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Evaluation and Management

  1. Unconscious patient
    1. Observation of spontaneous motion in an extremity
    2. Respiratory effort made with intrathoracic musculature versus abdominal musculature
    3. Response to painful stimuli
    4. Spinal (superficial & deep tendon) reflexes
  2. Conscious & Co operative patient
    1. Spinal tenderness
    2. ASIA (sensory & motor) scoring
    3. Rectal examination including touch, pinprick & deep pressure sensation, resting sphincter tone, maximum voluantry contraction & reflex contraction (bulbocavernosus & anal wink)
    4. Superficial & deep tendon reflexes.
  3. ​Initial Evaluation And Emergency Care In Spinal Trauma
    1. All the trauma patients are at risk of spinal injury.
    2. Many of the spinal injury patients are multiple trauma victims and therefore require emergency treatment.
    3. The treatment priorities are preserving life (1st), limb, and function. The spine must be protected as these priorities are addressed sequentially. (i.e. undue movements of spine are avoided).
    4. The ABCs of trauma are followed in order of priority, with airway ventilation and circulation being secured before further evaluation proceeds.
    5. Throughout the evaluation of other body systems, the cervical spine should be presumed to be injured and thus immobilized to avoid further neurological injury.
    6. Proper extrication of the patient and immobilization of cervical spine at the accident scene are critical to avoid further neurological injury. The head and neck to be aligned with the long axis of trunk and immobilized in supine position.
    7. Cervical extension should be avoided because it narrows the spinal canal more than flexion. Neutral flexion-extension head and neck alignment is optimal during prehospital transport of patients with cervical spinehinjury.
    8. Helmet & shoulder gear should be left in position until personnel trained in safe removal technique are available.
    9. After all life threatening injuries have been identified and stabilized, the secondary evaluation, including an extremity examination and neurological examination, can be safely carried out.
    10. When a spinal cord injury is suspected methyl prednisolone (steroid) should be started. Most benefit occurs in the first 8 hours, and additional effect occurs with in first 24 hours.
    11. The dose of methyl prednisolone is 30mg/kg loading dose + 5.4 mg/kg/hour x23 hour.
    12. When a medical center is reached, if a definitive cervical spine injury is identified & deemed unstable, skeletal traction for immobilization, reduction or both may be applied (eg. Gardner - wells traction, Halo traction etc)

Concept & Protocol of Definitive Management of Spinal Injuries

  1. Stable spine No neurological deficit
    1. Treated conservatively by 2 hourly turning routines, skin toilet, bladder & bowel care and specialized physiotherapy & occupational therapy
    2. During this period cervical spine is immobilized by cervical skeletal traction (6 weeks) followed by/or SOMI brace or philadelphia collar (6weeks)
    3. Bracing is continued until bone healing is sufficient for load bearing: 8 weeks in cervical injuries and 12 weeks in thoracolumbar injuries.
Spontaneous bony fusion is achieved -Discard collar /brace
No bony fusion & Spine is unstable -Spinal fusion (arthrodesis)/Instrument fixation
  1. Unstable spine Neurological deficit present
    1. Associated with Malalignment (subluxataion / dislocation)
    2. Close reduction by cervical traction as early as possible can achieve decompression & is the treatment of choice for alert, co operative patients
    3. In these patients MRI is not necessary before reduction and should not delay reduction
    4. Reduction in an unconscious or unexaminable patient should be preceded by an MRI scan. In this situation presence of an herniated disc may be treated with surgical decompression before reduction.
  2. Highly unstable injuries, such as
    1. Craniocervical dissociation
    2. Injuries with complete ligamentous disruption
    3. Distraction injuries
    4. Require compression for reduction, not further traction.
      Cervical traction in these patients will lead to catastroptic neurological deterioration or even fatal vascular injury. Reduction & compression is achieved by halo vest apparatus
  3. ​Definitive Treatment  
    1. Closed treatment remains the standard of care for most spinal injuries. The only consistent indications for surgical treatment are
    2. Skeletal disruption in the presence of neurological deficit
    3. Unstable purely ligamentous spinal column injury in skeletally mature patient.
    4. If neurological loss is incomplete and progressive
    5. Surgical options are - Arthrodesis with two rare exceptions: odontoid fractures & C2 fractures (these are treated with internal fixation (osteosynthesis).
  4. ​Vertebroplasty or kyphoplasty is
    1. percutaneous injection of bone cement (PMMA = polymethy methacrylate) into vertebral body.
    2. It can be used for osteolytic spinal metastes, multiple myleoma, aggressive hemangiomas, vertebra compression fractures. Its use has been recommended for patients with short life expectancy or in salvage cases. Contra-indications are infection or Tuberculosis.

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