Initial Assessment of Spinal Trauma
- Steroids
- Begin
methylprednisolone immediately in those with neuro deficit
- Bolus 30
mg/kg over 15 min, then give 5.4 mg/kg/hr IV x 23 hrs
- NEJM 322: 1405, 1990
- No
further steroids are given after completion
- Don't
forget ulcer prophylaxis when on steroids
- Radiographic
evaluation for fractures/malalignment
- Lateral
C-spine
- MUST
see all 7 cervical vertebra – including Swimmer's view (from under arm)
if necessary
- Prevertebral
soft tissue swelling
- Posterior
pharyngeal air shadow to anterior inferior aspect of C2 vertebral body; abnormal if greater than 7 mm in adults (unreliable
in children)
- Posterior
tracheal air shadow to anterior inferior aspect C6 vertebral body; abnormal
if greater than 14 mm in children or greater than 22 mm in adults
- Mneumonic:
safe if less than 6 mm at C2 or 2 cm at C6
- Full
cervical spine series in patients with pain/tenderness, those unable to
respond to exam and/or report pain, and those with distracting injuries
- Includes
flexion/extension
- AP
C-spine – useful to assess for Jefferson fracture (rule of Spence)
- Open-mouth
C-spine – to view odontoid process
- Thoracic
and Lumbosacral spine films as indicated by mechanism and/or exam
- Need AP
and lateral at minimum
- Widening
of disk space, widening/wedging of spinous processes – suggests
ligamentous injury
- Further
radiographic work-up for fractures seen on plain films
- Plain CT
through level of fracture with sagittal reconstructions
- MRI of
spine (if neurologic deficit)
- CT
myelogram may be helpful
- Tomograms
if difficult region to image on plain films
- Re-establish
proper alignment
- Cervical
traction with Gardner-Wells tongs or halo ring
- Up to
10 lbs/level may be applied
- Muscle
relaxation. with morphine and valium is essential
- Check
daily lateral C-spine film while in traction
- Check
daily for appropriate tension on pins if patient is in tongs
- Log
roll patient q2° to prevent decub ulcers
- Don't
forget to write for pin site care (1/2 strength H2O2
to sites tid)
- Indications
for cervical traction
- Immobilization
of unstable fracture
- Reduction
of subluxation or dislocation
- Distraction
of intervertebral foramina in patient's with radicular compression
- Alleviation
of pain produced by associated soft tissue injury
- Get
patient off backboard once initial studies are completed
- Prolonged
pressure from the board will result in decubitus ulcers
- Spinal
Shock
- Occurs
frequently with any spinal injury above the mid-thoracic level
- Manifested
by hypotension and bradycardia
- R/O other
causes of shock and assess volume status
- If
fluids don't resolve hypotension, use dopamine or neosynephrine drip I
- Indications
for acute surgical intervention
- Progression
of neurologic deficit
- Incomplete
spinal injury
- Surgical
correction
- General
rule is to allow patient 4-7 days to stabilize prior to surgical spine
stabilization
- Causes
of neurologic deterioration after spinal cord injury
- Acute: Loss
of alignment, overdistraction, hemorrhage, hypoxia, hypotension, spinal
abscess, ascending cord necrosis syndrome, additional spinal injury
- Delayed:
Syrinx, tethered cord, progressive spinal column deformity, sepsis,
hypotension, hypoxia, subdural or epidural abscess, hemorrhage (in
anticoagulated patients)