The Acute Management of Spinal Injuries

The types of trauma most likely to result in spinal fracture and neurologic deficit are: automobile, motorcycle, ATV (all-terrain vehicles) and snowmobile accidents, diving injuries, cave-ins, all codes of football and falls from heights. With a head injury or in any unconsciouspatient, assume that there may be a spinal injury.

All head injuries should be considered spinal injuries until proven otherwise.

3. When to Transport

All patients with recognised spinal injury are candidates for transport to a Spinal Unit. Transport should take place as soon as spinal injury is recognised and immediate life-threateningproblems, such as airway compromise and haemorrhage have been stabilised. Definitive care for associated injuries should, in most instances, be deferred until after transport to the SpinalUnit.

B. STABILISING AND PREPARING THE PATIENT FOR TRANSPORT

Immediately following an acute traumatic spinal cord injury, hypotension and hypoventilationmay threaten life and/or increase the extent of neurological impairment. Therefore, cardiorespiratory resuscitation and stabilisation of all other life-threatening injuries are thefirst steps in the treatment of acute spinal cord injured patients. Resuscitation techniques must at times be modified to ensure that any spinal fractures remain as stable as possible, so that further neurological damage does not occur. The aim is to transport the patient in the supine position.

2. Respiratory Insufficiency

(a) Establish Airway
(with cervical spine control)

Injuries of the cervical spine are commonly associated with airway obstruction and hypoventilation. If the patient is unconscious, the tongue may passively fall backward occluding the oropharynx. Airway patency can be restored by either the modified jaw thrust manoeuvre or by pulling the mandible forward (without inadvertently extending the neck) and then inserting an oropharyngeal airway over the tongue, whilst an assistant maintains the head in the NEUTRAL POSITION. Hypoventilation is common in patients with thoracic injuries and loss of respiratory musculature.

Ventilatory assistance may be required in these patients, usually with tracheal intubation. Measuring and recording the patient's Vital Capacity is very helpful.

A semi-rigid cervical collar such as the Stifneck collar should be applied as soon as cervical injury is suspected.

Steps in intubation (oral) are:
(i) Pre-oxygenation: 100% 02 via bag and mask
(ii) Cricoid Pressure: during pre-oxygenation and until intubation is complete (to prevent regurgitation and gastric insufflation).
(iii) Manual Axial Support (NOT TRACTION) by an assistant holding the head in the NEUTRAL POSITION throughout.
(iv) Oro-tracheal intubation in the usual manner.
(v) Blind Nasal Intubation may be performed by a suitably experienced anaesthetist.
(vi) A surgical airway (cricothyroidotomy or tracheotomy) is an emergency alternative when intubation is not possible.

NB. A retropharyngeal haematoma associated with a major injury of the upper cervical spine may also cause upper airway obstruction and necessitate intubation or creation of a surgical airway.

(b) Oxygen Therapy

Determination of arterial blood gases via oximetry or invasive means is an essential part ofthe initial management of cervical and thoracic spinal cord injuries. Because of local oedema and haemorrhage, spinal cord oxygen tension may quickly fall below normal tissue requirements even without systemic hypoxaemia.

Systemic hypoxaemia may increase the severity of a spinal cord injury and attempts should bemade to maintain arterial oxygen tension at or above 80mmHg

Oxygen should be delivered by a high concentration mask (50-60% unless contraindiated by chronic respiratory illness) using 100% oxygen at high flows (10-12 litres per minute). In the absence of high concentration masks or a non-rebreathing mask, a Hudson mask will suffice. If oxygen supplementation by face mask is inadequate, careful intubation and ventilatory assistance is indicated.

The use of Hyperbaric Oxygen Therapy is an additional treatment modality aimed at preventinghypoxia at the tissue level, and should ideally be commenced WITHOUT DELAY (preferably within afew hours).

