September 19, 2019
Neurosurgery – Spinal Trauma: By Richard Fox M.D.

Neurosurgery – Spinal Trauma: By Richard Fox M.D.

Trauma to the spine and spinal cord can occur
in a variety of settings, including motor vehicle accidents, shallow water diving, and
falls. Usually, significant trauma is needed to cause
spinal injuries in young, healthy individuals. However, keep in mind that older patients
or those with pre-existing conditions may have vulnerable bones. These conditions include: Rheumatoid Arthritis
Ankylosing spondylitis Osteoporosis
Cervical spondylosis Suspect serious spinal injury in these patients,
even if the history indicates minor trauma. Management should focus on minimizing risk
of further injury. Always immobilize all patients with suspected
spinal injury. The paramedics will have done this in the
field by putting a cervical collar on the patient and securing the patient to a rigid,
padded backboard with head supports in place. While you carry out your ABCs, make sure to
keep the patient immobilized until you can clear the spine. In fact, if the patient has a head injury
or is confused or complaining of spinal pain, assume a spinal injury or even a spinal cord
injury until proven otherwise, and keep patient immobilized. Failure to do so in the individual with an
unstable spinal injury can result in further neurologic damage. The spine can be cleared if there is absence
of clinical signs, such as midline cervical tenderness and neurological deficits, and
normal radiographs. Following initial stabilization, continue
to monitor the vital signs, keeping an eye out for signs of neurogenic shock. This can occur with injuries above T6 and
manifests as hypotension and bradycardia depending upon how high the injury occurs in the spine. Treatment includes fluid resuscitation, and
vasopressors. Special consideration of airway management
in cervical spine injury is due. High cervical cord injuries may result in
inability to breathe due to diaphragmatic paralysis, thus requiring immediate ventilatory
support. Those with lower cervical injury may not immediately
have respiratory distress because of preserved diaphragmatic function, but develop delayed
respiratory failure due to paralysis of accessory muscles of breathing. Anticipating the need for airway management
in the cervical spine injured patient well ahead of time gives opportunity to enlist
the help of airway experts (anesthesiologist, for example) in a controlled fashion. In the emergency setting, securing the airway
in the most practiced fashion for the individual physician (usually direct orotracheal intubation
with inline stabilization) is best. Spinal injury at levels below the conus (below
L1 usually) may result in compression of the cauda equina. This bundle of rootlets floating loosely in
spinal fluid can tolerate a surprising degree of canal intrusion in trauma. In the patient with lumbar level spinal trauma,
more detailed myotomal and dermatomal examination including perineal sensation may reveal focal
deficits in the patient who at first screening appears intact.

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