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Difficult cases are head injury and coma with a coexisting neck injury. Any doubt hard collar for the neck. If you scan the head in such a case get a cervical films spine to C7/T1

About

• Early management can have long term consequences
• Spinal cord runs from the foramen magnum to L1
• C3-5 : supplies diaphragm
• C5-T1: supplies arms

Anatomy

• There are 31 pairs of spinal nerves including:
• 8 cervical spinal nerves on each side of the spine called C1 through C8
• 12 thoracic spinal nerves in each side of the body called T1 through T12
• 5 lumbar spinal nerves on each side called L1 through L5
• 5 sacral spinal nerves in each side called S1 through S5
• 1 coccygeal nerve on each side, Co1

Aetiology

• Anterior dislocation of a vertebra due to trauma can cause spinal cord transection
• Fracture dislocation can be seen in both the young and elderly
• Bone fragments from fractured vertebrae can impinge on the cord.
• Haematoma can cause ischaemic damage to the cord

Structure

• Anterior column: Bone and ligaments including anterior half of vertebral body
• Middle column: Posterior longitudinal ligament and posterior half of vertebral body
• Posterior column: lamina and pedicles
• Damage to 2 out of 3 of these denotes an unstable spine

Causes

• Road traffic accidents 50% especially if thrown from a vehicle
• Falls: 25% even from standing in the elderly especially at C2
• Violence (especially gunshot wounds): 15%
• Sports accidents: 10 percent e.g. diving, rugby
• Others: 5% percent

Increased risk

• Ankylosing spondylitis
• Cervical spondylosis
• Narrow spinal canal

Dangerous mechanisms

• Fall from elevation = 3 foot/5 steps
• Axial load to head e.g. diving
• Motor vehicle speed = 100 km/hr, rollover, ejection from vehicle
• Motorised recreational vehicle
• Bicycle struck collision
• Rear ended and pushed into traffic
• Rear ended and hit by bus/large truck
• Rollover, Hit by high speed vehicle

Clinical

• Spinal shock - loss of reflexes below lesion, flaccid limbs, atonic bladder, loss of vasomotor control, atonic bowel. Can last 2 weeks
• Heightened activity - after 1-2 weeks with spasticity of limbs, increased reflexes, upgoing plantar, spastic bladder, increased autonomic function with sweating and vasomotor responses
• Midline pain especially on any movement and local tenderness and a sensory level below which sensation is lost. Log roll to examine back - assess perianal sensation and anal tone
• Diaphragmatic breathing as intercostal damaged and only C3-5 intact
• Acute paraplegia and quadriplegia if damage above T1
• Priapism due to lost sympathetic tone as well as hypotension and bradycardia

Transection may be incomplete

• Hemisection of cord (Brown Sequard syndrome): loss of ipsilateral post columns and corticospinal and c/l spinothalamic
• Anterior cord: Bilateral weakness and spinothalamic loss. Preserved posterior columns
• Central cord syndrome: Weakness and loss of sensation in both arms, intact motor and sensation in legs.

Investigations

• Radiology: Lateral/anteroposterior and odontoid peg views of spine
• Lateral view must show C7/T1 junction
• CT scan head and cervical spine (especially C1/2 lesions) and may be done instead of plain films. Fractures may exist at multiple levels.
• MRi is better for showing bone and ligamentous injury

Management

• ABCs to ensure blood pressure and oxygenation, IV fluids. Skincare with 2 hourly turns to prevent decubitus ulcers, intermittent catheterisation to prevent overdistension of bladder and infection.
• The spine must be immobilised using a hard collar initially and additional with sandbags.
• Respiratory compromise may necessitate rapid sequence induction
• Once a diagnosis is confirmed then steroids are given though this is controversial. Follow local policies. IV Methylprednisolone is the drug used.
• Urgent neurosurgical assessment and decompression and stabilisation. However, the evidence for neurological benefit in many patients is lacking. Surgery may be needed for spinal instability and to prevent further damage and to allow early mobilisation and rehabilitation.
• Coexisting other trauma must be looked for and managed. High cervical lesions (above C5) may cause respiratory weakness requiring ventilation
• If possible then transfer to a spinal unit within 24 hrs improves outcome

