Spinal Injury Assessment Quiz

Spinal Trauma - Suspicion and Management

• Early Suspicion: Spinal injury should be suspected early for immediate immobilization and airway management. Neck injuries are the most common. Failure to immobilize unstable injuries can cause further cord or nerve root damage.

• When to Suspect:

  • Major trauma
  • Minor trauma with spinal pain or neurological symptoms
  • Altered consciousness after injury (flaccid areflexia, decreased anal tone, diaphragmatic breathing issues, limited movement in C5, C7, and below clavicle)
  • Hypotension with bradycardia or priapism.

• Dangerous Mechanisms of Injury:

  • Motor Vehicle Accidents (MVAs) with patient ejection or rollover
  • Pedestrian accidents or bicycling accidents without a helmet
  • Falls from heights (> 3 feet for children, >5 feet for adults)
  • Head struck by high-impact objects

• Pre-existing Spinal Disease: Suspect a spinal injury when a patient has rheumatoid arthritis, ankylosing spondylitis, severe osteoarthritis, osteoporosis, or is on steroid therapy. These conditions can make injuries worse.

Spinal Trauma - ABCDE Approach

• Airway Management and Immobilization (A):

  • Perform rapid manual immobilization without traction
  • Keep the head and neck in a neutral position by using both hands around the neck and interlocking the movement to avoid any movement.
  • Use sandbags or blocks placed on the sides of the head and tape/ straps to prevent rotation.
  • Use a cervical collar (Stifneck or Miami J collar—better than a hard collar) to avoid overtightening
  • Make sure the airway is clear to avoid hypoxia that compromise the damaged cord
  • If the patient is unconscious, perform jaw thrust and clear the airway with suction if needed. Adjuncts like OPA or NPA might be useful.
  • If endotracheal intubation (ETT) is needed, it must be performed by an expert in advanced anesthetic techniques (usually rapid sequence intubation (RSI)) with assistance to control the head and neck to limit cervical spine movement

• Breathing and Ventilation (B):

  • Regularly assess breathing and diaphragmatic breathing (using accessory muscles if needed)
  • Continuously monitor oxygenation (pulse oximetry) and ventilation (ABG analysis), to avoid deterioration due to cord oedema/ ischaemia.
  • Tracheal intubation and controlled ventilation might become necessary if needed.

• Circulation (C):

  • Monitor ECG (electrocardiogram), blood pressure (BP), and heart rate (HR).
  • Insert a urinary catheter to monitor urine output (UOP) and prevent bladder distension.
  • Insert a nasogastric (NG) tube to prevent gastric distension (common after cord injury) and reduce risk of aspiration if there is no craniofacial injury.
  • May need to assess for neurogenic shock (pathophysiology: loss of vasomotor tone, decreased blood pressure; presentation: flaccidity and areflexia, warm VD, bradycardia, hypotension, and hypothermia)
  • Exclude and treat other causes of hypotension like blood loss or tension pneumothorax. If blood loss is suspected an IV fluid is usually sufficient to correct hypovolaemia
  • Consider inotropes for hypotension if volume replacement is not successful and correct bradycardia using atropine if needed

• Disability (D):

  • Level of Injury: The point where the spinal cord is injured. This determines the effected body part or areas that are affected and unaffected.

  • Sensory Level: The most caudal segment of the spinal cord with intact sensation on both sides of the body.

  • Assess sensation using light touch and pinprick tests to determine sensory level.

  • Types of Spinal Cord Injury: (Complete, Sensory Incomplete, Motor Incomplete, Motor Incomplete, Normal)

  • Complete: No motor or sensory function below level of injury, no muscle movement, light touch, pin prick or pressure feelings.

  • Sensory Incomplete: Feeling present but limited movement below the level of injury

  • Motor Incomplete: Some muscles can move below neurological level but cannot support gravity

  • Motor Incomplete: Many muscles can move below neurological level but can support gravity

  • Motor Level: The lowest cord segment where a muscle has a strength grade of 3 (muscle strength 0-5, 0 being paralysis, 5 being normal).

• Exposure (E): Log roll the patient using adequate methods. Consider using a 6+ lift and slide maneuver

• Cervical Spine Imaging: Imaging is needed in cases of suspected injury but must be avoided if no risks are present such as symptoms of neuro deficit, spinal tenderness, altered mental states and intoxication or distracting injuries.