(c) Ventilatory Assistance

The most reliable sign of impending ventilatory decompensation is a respiratory rate greaterthan 35 per minute. Ventilatory assistance should be considered before the patient's respiratoryrate gets this rapid. Altered consciousness, apparent drug or alcohol intoxication, systemic hypoxaemia or hypercarbia (CO2 over 40mmHg) are also indications for assisted ventilation. Endotracheal intubation is recommended for any patient requiring ventilatory assistance.

(d) Chest X-ray

Radiographic evaluation of the chest is essential prior to transport of any patient with cervical or thoracic spinal cord injury, because of the frequency of associated chest injuries,particularly pneumothorax. If a pneumothorax is present, a chest tube must be inserted beforetransport. A Heimlich valve is mandatory.

3. Circulatory Insufficiency

(a) Differentiate Hypovolaemic from Neurogenic Shock

In cervical and thoracic spinal cord injuries, Neurogenic shock with bradycardia and hypotension are common. In Neurogenic Shock, unlike Hypovolaemic Shock, the pulse rate isslow and of good amplitude and the skin is usually warm and dry except if the patient has been exposed to a cold environment (see 5). Tachycardia and clammy skin are seen inhypovolaemia.

Neurogenic and Hypovolaemic shock may coexist.

When this happens, Neurogenic shock exacerbates the effects of Hypovolaemic shock by disabling the vasoconstrictive reflexes that ordinarily preserve blood flow to vital organs.

(b) Intravenous Lifelines

Two intravenous lines, preferably 14 or 16 gauge, should be established for administration ofresuscitation fluids and medications.

The maintenance of tissue perfusion cannot be over-emphasised. Spinal cord ischaemia may be due to hypotension (either from spinal shock or hypovolaemia) and can cause increased cord damage and extend the neurological deficit.

In the absence of overt Hypovolaemic shock, Hartmann's solution should be infused at a rate sufficient to maintain a systolic blood pressure of above 80mm Hg, generally 50-100ml per hour.Pressor agents are rarely necessary and should be administered only if the central venouspressure indicates satisfactory intravascualr volume. Neurogenic Shock with associated Hypovolaemic Shock should be treated with Normal saline or Hartmann's solution in order to increase the intravascualr volume and blood pressure. Intractable hypotension should raise the possibility of concealed internal haemorrhage. Sinus bradycardia down to 50 associated with cervical spine cord injury does not require specific therapy. With rates below 50, nodalor ventricular "escape" rhythms emerge that can be corrected with Atropine (0.5-1.0mg)administered as often as necessary up to 2.0mg per hour.

NB. normal quadraplegic BP range 80/40 - 100/60

DO NOT FLUID OVERLOAD: Cord oedema and reduced perfusion will result.

4. Spinal Splinting

The key to proper management of spinal trauma is to recognise that an unstable spine may exist. Patients who arrive in the emergency department with neck already immobilised in the supine position should not be removed from the spinal splint until the extent of the injury is determined. Inadvertent movements of the neck must be prevented during resuscitation. The preferred means of rapidly and safely immobilising the neck from flexion and extension is to apply a semi-rigid cervical collar, such as The Stifneck. Lateral cervical immobilisation also needs to be maintained. This can be accomplished using blanket rolls, ablanket halo, Russell Extrication Device (R.E.D) or other type of immobilisation boards.

5. Impaired Temperature Regulation

The temperature of patients with cervical spinal cord injuries tends towards that of their immediate environment (Poikilothermia). Body temperature should be determined regularly (orallyshould suffice), and in most acute cases the patient should be kept covered and warm. "Space blankets" can be of great value in these instances.

6. Internal Injuries

Loss of sensation over the thorax, abdomen or limbs is often associated with altered sensation from abdominal viscera or skeletal structures. Thus, injuries to all but the most caudal segments of the spinal cord may abolish the spontaneous pain, tenderness to palpitation,local guarding, or generalised rigidity which are often present with other intraabdominal injuries. Spinal cord injury alone can also produce the auscultatory and radiographic signs of ileus, within 30mins-48 hours of injury. Patients should be transported supine with a NasogastricTube on continuous drainage (with suction if required).

