SPINE TRAUMASPINE TRAUMA

Moderator: Dr.BhallaModerator: Dr.Bhalla

www.anaesthesia.co.in anaesthesia.co.in@gmail.com

Spinalcord anatomySpinalcord anatomy

Spinal cord is 18 inches lying Spinal cord is 18 inches lying in the vertebral columnin the vertebral columnExtends from foramen Extends from foramen magnum to L1-L2 vertebramagnum to L1-L2 vertebraSpinal cord has 31segments Spinal cord has 31segments 8cervical, 12thoracic, 5lumbar, 8cervical, 12thoracic, 5lumbar, 5sacral and 1coccygeal5sacral and 1coccygealC3-C5-Phrenic nerveC3-C5-Phrenic nerveC5-T1-motor to upper limbC5-T1-motor to upper limbT1-T5-sympathetic supply to T1-T5-sympathetic supply to heartheartL2-S2- motor supply to lower L2-S2- motor supply to lower extremitiesextremities

Blood supplyBlood supply

1 anterior spinal 1 anterior spinal arteryartery

2 posterior spinal 2 posterior spinal arteryartery

Radicular branchesRadicular branches

Artery of adamkiewiczArtery of adamkiewicz

Anatomy Anatomy

Ascending tractsAscending tracts

Desending tractsDesending tracts

IncidenceIncidence

Affects 10000 a yearAffects 10000 a year

Age group-16-30 yearsAge group-16-30 years

Male: female=4:1Male: female=4:1

Automobile accidents are the most Automobile accidents are the most common cause in person <65 yearscommon cause in person <65 years

Falls are the most common cause in Falls are the most common cause in person>65yearsperson>65years

CausesCauses

Motor vehicle collision Motor vehicle collision 47%47%

Fall from height 23%Fall from height 23%

Penetrating injuries Penetrating injuries 14%(gun shot, bullet 14%(gun shot, bullet injuries)injuries)

MVC47%

Other/ Unkn.7%

Sports9%

Falls23%

Violence14%

MVC47%

Other/ Unkn.7%

Sports9%

Falls23%

Violence14%

Mechanisms of injuryMechanisms of injury

Distraction-hyperextension of spine as in Distraction-hyperextension of spine as in hangings hangings

Compression-caused by axial loadings as Compression-caused by axial loadings as in fallsin falls

Torsional-high energy motor vehicle Torsional-high energy motor vehicle collisionscollisions

Penetrating-stab or gunshot woundsPenetrating-stab or gunshot wounds

Sites of spinal cord injury Sites of spinal cord injury

M/C junction between flexible and M/C junction between flexible and inflexible segmentsinflexible segmentsMid-thoracic injuries are less common Mid-thoracic injuries are less common because of the rotational stabilisation because of the rotational stabilisation provided by rib cage and intercostal provided by rib cage and intercostal musculaturemusculatureSo injuries are much common above and So injuries are much common above and below the thoracic vertebra below the thoracic vertebra --lower cervical and upper thoracic --lower cervical and upper thoracic

Pathophysiology of SCIPathophysiology of SCI

Primary injuryPrimary injury

Spinal vascular disruption may result in Spinal vascular disruption may result in diminished arterial supply or venous diminished arterial supply or venous drainagedrainage

Cellular edema will lead to increased Cellular edema will lead to increased pressure within the spinal canal, with pressure within the spinal canal, with compromise to blood flowcompromise to blood flow

Pathophysiology of SCIPathophysiology of SCI

Pathophysiology of SCIPathophysiology of SCI

Secondary injurySecondary injury Hypotension Hypotension HypoxiaHypoxia Anemia Anemia During intubationDuring intubation

Degree of InjuryDegree of Injury

Complete transectionComplete transectionTotal paralysis and loss of sensory and motor Total paralysis and loss of sensory and motor function although arms or rarely completely function although arms or rarely completely paralyzedparalyzed

Incomplete (partial transection)Incomplete (partial transection)Mixed loss of voluntary motor activity and Mixed loss of voluntary motor activity and sensationsensation

Complete transectionComplete transection

High cervicalHigh cervical

Low cervicalLow cervical

High thoracicHigh thoracic

Low thoracicLow thoracic

lumbarlumbar

Acute phaseAcute phase

Subacute phaseSubacute phase

Chronic phaseChronic phase

Complete transection of SCComplete transection of SC

High cervical lesionsHigh cervical lesions Resp insufficiencyResp insufficiency QuadriplegiaQuadriplegia Horners syndromeHorners syndrome Hypotension – no tachycardia (T1-T5)Hypotension – no tachycardia (T1-T5) Temperature regulation is alteredTemperature regulation is altered GI- ileus, abd distensionGI- ileus, abd distension GU- bladder bowel incontinenceGU- bladder bowel incontinence Blood -DVTBlood -DVT

Complete transection of SCComplete transection of SC……

Low cervicalLow cervical No diaphragmatic involvementNo diaphragmatic involvement

High thoracic (above T7)High thoracic (above T7) Paraparesis Paraparesis Autonomic invol.Autonomic invol.

