually.
About 80% of SCI patients are male. The most common age range is 16-30 years. When we look at the causes of occurrence, motor vehicle accidents take the first place with 44%. This is followed by assault with 24%, falls with 22%, sports injuries with 8% and other causes with 2%. The clinical picture is 45% complete SCI (28% paraplegia, quadriplegia) and 55% partial SCI (32% quadriplegia, 23% paraplegia).
85% of patients who survive the first 24 hours are still alive 10 years later. The most common cause of death used to be renal failure, but is now respiratory failure.
Purpose of Treatment
Accurate diagnosis is the key to treatment. It is necessary to avoid conditions that may worsen the neurological picture and to prevent additional trauma from cardiovascular or respiratory insufficiency.
Physiopathology
The spinal cord consists of 31 segments and ends at L1. In traumas below L1, spinal roots are affected. Above L1, both spinal cord and roots are affected. The fibers in the spinal cord are arranged in a certain order. The corticospinal tract is in the front and the sensory tracts are in the back. Unlike the other two, the lateral spinothalamic tract crosses to the opposite side 2-3 segments above the spinal cord.The anterior spinothalamic tract carries the sense of light touch. Pathways involved in autonomic function are located in the anterior intermedial division. Sympathetics originate between C7-L1 and parasympathetics between S2-S4. The higher the lesion, the greater the autonomic dysfunction.
Clinic
If neurologic impairment occurs after any trauma, the diagnosis of SCI is easy to make, but it should be kept in mind that there may have been an unstable injury to the spinal column, especially in the absence of neurologic deficits. The first order of business in spinal cord injuries should be to ensure that the patient's airway is patent and to restore respiratory and circulatory parameters. Examination and imaging studies related to the trauma should be started only after these are achieved. Respiration is impaired in direct proportion to the height of the spinal segment affected by the trauma. The higher the lesion, the more respiration is affected. Not only motor and sensory functions are affected in spinal trauma. When autonomic fibers are also affected, an important condition called spinal shock occurs. The distinctive feature of this condition is that bradycardia and peripheral vasodilation accompany the drop in blood pressure. It usually does not occur in traumas below the T6 level. In patients with lesions below this level who are in shock, a hemorrhagic cause should be sought first.
It is very important to examine the perineum during the examination. Sensory and reflex examinations of the perineum may give an idea about whether the prognosis of the patient will be good or bad.
Spinal cord traumas are characterized by complete lesions and partial lesions.
Complete Lesion: All motor and sensory functions are lost in the part of the body under the traumatized spinal lesion. Neurogenic shock is seen depending on the level of the lesion. Sphincter control is not possible and retention of internal organs and ileus occur. Horner's syndrome may also be seen at high levels. Respiration is also impaired in lower cervical region injuries. Initial flaccid paralysis turns into spastic paralysis within 3-4 weeks.
Partial Lesions: These include anterior cord syndrome, Brown-Sequard syndrome, posterior cord syndrome, central cord syndrome, conus medullaris and cauda equina syndromes. Cord concussion is mentioned if neurologic functions recover in a short time.
Anterior cord syndrome: Typically occurs with anterior spinal artery occlusion. There is paralysis, pain and loss of temperature sensation below the level of the lesion. The senses of touch, vibration and position are intact. The prognosis is the worst. Recovery is only between 10-20%.
Brown-Sequard syndrome (half incision) is mostly seen in penetrating traumas and there is loss of upper motor neuron type strength on the same side below the level of the lesion, pain starting 1-2 segments below the lesion on the opposite side and loss of heat sensation. There is loss of position and vibration sensation on the same side. Mild sense of touch is preserved. It is rare to see all findings together in the clinic. This is the most favorable prognosis among cord traumas, 90% of patients are able to walk.
Central Cord Syndrome: There is motor loss, more in the arms. Pain and heat senses are mostly affected. The quadriplegia seen in the head soon becomes dyskeletal in the legs. This is the most common form of partial injury. 50% of patients recover enough to walk.
Posterior Cord Syndrome: Senses of position and vibration are lost. There is pain and paresthesias in the neck and arms and moderate paresis in the arms.
