Cervical Spine Trauma and Spinal Cord Emergencies



Cervical Spine Trauma and Spinal Cord Emergencies


E. Megan Callan

Charles M. Andrews



THE CLINICAL CHALLENGE

The vast majority of spinal cord injuries occur from trauma, although other causes must be considered (Table 13.1). The mean age at the time of injury is 37 years and there is a bimodal age distribution, with the first peak between 16 and 30 years of age and the second peak older than 60 years.1 The ratio of males to females is approximately 4:1. In descending order of prevalence, the greatest causes for acute spinal trauma are motor vehicle accidents (˜40%), followed by falls (˜20%), violence, and sporting injuries. The level of spinal cord injury most often occurs in cervical spine (˜60%), thoracic (˜32%), and lumbosacral (˜9%). Injury to the spine in the setting of trauma can occur in isolation, or in polytrauma with other potential life-threatening injuries. Spinal immobilization is always an important consideration in these patients.

Spinal cord compression due to a structural abnormality is a neurosurgical emergency. Signs of injury must be recognized and urgent imaging obtained to direct treatment. About 20% of patients with a major spine injury have a second injury at a noncontiguous level; therefore, complete spine imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is recommended.




PREHOSPITAL CONCERNS

The patient with a spine injury may have injuries at multiple levels. Between 25% and 50% of patients with a spinal cord injury have also sustained a head injury, whereas spinal cord injury is seen in 10% to 30% of polytrauma patients.4 The goal of prehospital management is to minimize secondary injury. After ensuring oxygenation and perfusion, a secondary evaluation includes enquiry about pain in the neck or back, tenderness to palpation, weakness or altered sensation, signs of incontinence, and other signs of injury. Given the mechanism of injury, prehospital providers are often tasked with removing patients from harmful situations before further evaluation and transport. Care must be taken to restrict motion of the patient’s spine as much as possible during patient movement and transport. It is recommended to place the patient in a rigid cervical collar with the head stabilized in a forward-facing position. A spine log roll may be used to keep the patient in a spine-neutral position to be placed on a rigid backboard with straps. These immobilization techniques have side effects of their own, including discomfort, pressure sores, restriction of respiration, and difficulty with maintaining airway protection; see section “Evidence.” In brief, there is only evidence to use restricted spine motion with a rigid backboard or similar device in a subset of patients: blunt trauma with altered level of consciousness, spinal pain or tenderness, neurologic disability (weakness or numbness), anatomic deformity of the spine, high-energy mechanism with either intoxication, inability to communicate, or other distracting injury.

Patients with high cervical spine injuries may have diaphragmatic weakness or respiratory accessory muscle weakness leading to respiratory failure and death. If bag mask ventilation is ineffective, an advanced airway intervention is indicated. Concomitant facial fractures or thoracic injuries (such as pneumothorax or aspiration) may confound the clinical picture. Trained emergency medical services personnel may use an advanced airway with in-line immobilization of the cervical spine. Hypotension may occur either due to hypovolemic/hemorrhagic shock or autonomic dysfunction (neurogenic shock). Crystalloid or colloid intravenous (IV) fluid volume resuscitation with at least two large-bore IVs can help maintain blood pressure until arrival at the hospital. The desired mean arterial pressure (MAP) is 90 mm Hg, and episodes of hypotension with systolic blood pressure below 90 mm Hg should be avoided because this can exacerbate neurologic injury.













Jun 23, 2022 | Posted by in EMERGENCY MEDICINE | Comments Off on Cervical Spine Trauma and Spinal Cord Emergencies
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