Hypotension combined with tachycardia is seldom, if ever, attributable solely to spinal cord injury.

In the absence of other overt sources of haemorrhage, investigation of potential abdominal sources of haemorrhage by diagnostic peritoneal lavage or CT should be undertaken under these circumstances, as well as a secondary survey of other systems for missed sources.

C. NEUROLOGICAL EVALUATION

The physician that first sees the patient should document the extent of the initial neurological deficit and determine the presence of any associated injury to the vertebral column.

1. Diagnosis of Spinal Cord Injury

Signs and symptoms of spinal cord injury are usually readily apparent in the alert patient, but can be obscured by altered consciousness. The following clues should alert the physician tothe possibility of a spinal cord injury in an unconscious patient.

(a) A cervical spinal cord injury should be suspected if an unconscious patient grimaces, vocalises or opens his eyes in response to pinching the border of his trapezius muscle but doesnot move his limbs. Similarly, a patient who moves both arms but neither legs in response to noxious local stimuli may have a spinal cord injury below the cervical level. Corroborative findings often include hypo- or areflexia and flaccidity of the paralysed limbs, a flaccid analsphincter, or priapism.

(b) "Paradoxical Respiration"

In this condition, the thoracic cage, although stable, passively collapses with inspiration (as the diaphragm contracts) and expands with expiration (as the diaphragm relaxes) in a reversal of the normal cycle of thoracic ventilatory movements. This pattern of breathing shouldbe looked for carefully and differentiated from bilateral flail chest, in which there will be instability of the chest wall.

(c) Hemiparesis opposite pinprick hemianaesthesia suggests cord injury. Both head and spinal injuries can cause hemiplegia, but only spinal injuries routinely produce contralateralhemimotor and hemisensory deficits. (Brown-Sequard Syndrome).

(d) In a cervical injury where central fibres only are damaged, the Central Cord Syndromeresults (upper limbs paralysed, lower limbs less/not affected).

2. Documentation of the Extent of Neurological Deficit

Management of spinal cord injured patients depends to a large extent upon whether the patienthas a Complete or Incomplete physiological transsection of the spinal cord, and ifincomplete, whether the neurological deficit is progressing or resolving with the passage of time. The first step in determining whether the patient is deteriorating, improving or stable is to question him/her (and ambulance personnel or members of the rescue squad) about limb movement and sensation immediately after the injury.

(a) Complete v Incomplete

Complete spinal cord injury is characterised by no voluntary movement and no sensation of any type below the level of the spinal cord trauma. With any sparing at allof motor or sensory function below the level of the spinal cord injury (Incomplete lesion) the prognosis of future return of function is much more favourable.

The level of spinal cord injury is designated at the last (or highest) fully intact myotome or dermatome.

(b) Motor Examination

Examining physicians should identify the highest spinal cord motor segment associated with normal voluntary motor function and then determine whether any voluntary motor functions below this level has been spared. The movements commonly used to test the integrity of spinal cord myotomes and roots are listed below.

(c) Sensory Examination

The physician should determine the upper level of sensory deficits as well as any areas of intact or spared sensation below this level. Areas commonly tested include the clavicle (C4), lateral aspect of the arm (C5), forearm and thumb (C6), middle finger (C7), little finger (C8), medial aspect of the arm (T2).

The nipples approximate the T4 level (but remember that the cervical plexus can supply this area: confirm with motor examination) and the umbilicus, T10.

The inguinal ligament or groin crease corresponds to L1, the knee to L3, the medial aspect ofthe dorsal of the foot to L5 and the lateral aspects to S1.

The perineum and perianal areas are innervated by S4 and S5. Anorectal sensation can be evaluated as part of the digital rectal examination. It is of particular importance to determineany areas of intact or spared sensation on the buttocks, perineum or genitalia as this is often the only sign that a spinal cord injury is less than complete.

