Week 5 - Spinal Injuries PDF

8/7/2023 PAR212 – Week 5 Spinal Injuries Matthew Hill 1 2 1  8/7/2023 Learning Outcomes 1. Describe the epidemiology of spina...

8/7/2023 PAR212 – Week 5 Spinal Injuries Matthew Hill 1 2 1  8/7/2023 Learning Outcomes 1. Describe the epidemiology of spinal trauma across the lifespan in Australia. 2. Use knowledge of spinal anatomy and physiology to predict significant clinical findings associated with spinal cord injury (SCI) at different levels of the vertebral column. 3. Explain the difference between spinal shock and neurogenic shock by reference to pathology and clinical findings. 4. Describe the appropriate management of a patient of any age with suspected spinal injury and evaluate the efficacy of this care. 5. Describe common rehabilitation issues for patients with SCI and discuss the role of the paramedic in managing these patients’ health problems in the community. 6. Describe the presentation, pathophysiology and common causes of autonomic dysreflexia, and discuss the management of patients with this health emergency. 3 Spinal Anatomy (Thompson, 2019) 4 2  8/7/2023 Spinal Anatomy (Thompson, 2019) 5 Spinal Anatomy (Thompson, 2019) 6 3  8/7/2023 Spinal Anatomy (Thompson, 2019) 7 Spinal Anatomy (Thompson, 2019) 8 4  8/7/2023 Spinal Anatomy (Thompson, 2019) 9 Spinal Injury “injury of the spine or spinal cord with Psychological associated motor, sensory and/or autonomic deficit”4 SCI has an impact on: Individuals Burden of Families SCI Society Physical Economic SCI can result from: Trauma, spinal cord lesions, tumours, vascular lesions, multiple sclerosis, congenital defects, or infections or abscesses of the spinal cord (AIHW, 2021) – CC-BY 3.0 10 5  8/7/2023 Epidemiology Incidence (2015-2016 data) 12.1 cases per million population Tetraplegia Age >15 years in Australia4 Estimated total cost $1.3 billion7 21-32 cases per million population Individual lifetime cost $9.5 million per case7 All ages in Australia.5 Paraplegia 23 cases per million population Global (2007)2 Estimated total cost $690 million7 ~180, 000 new cases each year6 Individual lifetime cost $5 million per case7 (AIHW, 2021) – CC-BY 3.0 11 Epidemiology Morbidity Mortality Of the 187 cases of SCI in persons ≥15 years 12-month mortality rate 8.2% (Tetraplegia) old reported to the ASCIR in 2017-2018: 4.1% (Paraplegia) 94% (176) had persisting neurological deficit Mortality decreases with time in the first 12 on discharge from hospital months. Mortality rates after the first year for people with SCI still higher than general population. Standardised mortality ratio (SMR) 2.2 (Tetraplegia) 1.7 (Paraplegia) (AIHW, 2021) – CC-BY 3.0 12 6  8/7/2023 Epidemiology (AIHW, 2021) – CC-BY 3.0 13 Epidemiology (AIHW, 2021) – CC-BY 3.0 14 7  8/7/2023 Classification of spinal cord injuries Neurological Level Extent of injury Lowest level that has full neurological Degree of motor and/or sensory function. deficit Tetraplegia/Quadriplegia Paraplegia Injury at the cervical level. Injury at thoracic, lumbar, or sacral Reduction or loss of motor and/or segments. sensory function in arms, trunk, legs, Reduction or loss of motor and/or and pelvic organs. sensory function in the trunk, legs, and pelvic organs. Complete Incomplete No sensory and motor function in the Some sensory and/or motor function lowest sacral segments (S4–S5). below the neurological level of injury Complete injury above at a high that includes the lowest sacral cervical neurological level is segments S4–S5. considered most severe. (AIHW, 2021) – CC-BY 3.0 15 Level of spinal cord injury (AIHW, 2021) – CC-BY 3.0 16 8  8/7/2023 Mechanism of SCI (AIHW, 2021) – CC-BY 3.0 17 Mechanism of injury Stability Flexion Mechanism of SCI Anterior wedge fracture Stable Flexion teardrop fracture Extremely unstable Clay shoveler’s fracture Stable Subluxation Potentially unstable Bilateral facet dislocation Always unstable Hyperextension8 Atlanto-occipital dislocation Unstable Head and neck forcibly extended backwards. Anterior atlantoaxial dislocation with or without fracture Unstable Hyperflexion8 Odontoid fracture with lateral placement Unstable Fracture of transverse process Stable Chin towards chest. Flexion rotation Vertical compression (Axial load)8 Unilateral facet dislocation Stable E.g. diving injuries or fall from height onto feet. Rotary atlantoaxial dislocation Unstable Extension Rotation/Flexion rotation8 Posterior neural arch fracture (C1) Unstable Often highly unstable. Hangman’s fracture (C2) Unstable Extension teardrop fracture Penetrating trauma8 Posterior atlantoaxial dislocation with or without fracture Unstable Vertical compression Burst fracture of vertebral body Stable Jefferson fracture (C1) Extremely unstable Isolated fractures of articular pillar and vertebral body Stable Table 1: Mechanism of SCI and fracture stability9 18 9  8/7/2023 Pathophysiology of SCI9 Primary Injury Refers to the immediate trauma which may result in: Contusion Compression Shear injury Transection (complete/partial) Haemorrhage Often coincides with vertebral column injury: Fracture/s Dislocation Tearing of ligament/s Disruption/herniation of intervertebral disc/s Most vertebral injuries involve both a fracture and dislocation. 19 Pathophysiology of SCI9 Secondary injury Begins within minutes and develops over hours. Exact process not completely understood. Believed to result from: Hypoxia Ischaemia Inflammation Oedema Excitotoxicity Abnormal ion movement Apoptosis Results in deterioration in neurological function over the first 8-12 hours in patients with incomplete spinal cord syndrome. 20 10  8/7/2023 Spinal cord syndromes9,10 Anterior cord syndrome Impairment of all tracts except posterior columns. Position and vibratory sensation preserved. Central cord syndrome Upper limb paresis > lower limb paresis. Decreased pain and temperature sensation loss in upper neck, shoulders, and upper trunk. Light touch, position, and vibratory sensation preserved. Brown-Sequard syndrome Unilateral lesion (typically from penetrating trauma). Ipsilateral loss of touch, position, vibratory sensation. Ipsilateral paresis. Contralateral loss of pain and temperature sensation. 21 Spinal Shock vs Neurogenic Shock3,10 Spinal Shock Transient cord injury (may last several hours to weeks) Flaccid paralysis caudal to the site of injury Areflexia Loss of bowel/bladder control/priapism (in males) Anaesthesia Neurogenic Shock Interruption to normal sympathetic nervous system function Can occur secondary to spinal cord injury at or above the sympathetic outflow tract (above T5). Patients may present with: Hypotension Bradycardia Generally poorly responsive to volume replacement 22 11  8/7/2023 Examination3 Mechanism of injury Impaired motor function Pain/tenderness over or adjacent to the spinal Diaphragmatic ventilation vertebra “C3,4,5 keeps the diaphragm alive” Lesions above C5 will cause partial to complete Impaired sensory function diaphragmatic paralysis Local or generalised paraesthesia Lesions at C5 and below will allow full Loss of proprioception diaphragmatic movement, but intercostal muscles (innervated from T1) and abdominal Impaired autonomic function muscles (innervated from T12) are affected Hypotension Hypoxia is associated with adverse neurological outcomes in spinal cord injury Bradycardia Paralysis Thermoregulation Priapism Flaccidity Abnormal posturing 23 Motor/Sensory Examination ASIA-ISCOS-IntlWorksheet_2019.pdf (asia-spinalinjury.org) 24 12  8/7/2023 Motor Examination Table 2: Effects of Spinal Cord Injury by Location10 Location of Lesion Possible Effects Respiratory paralysis At or above C5 Quadriplegia Paralysis of legs, wrists, and hands Weakness of shoulder abduction and elbow flexion Between C5 and C6 Loss of biceps jerk reflex Loss of brachioradialis deep tendon reflex Paralysis of legs, wrists, and hands, but shoulder Between C6 and C7 movement and elbow flexion usually possible Loss of triceps jerk reflex Between C7 and C8 Paralysis of trunk, legs, and hands Horner syndrome (constricted pupil, ptosis, facial Between C8 to T1 anhidrosis) Paralysis of legs Between T1 and conus medullaris Paralysis of legs 25 Management3 Principles Identification and reversal of life threats in the primary survey Appropriate spinal motion restriction Manual in-line stabilisation Cervical collar Combi-carrier KED/NEIJ (if appropriate) Maintaining a high index of suspicion of SCI Cardiovascular and ventilatory support Ensuring appropriate thermoregulation 26 13  8/7/2023 NEXUS (National Emergency X-Radiography Utilization Study) Validated in both adults and paediatrics3 No posterior midline cervical spine tenderness Highly sensitive (99% [95% CI, 98% to 99.6%])11 + Aimed at identifying trauma patients who are No evidence of intoxication at very low risk of sustaining a SCI3 + A normal level of alertness Radiography is required for all patients