Chapter 28. Spinal injuries
Spinal cord injury may be either complete (i.e. with no motor or sensory function below the level of injury) or incomplete (with partial preservation of sensory or motor function, or both). In 50% of cases of spinal injury there are associated injuries which also may require their own urgent management. As with head injuries the aim is to avoid exacerbating the primary injury.
Three elements contribute to spinal cord injury:
• Biomechanical movement
• Hypoxia due to A or B problems
• Underperfusion – C problems.
Causes of spinal cord injury
The principal causes of spinal cord injury are:
• Motor vehicle collisions
• Falls
• Sports:
Gymnastics and trampolining
Rugby football
Horse riding and hunting (female to male 5:1)
Skiing
Hang gliding
• Aquatic injuries, e.g. diving into shallow water
• Weight falling on the back.
Diagnosis
Signs and symptoms of spinal injury include:
• Pain (highly suggestive of bony injury)
• Swelling
• Bruising (rare and usually late)
• Irregularity in the spine on palpation (a ‘step’) – occurs in only 10% of cases).
Sensory disturbances from spinal cord injury are even wider in their spectrum:
• ‘Pins and needles’ (paraesthesia)
• Electric shock-like pain at the moment of impact with no other indicator that injury has taken place
• Disturbances of proprioception, where the patient feels he or she is still in the same position as at the moment of impact, despite clearly now lying in another
• Burning pains through both arms or both lower limbs.
Burning pains in the upper limb are seen in motor vehicle deceleration accidents. In the lower limbs, burning pains are associated with ‘hyperpathia’ (touch registers as pain), seen most frequently in conus injuries.
Minor degrees of sensory or motor loss are frequently described by patients either in terms of ‘clumsiness’, ‘stiffness’ or ‘heaviness’ and such complaints must always be treated seriously.
Patients who have congenitally abnormal spines or diseases such as ankylosing spondylitis or rheumatoid arthritis do not require the same degree of force to produce a cord injury as those with a normal spine.
Assessment
• Any patient who is unconscious as a result of a head injury (or who could have had a head injury in association with unconsciousness) and any victim of trauma who is unable to give an account of the accident (e.g. through intoxication) must be regarded as having a spinal cord injury until proved otherwise
• It is essential to have a high index of suspicion. If the situation suggests that there could be a spinal cord injury the patient must be treated as if there is
• When a history is available and clearly excludes the possibility of a spinal injury or when it is apparent from the injury mechanism that a spinal injury has not occurred, immobilisation of the spine is not necessary.
Neurological examination at the accident site should not be detailed. In motor terms, attendants should be looking at voluntary power, e.g. bending large joints normally. It is important to observe whether the chest wall moves during breathing or whether it is the diaphragm alone which is responsible for respiratory effort (diaphragmatic breathing, see below).
• Do not let the patient get up
• Do not allow others to get the patient up
• Do not get the patient up yourself. Think spinal cord injury!
Sensory levels
• Root of the neck is C4
• The nipple line (in the male) is T4
• The umbilicus is T10
• Foot (sole) is S1.
Immediate management
Because of the risk of anoxic damage and damage from underperfusion, catastrophic haemorrhage <C>, airway (A), breathing (B) and circulation (C) must take priority over a cord injury or a potential cord injury.
The problems found in a primary survey are not only life-threatening but will inevitably make any spinal injury worse. Careful horizontal movement (e.g. a properly applied ‘log roll’), will prevent further permanent damage.
The patient should be moved as little as possible.
Causes of deteriroration in established or suspected spinal injury
• Hypoxia from underventilation, airway obstruction or lung damage either as a result of associated injuries or from aspiration of vomit
• Underperfusion from reduced cord blood flow which may be due to positioning (e.g. sitting up) or to shock
• Mechanical displacement of vertebrae
• Displacement of vertebral fragments.
Reasons for missing a spinal injury
• Stress leading to endorphin release distracting injuries elsewhere or between release and distracting injuries
• Central nervous depression from brain injury
• Intoxication from alcohol or drugs
• Uncooperative or aggressive behaviour.
Emergency extrication
Emergency extrication, that is, without the availability of appropriate extrication devices or the assistance of relevant emergency services, is justifiable only when there is an immediate threat to life.
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