Low thoracic and lumbarLow thoracic and lumbar Bladder and bowel invol.Bladder and bowel invol. Autonomic sys. SparedAutonomic sys. Spared

Acute phaseAcute phase

Spinal shockSpinal shock

Loss spinal reflexes Loss spinal reflexes causes flaccid paralysiscauses flaccid paralysis

Resp difficultyResp difficulty

Bladder bowel involved Bladder bowel involved

Fever –loss of Fever –loss of perspirationperspiration

3-6 Weeks3-6 Weeks

Neurogenic shockNeurogenic shock

Loss of vasomotor toneLoss of vasomotor tone

Hypotension without Hypotension without tachycardiatachycardia

Close monitoring of HRClose monitoring of HR

Typically 3 days- 3 Typically 3 days- 3 weeks weeks

Sub acute phaseSub acute phase

Flaccidity of spinal shock is replaced by Flaccidity of spinal shock is replaced by spasticityspasticity

Usually returns in 3 weeksUsually returns in 3 weeks

Hyperreflexia and increased muscular Hyperreflexia and increased muscular tone are noted with extensor plantor tone are noted with extensor plantor response response

Autonomic DysreflexiaAutonomic Dysreflexia

It is characterised by massive firing of It is characterised by massive firing of sympathetic neurons after distention, sympathetic neurons after distention, stimulation or manipulation of bladder and stimulation or manipulation of bladder and bowelbowel

Cutaneous stimulation with painful or cold Cutaneous stimulation with painful or cold stimuli can lead to massive sympathetic stimuli can lead to massive sympathetic firingfiring

Mediated at brain stem levelMediated at brain stem level

Autonomic DysreflexiaAutonomic Dysreflexia

An acute emergencyAn acute emergency

Occurs only after spinal Occurs only after spinal shock has resolvedshock has resolved

The increase in ICP and The increase in ICP and blood pressure can lead blood pressure can lead to cerebral hemorrhageto cerebral hemorrhage

Classic signsClassic signs

pounding headachepounding headache

marked hypertensionmarked hypertension

diaphoresis (particularly diaphoresis (particularly of the forehead)of the forehead)

BradycardiaBradycardia

FlushingFlushing

PiloerectionPiloerection

nausea and nasal nausea and nasal congestioncongestion

Mass reflexMass reflex

Occurs after spinal cord transectionOccurs after spinal cord transection

Mild noxious stimuli may trigger, Mild noxious stimuli may trigger, withdrawal, defecation, sweatingwithdrawal, defecation, sweating

Advantages Advantages

Elicit voiding and defecationElicit voiding and defecation

Control of micturition and defecationControl of micturition and defecation

Incomplete cord patternsIncomplete cord patterns

Anterior cord syndromeAnterior cord syndrome Posterior cord syndromePosterior cord syndrome Brown-Sequard syndromeBrown-Sequard syndrome Cauda equina syndromeCauda equina syndrome

Anterior cord syndromeAnterior cord syndrome Compression of the ant. Compression of the ant.

CordCord motor paralysis at lesion motor paralysis at lesion

and belowand below Pain and loss of Pain and loss of

temperature sensation temperature sensation below site.below site.

Touch, position, Touch, position, vibration and motion vibration and motion remain intact.remain intact.

Posterior cord syndromePosterior cord syndrome

Assoc with cervical Assoc with cervical hyperextension hyperextension injuriesinjuries

Dorsal area of cord is Dorsal area of cord is damaged resulting in damaged resulting in loss of proprioceptionloss of proprioception

Pain, temperature Pain, temperature sensation and motor sensation and motor function remain intact.function remain intact.