unless they meet ALL of the following criteria: + No focal neurological deficit + No painful distracting injuries 27 28 14  8/7/2023 Complications of SCI10 Increased risk of blood clots Urinary tract infections Contractures Atelectasis Pneumonia Pressure ulcers Spasticity Neurogenic pain (burning/stinging) Paralytic ileus Labile temperature – lack vasomotor control and cannot sweat below lesion Nutrition Cardiovascular instability Neurogenic shock Autonomic dysreflexia 29 Autonomic Dysreflexia12 Syndrome of massive imbalanced reflex sympathetic discharge. Occurs in patient’s with and existing, non-acute spinal cord injury above the level of T6. Can be caused by: Distended bladder (due to blocked catheter) UTI Bowel irritation (e.g., constipation) Skin irritation (e.g., pressure sores) Any other event that would be deemed painful. 30 15  8/7/2023 Autonomic Dysreflexia: Pathophysiology12 Stimuli below the level of the spinal cord injury causes excessive, unmodulated reflex activity from the sympathetic nervous system. Vasoconstriction Skin pallor Compensatory Overactivity of ↑Noradrenaline below level of Piloerection bradycardia and the sympathetic ↑Dopamine injury ↑BP (s mulates vasodilation ganglia (uncontrolled) baroreceptors) above the injury 31 Autonomic Dysreflexia: Clinical Features12 Relative hypertension (>90-100/60 mmHg may be significant) Flushing of skin above level of injury and pallor below level of injury Bradycardia Diaphoresis and piloerection above the level of injury Pounding headache (worsens as BP rises) Visual disturbances (e.g., blurred vision) CVA/TIA symptoms Acute coronary syndromes Anxiety and apprehension Irritability/combative behaviour in people with limited cognitive or communication ability. 32 16  8/7/2023 Autonomic Dysreflexia: Management12 Sit patient upright with legs dependant Loosen/remove tight clothing Ensure urinary catheter is not kinked Remove noxious stimuli (if possible) Avoid pressure to the patient’s abdomen If SBP >=160 mmHg consider: GTN Morphine OR Fentanyl Transport to hospital 33 References 1. Thompson, G. S. Understanding anatomy & physiology: A visual, auditory, interactive approach. FA Davis; 2019. 2. Australian Institute of Health and Welfare. Spinal cord injury, Australia 2017-2018. Published 2021. Accessed August 14, 2022. https://www.aihw.gov.au/getmedia/5b4a8579-a010-40f0- 9ad6-31522a4fcc12/aihw-injcat-219.pdf.aspx?inline=true 3. Clinical Quality & Patient Safety Unit, QAS. Clinical Practice Guidelines: Trauma/Spinal cord injury. Queensland Ambulance Service. Published January 2019. Accessed August 14, 2022. https://www.ambulance.qld.gov.au/docs/clinical/cpg/CPG_Spinal%20cord%20injury.pdf 4. Australian Institute of Health and Welfare. Spinal cord injury, Australia 2015-2016. Published 2019. Accessed August 14, 2022. https://www.aihw.gov.au/getmedia/0195103b-ddff-42a0-859f- 5aa8cd6874fd/aihw-injcat-202.pdf.aspx?inline=true 5. New PW, Baxter D, Farry A, Noonan VK. Estimating the incidence and prevalence of traumatic spinal cord injury in Australia. Archives of physical medicine and rehabilitation. 2015 Jan 1;96(1):76-83. 6. Lee BB, Cripps RA, Fitzharris M, Wing PC. The global map for traumatic spinal cord injury epidemiology: update 2011, global incidence rate. Spinal cord. 2014 Feb;52(2):110-6. 7. Economics A. The economic cost of spinal cord injury and traumatic brain injury in Australia. Report by Access Economics for the Victorian Neurotrauma Initiative. Canberra: Access Economics. 2009 Jun;31. 8. Curtis K, Ramsden C, Shaban RZ, Fry M, Considine J. Emergency and Trauma Care for Nurses and Paramedics. 3rd ed. Elsevier; 2019. 9. Hansebout, R., & Kachur, E. (2022). Acute traumatic spinal cord injury. from Up To Date https://www.uptodate.com/contents/acute-traumatic-spinal-cord- injury?search=spinal%20cord%20injury&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 10. Mao, G. (2021). Spinal Trauma. In MSD Manual Professional Version. Retrieved from https://www.msdmanuals.com/en-au/professional/injuries-poisoning/spinal-trauma/spinal-trauma 11. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. New England Journal of Medicine. 2000 Jul 13;343(2):94-9. 12. Clinical Quality & Patient Safety Unit, QAS. Clinical Practice Guidelines: Autonomic dysreflexia. Queensland Ambulance Service. Published July 2022. Accessed August 14, 2022. https://www.ambulance.qld.gov.au/docs/clinical/cpg/CPG_Spinal%20cord%20injury.pdf 34 17