Cauda Equina and Conus Medullaris Syndromes: Painful poolyradiculopathy is in the foreground. Asymmetric lower motor neuron type paresis and sphincter defects occur. When only the conus medullaris is affected, sphincter disorders are in the foreground.
Diagnosis and Treatment Planning:
The diagnosis is made primarily by anamnesis and examination. After the patient's vital functions such as respiration and circulation are corrected, head trauma and internal organ injuries that may be of vital importance should be investigated. X-ray examination can then be started. After direct radiologic examinations in at least two planes in accordance with the type of trauma, the most useful methods of investigation are CT and MRI. Hemogram follow-up and urine analysis should not be neglected. US is the easiest method of investigation in suspected intra-abdominal injury.
Spinal trauma is classified according to ASIA classification. Neurologic loss is scored between 0-5.
The term SCIWORA is used for patients with neurologic symptoms without radiologic signs.
Treatment
The main aim of treatment is to prevent the progression of neurologic deficits, to correct instability, if any, and to decompress. Immobilization, hemodynamic and autonomic disorders are controlled. Gastrointestinal (ileus, constipation, ulcer), genitourinary (infection, hydronephrosis), dermatologic (bedsores), musculoskeletal (osteoporosis, fractures, overuse syndrome, acute and chronic pain) disorders are also treated.
In case of suspected trauma, the patient's head and neck are first identified. Rotations should be done as a whole. The transfer board should be removed as soon as possible. Treatment of airway and hemodynamics is the top priority. If there is acute respiratory failure, impaired consciousness, hyperpnea, hypoxia, high PCO2, low vital capacity, the patient should be intubated. In the presence of autonomic disorder, intubation may increase bradycardia, pure O2 inhalation and atropine are given. In spinal ooc treatment, 2 liters of fluid is given first, the aim of treatment is to increase blood pressure, correct bradycardia, ensure adequate diuresis (>30cc/hour) and prevent hypothermia. Dopamine may be used during this process. It should be kept in mind that 25% of patients with spinal trauma may also have head trauma.
Surgical Treatment: The benefit of emergency surgery in the absence of obvious compression of the canal is controversial. Radicular impingement, facet dislocations, severe stenosis of the canal and the presence of a foreign body may warrant emergency surgery. In unstable cases where these are not present, surgery should be performed after the general condition of the patient has improved.
Medical Treatment: Haldol and iv droperidol can be used in high doses in agitated patients. They have no negative effects on respiration and circulation. Corticosteroids: They have both anti-inflammatory and salt-sparing effects.
The generally accepted treatment protocol with NASCIS studies is as follows:
Methylprednisolone is first given as a 30 mg/kg bolus (within 15 minutes). The dose of 5.4 mg/kg is continued for the next 23 hours. Infusion is started 45 minutes after the bolus. Dexamethasone: 10-100 mg iv bolus followed by 6-10 mg iv every hour for 24 hours. Child doses are the same.
Principles of medical care:
Empirical antibiotic use. Change of position every 1-2 hours, intubation if necessary, blood pressure >70 mmHg, skin care, fight against nosocomial infection, measures to prevent deep vein thrombosis and pulmonary embolism, bladder care, bowel softeners, ascorbic acid and vitamin supplementation. Anticholinergics inhibit urinary emptying. Bethanecol (flaccid paralysis), oxybutyrin (spastic paralysis) may be useful.
Bladder and rectal exercises are performed, fluid-electrolyte and nutrition are monitored. Pain and anxiety should be controlled. Narcotics prevent bladder and rectal emptying. GIS protective medications should be given, and psychological and emotional support is given. Fusion therapy and rehabilitation exercises should be started as soon as possible.
Prognosis: If cord function is completely lost, the probability of recovery is <5%. If it persists for more than 72 hours, this rate becomes 0%. The chance of recovery is higher in partial lesions. The probability of walking is >50% in those with partially preserved sensory functions. 90% of patients return home and partially recover. The most effective way to reduce mortality is the use of antibiotics. The 5-year survival rate in quadriplegic patients is 90%.