Brown-Sequard syndromeBrown-Sequard syndrome

Partial transection of cordPartial transection of cordBSS may be caused by a BSS may be caused by a spinal cord tumor, spinal cord tumor, penetrating injuries to penetrating injuries to spinal cordspinal cordParalysis and loss of Paralysis and loss of vibration sense on same vibration sense on same side of the body side of the body loss of pain and loss of pain and temparature temparature (hemianesthesia) on the (hemianesthesia) on the opposite side. opposite side.

Approach to patientApproach to patient

ABC ABC

Associated injuriesAssociated injuries

Spinal shockSpinal shock

Airway managementAirway management

Suspected cervical spine injurySuspected cervical spine injury

Respiratory distress No respiratory distressRespiratory distress No respiratory distress

ABC HistoryABC History

Clinical examClinical exam

InvestigationsInvestigations

Signs and Symptoms Signs and Symptoms

Neck or back painNeck or back painPenetrating injury of neck or backPenetrating injury of neck or backTenderness to palpation of spineTenderness to palpation of spineLoss of strength in extremitiesLoss of strength in extremitiesLoss of feeling in extremitiesLoss of feeling in extremitiesParalysisParalysisIncontinenceIncontinenceSCIWORA (spinal cord injury without SCIWORA (spinal cord injury without radiological abnormality) common in pediatric radiological abnormality) common in pediatric age groupage group

How to exclude Cervical Spine How to exclude Cervical Spine Injuries Injuries

NEXUS CRITERIANEXUS CRITERIA

Normal mental statusNormal mental status

Not intoxicatedNot intoxicated

Normal neurological examinationNormal neurological examination

No tenderness to palpation of C spineNo tenderness to palpation of C spine

No pain with active range of motionNo pain with active range of motion

ImagingImaging

X-ray cervical spineX-ray cervical spine AP viewAP view Lateral viewLateral view Odontoid viewOdontoid view

CT scanCT scan

MRIMRI

Lateral viewLateral view

Anterior vertebral Anterior vertebral marginsmargins

Posterior vertebral Posterior vertebral marginsmargins

Spinolaminar junction Spinolaminar junction lineslines

cervical spine injuriescervical spine injuries

MANAGEMENTMANAGEMENT

A-AirwayA-Airway

B-BreathingB-Breathing

C-CirculationC-Circulation

To prevent secondary spinal cord injuriesTo prevent secondary spinal cord injuries HypotensionHypotension HypoxiaHypoxia AnemiaAnemia

Cervical spine immobilizationCervical spine immobilization

Patients neck should be immobilized at the Patients neck should be immobilized at the earliest until complete evaluation has been earliest until complete evaluation has been made to exclude cervical spine injurymade to exclude cervical spine injurySoft collarsSoft collars unsatisfactory as they permit 75%neck unsatisfactory as they permit 75%neck

movementmovement

Rigid collarRigid collar They reduce flexion extention to 70% They reduce flexion extention to 70%

reduces rotational movements by 54%reduces rotational movements by 54%

Cervical spine immobilization…Cervical spine immobilization…The best method of The best method of immobilization is immobilization is Secure the patient in a Secure the patient in a

hard board hard board from head to feet from head to feet

With sand bags placed With sand bags placed on either side of head on either side of head

Rigid collar around neckRigid collar around neck

This method reduces This method reduces neck movement to 5% neck movement to 5% of normalof normal

Spinal ImmobilizationSpinal ImmobilizationTransfer patient to long spine board as Transfer patient to long spine board as soon as feasiblesoon as feasible

Logroll in unisonLogroll in unison

Stabilize head and neck with sandbags or Stabilize head and neck with sandbags or rolled blanketsrolled blankets

Airway controlAirway control

Clear the airway Clear the airway

Maintain adequate oxygenationMaintain adequate oxygenation

Initial maneuver of maintaining airway patency Initial maneuver of maintaining airway patency should not displace the cervical spine should not displace the cervical spine

Acceptable maneuvers include:Acceptable maneuvers include: Lifting the chin (5mm)Lifting the chin (5mm) Forward displacement of mandibleForward displacement of mandible Placement of appropriate sized oral or nasal airwaysPlacement of appropriate sized oral or nasal airways

Indications of tracheal intubationIndications of tracheal intubation

GCS<8GCS<8

Loss of protective airway reflexLoss of protective airway reflex

Hemorrhage into the airwayHemorrhage into the airway

Pao2<60mmhgPao2<60mmhg

Paco2>45mmhgPaco2>45mmhg

SeizuresSeizures

Actual or impending airway obstructionActual or impending airway obstruction

Airway controlAirway control

Blind nasal vs orotrachealBlind nasal vs orotracheal

Safest method is debatableSafest method is debatable

Depends on anesthesiologist opinion with Depends on anesthesiologist opinion with which he is well versedwhich he is well versed