(d) Reflex Examination

Reflexes are usually absent at first. Reflex activity returns from hours to weeks after injury. Reflex perianal muscle contraction usually returns before peripheral deep tendon reflexes. Anal tone is tested by digital rectal examination, and reflex by stimulating the perianal skin, perineal reflexes by pinching the glans or base of the penis (bulbocavernosus reflex), or by tugging on the urethral catheter. When reflexes are found to be intact, test for preservation of voluntary motor and sensory activity in the same sacral spinal cord segments.

(e) Sphincter Examination

Digital rectal examination is an important part of determining the extent of spinal cord injury. If the patient can feel the palpating finger, or if he can voluntarily contract his levator muscles around it, then he has an Incomplete lesion.

D. RADIOGRAPHIC EXAMINATION

Transport should not be delayed unduly awaiting x-rays.

In the initial evaluation of patients with signs of spinal cord injury, a detailed radiographicexamination is usually much less important than a detailed neurologic examination. (The conversemay be true when osseous or ligamentous spinal injury is suspected in the absence of signs of injury to the nervous system.)

Basic radiographic studies of the spine will include:

1. Cervical Spine

The full cervical spine series consist of a cross-table lateral, anterior-posterior and bilateral oblique views, and an open-mouth odontoid view.

(a) In the cross-table lateral view, all seven cervical vertebrae MUST be visualised.This may be facilitated by gently putting traction on the wrists to lower the shoulders as muchas possible, without causing or increasing pain or producing neurological deterioration (in a conscious patient). If this is still not possible, a "Swimmer's" view, taken through the axilla with the arm abducted may help visualise C7-T1, or a CT scan should be obtained.

(b) The antero-posterior view helps evaluate lateral and rotatory dislocations.

(c) The odontoid view, which can be obtained only in a conscious patient, visualises the odontoid process and demonstrates the lateral atlantoaxial (C1-C2) articulations.

(d) Bilateral oblique views demonstrate facet disarticulation and locking.

2. Thoracic Spine

Lateral and artero-posterior -- All 12 vertebrae should be visualised.

3. Lumbo-sacral Spine

Lateral and antero-posterior -- All five lumbar vertebrae and the sacrum should be visualised.

4. Chest

A supine antero-posterior view of the chest is important to rule out associated chest injuries. (The standard PA view obtained with the patient sitting should not be attempted.) Inspiratory and Expiratory views should be taken if pneumothorax is suspected.

Major spinal cord injuries may be present even though there is not radiographic evidence of damage to the vertebral column. Radiographs do not show the extent of bone displacement that may have existed at the moment of injury as the result of ligamentous instability and even CT scan may not visualise the injury.

E. TREATMENT

A primary goal of early therapy is to decompress the spinal cord by restoring the normal sagittal diameter of the spinal canal. Reduction of a partial or complete dislocation (subluxation) may also reduce pain. Ideally, closed reduction of a cervical dislocation can be accomplished promptly by skeletal traction in experienced hands. Only physicians familiar with techniques of applying skeletal traction should consider carrying this out prior to transport.It may not be desirable or necessary when prompt, early transport to a Spinal Unit is available.The cervical spine should be kept immobilised in a semi-rigid collar such as the Stifneck until the patient arrives at the definitive treatment centre wherereduction can be accomplished.

Post-traction radiographs must be taken.

2. Steroids

Steroids should not be administered in the hope that they will ameliorate spinal cord injury. Glucocorticosteroids in the treatment of acute spinal cord and/or head injuries have now been shown to have no therapeutic effect on patient outcome, and have undesirable side-effects. These findings are based on recent and well documented studies.

3. Visceral Paralysis

(a) Bladder Catheterisation

Urinary retention promotes ureterovesical reflux and overdistention of the bladder. Intermittent catheterisation is not the urinary drainage method of choice during the early post-injury period, as continuous monitoring of urine output is essential in the initialevaluation of multiple injured patients and is always necessary during transportation. A normal Foley catheter should be inserted under meticulously sterile conditions.