Collection of Algorithms

About

• On arrival at the scene of the incident, use a prioritising sequence to assess people with suspected trauma, for example ABCDE
  • catastrophic haemorrhage
  • airway with in-line spinal immobilisation (for guidance on airway management refer to the NICE guideline on major trauma)
  • breathing
  • circulation
  • disability (neurological)
  • exposure and environment.
• At all stages of the assessment: protect the person's cervical spine with manual in-line spinal immobilisation, particularly during any airway intervention and avoid moving the remainder of the spine
• Assess the person for spinal injury, initially taking into account the factors listed below. Check if the person:
  • has any significant distracting injuries
  • is under the influence of drugs or alcohol
  • is confused or uncooperative
  • has a reduced level of consciousness
  • has any spinal pain
  • has any hand or foot weakness (motor assessment)
  • has altered or absent sensation in the hands or feet (sensory assessment)
  • has priapism (unconscious or exposed male)
  • has a history of past spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine.

Assessment for cervical spine injury

• Assess whether the person is at high, low or no risk for cervical spine injury using the Canadian C-spine rule as follows
• HIGH risk: at least one of the following high-risk factors
  • Age 65 years or older
  • Dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head – for example, diving, high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)
  • paraesthesia in the upper or lower limb
• LOW risk if they have at least one of the following low-risk factors
  • involved in a minor rear-end motor vehicle collision
  • comfortable in a sitting position
  • ambulatory at any time since the injury
  • no midline cervical spine tenderness
  • delayed onset of neck pain
  • low risk if unable to actively rotate their neck 45 degrees to the left and right (the range of the neck can only be assessed safely if the person is at low risk and there are no high-risk factors)
• NO risk: the person has no risk if they: have one of the above low-risk factors and are able to actively rotate their neck 45 degrees to the left and right.

Assessment for thoracic or lumbosacral spine injury

• Assess the person with suspected thoracic or lumbosacral spine injury using these factors:
  • age 65 years or older and reported pain in the thoracic or lumbosacral spine
  • dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)
  • pre-existing spinal pathology, or known or at risk of osteoporosis – for example steroid use
  • suspected spinal fracture in another region of the spine
  • abnormal neurological symptoms (paraesthesia or weakness or numbness)
  • on examination:
    • abnormal neurological signs (motor or sensory deficit)
    • new deformity or bony midline tenderness (on palpation)
    • bony midline tenderness (on percussion)
    • midline or spinal pain (on coughing)
  • on mobilisation (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs).
• Be aware that assessing children with suspected thoracic or lumbosacral spine injury is difficult and the child's developmental stage should be taken into account.

When to carry out or maintain full in-line spinal immobilisation

• Carry out or maintain full in-line spinal immobilisation if:
  • a high-risk factor for cervical spine injury is identified and indicated by the Canadian C-spine rule
  • a low-risk factor for cervical spine injury is identified and indicated by the Canadian C-spine rule and the person is unable to actively rotate their neck 45 degrees left and right
  • they do not have any of the factors listed above
• Do not carry out or maintain full in-line spinal immobilisation in people if:
  • They have low-risk factors for cervical spine injury as identified and indicated by the Canadian C-spine rule, are pain-free and are able to actively rotate their neck 45 degrees left and right
  • they do not have any of the factors listed in the recommendation above

How to carry out full in-line spinal immobilisation

• When immobilising the spine tailor the approach to the person's specific circumstances. The use of spinal immobilisation devices may be difficult (for example in people with short or wide necks, or people with a pre-existing deformity) and could be counterproductive (for example increasing pain, worsening neurological signs and symptoms).
• In uncooperative, agitated or distressed people, including children, think about letting them find a position where they are comfortable with manual in-line spinal immobilisation.
• When carrying out full in-line spinal immobilisation in adults, manually stabilise the head with the spine in-line using the following stepwise approach:
  • Fit an appropriately sized semi-rigid collar unless contraindicated by: a compromised airway or known spinal deformities, such as ankylosing spondylitis (in these cases keep the spine in the person's current position).
  • Reassess the airway after applying the collar.
  • Place and secure the person on a scoop stretcher.
  • Secure the person with head blocks and tape, ideally in a vacuum mattress.
  • When carrying out full in-line spinal immobilisation in children, manually stabilise the head with the spine in-line using the stepwise approach in recommendation

References

• Spinal injury: assessment and initial management