Advanced trauma and life support (1993)Advanced trauma and life support (1993) Nasotracheal in a spontaneously breathing Nasotracheal in a spontaneously breathing Orotracheal in a apneic patientOrotracheal in a apneic patient

Orotracheal intubationOrotracheal intubation

Safest and surest method of intubating the Safest and surest method of intubating the tracheatrachea

It is the best method to secure the in an It is the best method to secure the in an emergency settingemergency setting

Manual in line stabilisation (MILS) Manual in line stabilisation (MILS) technique should be usedtechnique should be used

MILS techniqueMILS technique

It is the continuous It is the continuous immobilization of the immobilization of the neck during tracheal neck during tracheal intubation that is intubation that is important for reducing important for reducing the incidence of the incidence of secondary SCIsecondary SCI

Orotracheal intubation…Orotracheal intubation…

Preoxygenation for 3 minutesPreoxygenation for 3 minutes

Administration of a Intravenous induction Administration of a Intravenous induction agentagent

Application of cricoid pressure by the Application of cricoid pressure by the assistantassistant

Administration of rapidly acting Administration of rapidly acting neuromuscular blocking drugneuromuscular blocking drug

Laryngoscopy and Intubation of tracheaLaryngoscopy and Intubation of trachea

Elevation of Elevation of laryngoscpe results in laryngoscpe results in extention of atlanto extention of atlanto occipital jointoccipital joint

(2002)

Canadian Journal of Anesthesia 49:733-744 (2002)

Edward Crosby, MD et al

Difficulties Difficulties

Cervical collar-reduces mouth openingCervical collar-reduces mouth opening

Cricoid pressure-distorts the viewCricoid pressure-distorts the view

MILSMILS

0

10

20

30

40

50

60

in mms

mouth opening

Collar tapeSand bags MILS Optimal position

Kj heath et al Anesthesia 1994

To improve the success rateTo improve the success rate

Remove the anterior part of collarRemove the anterior part of collar

Gum elastic bougieGum elastic bougie Nolan et alNolan et al

Anesthesia 1993Anesthesia 1993

Mccoy laryngoscopyMccoy laryngoscopy D A Gabbott et alD A Gabbott et al

Anesthesia 1996Anesthesia 1996

Nasotracheal intubationNasotracheal intubation

Sucessful in 90% of patientsSucessful in 90% of patientsRequires multiple attemptsRequires multiple attemptsContraindicationContraindication Base of skull fracture and mid-facial injuriesBase of skull fracture and mid-facial injuries Apnea Apnea

DisadvantagesDisadvantages Bleeding can occur in the airway making other Bleeding can occur in the airway making other

methods of securing the airway difficultmethods of securing the airway difficult AspirationAspiration Vomitting Vomitting

Role of intubating LMA in Role of intubating LMA in emergency settingemergency setting

Can be used safely for intubationCan be used safely for intubation

Provides a means for ventilation in case of Provides a means for ventilation in case of failed tracheal intubationfailed tracheal intubation

Adv-will allow tracheal intubation in patient Adv-will allow tracheal intubation in patient in patient with rigid cervical collarin patient with rigid cervical collarkomotsu et al komotsu et al BJA;2004,93(5) 655-659BJA;2004,93(5) 655-659

Does not require a, secretion free or a Does not require a, secretion free or a blood free airwayblood free airway

ILMA -DisadvantagesILMA -Disadvantages

Risk of aspiration in trauma patientsRisk of aspiration in trauma patients

LMA can exert high pressures while insertion LMA can exert high pressures while insertion insufflation and while in situ this increases the insufflation and while in situ this increases the risk of posterior displacement of spinerisk of posterior displacement of spine Anesthesia-Analgesia 1999,89:1296-1300Anesthesia-Analgesia 1999,89:1296-1300

Eventhough there is posterior movement of C-Eventhough there is posterior movement of C-spine clinically this not significantspine clinically this not significant Textbook of laryngeal mask anesthesia Textbook of laryngeal mask anesthesia

by Brimacombeby Brimacombe

other methodsother methods

Fibroptic intubationFibroptic intubation

Lightwand Lightwand

Retrograde intubationRetrograde intubation

Bullard laryngoscopyBullard laryngoscopy

CricothyroidotomyCricothyroidotomy

Surgical airwaySurgical airway

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