Prior to the introduction of any type of urinary catheter, a rectal examination for occult blood and prostate displacement should be performed on the multiply injured male patient to rule out membranous urethral injury that could be aggravated by catheter placement.

(b) Gastric Drainage

Ileus is common following injuries of the cervical or upper thoracic spinal cord. In order toprevent aspiration of gastric contents and/or gastric dilatation that interferes with breathing,gastric decompression and drainage with a nasogastric tube is recommended. A decompressed upper bowel will also prevent venous back-pressure from further jeopardising spinal cord perfusion. It is essential before transport. Nasogastric tube (NGT) is contraindicated only in patients with severe facial injuries and/or basilar skull fractures, in which case, orogastric insertion is recommended.

4. Other Medications

Anti-emetic medication may be given immediately prior to air transport for nausea control. Small amounts of narcotic analgesic medications can be given intravenously for pain management, bearing in mind monitoring of consciousness. Pupillary reaction should be present even when constriction is present, and dilation will still occur with raised intracranial pressure. Medications administered should be documented in the transport record.

5. Hyperbaric Oxygen Therapy

For some cases, the delivery of oxygen under pressure in a Hyperbaric chamber may further alleviate tissue hypoxia. Most Spinal Units now have access to such a facility on-site, and it should be instituted as soon as possible after the injury, preferably within 8 hours.

6. Preventing Pressure Sores

Attention should be paid to pressure relief for the skin over bony prominences, particularly the sacrum and heels. The patient may be lifted briefly, by at least 4 persons, plus one supporting the neck, or a device such as the Jordan Frame, every two hours. A sheepskin or foam pad, or "Sof-care" mattress (wheelchair size only), can be inserted under the sacrum by carefully lifting the pelvis. Foam or sheepskin heel padding should be used routinely.

Spinal boards should be used for the shortest, practicable periods of time, and the slats of the Jordan Frame removed between uses to prevent pressure areas. The neck should be supported for all lifts until cervical injury has been ruled out. Keys and money should be removed from the pockets, and ideally all clothes should be removed - cut off if necessary.

F. TRANSPORTING THE "SPINAL PATIENT"

Whenever possible, spinal injured patients should go direct to Spinal Units from the field, as time may be critical. Likewise, a speedy dispatch from the peripheral hospital is an essential link in the treatment chain. For interhospital transfers further than 10km and within 200km of the Spinal Unit, Helicopter transfer is indicated.

The benefits are:

1. High speed 150km/hr direct door-to-door delivery, without "traffic" nor the need to disrupt the traffic flow with Ambulances travelling at slow speeds.
2. Minimising the number of times the patient is handled, lifted or moved.
3. A doctor trained in Spinal Cord Injury management can accompany each patient. This is particularly important when the SCI is not isolated but part of a multiple-injury scenario.
4. Low vibration in the helicopter (unlike road vehicles and even fixed wing aircraft) minimises further tissue trauma.
5. Time, time, time... reperfusing the cord is critical.

Before transport the following important matters should be confirmed:

1. The airway is clear and "guaranteed"
2. Ventilation (either spontaneous or assisted) is satisfactory. Supplemental oxygen is being administered. Endotracheal and other tubes are securely attached to the patient.
3. Neurological assessment is completed and documented.
4. Chest x-ray is completed, examined and preferably reported by a radiologist.
5. Blood pressure is stable and IV lifelines are established.
6. The stomach has been decompressed with a NGT.
7. Urinary bladder drainage has been established.
8. The entire spine has been immobilised securely for transport in devices such as the R.E.D (Russel Extrication Device) and Stifneck Collar.
9. Pressure on the skin over bony prominences has been relieved.
10. Spinal Unit has accepted patient and Retrieval Team notified.