S3E11 - Spinal Trauma - Trauma/Neuro
We’re back with some more spinal trauma for you. Orla re-joins us this month along with Liam and Marike to discuss an unusual case of spinal injury in the ED today. It’s one not to miss. We’re then catching up with Dr. Deirdre Glynn, Consultant in Emergency Medicine at St. James’s Hospital and trauma and POCUS enthusiast.
Check out our learning points below.
Stoicism in the Irish Community
The classic approach of getting a detailed history of before, during and after the event serves us well in a scenario like this. Did the patient, for example, feel light headed, or have chest pain before the tractor overturned? Do they remember how it happened? What did they notice immediately after they fell? In a stoic cohort who don’t often present to the Emergency Department, asking open but focused questions is key to identifying issues and diagnoses.
In this case, the patient reported attempting to return home, but struggling as his legs felt funny, like they "wouldn't co-operate" and he felt lightheaded. Further digging reveals some niggly back pain, but nothing he needs any analgesia for.
Neurological Red Flags and Examination
Several aspects of this history raise concern for a neurological insult, so if the patient hasn't already been put on spinal precautions, they should be now. While our patient appeared clinically quite well on inspection, this case highlights how integral the methodical cABCDE approach is to working these patients up.
This is a presentation of trauma - it should be approached with the same care that would be taken were there a pre-alert for an RTC. Assemble your trauma team and approach as you always would. Having performed a head to toe assessment for life threatening injuries, this patient should have a full neurological exam performed, including....
The Log Roll
Log rolls can be painful if patients have peripheral injuries, and limiting movement is particularly important in patients with unstable spinal fractures. They should be done sparingly, and thus, examination must be thorough and infrequent.
It's important to communicate clearly with the patient before performing a log role. While your team can limit movement through good co-ordination and communication, explaining to the patient that they will be held and cannot fall will reduce patient movement from fear of the unknown.
A senior team member should examine in a log roll and the room must be quiet so the patient can be heard, as the examiner cannot see their face. It should be explained that you will be assessing light and sharp touch at the midpoint of the gluteal fold for S3 and perianally for S4/5. Test sensation on the patient’s sternum prior to the roll so they know what to expect.
Explain the need for an anal examination and that it’s necessary to check their spinal function. Make sure they know that you are going to assess for
1. Deep Anal Pressure - gentle pressure on the rectal wall to assess whether they can feel it or not (present or absent) and
2. Voluntary Anal Contraction - to squeeze around your finger (think of holding in a fart at mass).
An alternative for DAP- can be to press on one side of the rectal wall and ask the patient which side you are pressing on- up or down.
Relevant Clinical Findings
A - Patent airway
B - Chest clear
C - Abdomen is soft with a palpable bladder. eFAST reveals 850ml of urine in the bladder
D - Upper limb exam
Nil of note
Lower limb exam
Loss of all sensation in the T12-L1 distribution only.
2 point discrimination and normal touch sensation decreased in both lower limbs.
Crude touch is still present.
Decreased power ⅗ in all muscle groups
Reflexes - brisk bilaterally. Plantars upgoing bilaterally
Conus Medullaris Syndrome
Usually caused by an isolated lesion at the terminal end of the cord or conus medullaris. This is usually between T12 and L1 in adults. In the context of trauma, it can be caused by retropulsion or displacement of a vertebral fracture. Depending on the mechanism of trauma, this is most likely to be a “burst-type” fracture.
Thoracolumbar burst fractures are a common high-energy traumatic fracture to the vertebra that can cause disruption of the anterior and middle columns leading to retropulsion of bone. They usually occur due to axial loading in a flexed position such as in falls from height or in road traffic accidents. The thoracolumbar junction is quite vulnerable to traumatic injury due to it acting as a fulcrum of increased motion and rotation.
It usually manifests itself as severe lower back pain with bladder and bowel dysfunction. This is usually with urinary retention and loss of anal tone. The bulbocavernosus reflex is initially lost but may return after the acute phase when primary cord oedema begins to settle. Patients often report reduced sensation around the perineum and mild to moderate motor symptoms involving the lower extremities.
Airway or the Highway
Patients with spinal cord injury are at high risk of respiratory compromise, regardless of the level of injury. The act of exhaling is passive, but coughing involves intercostal and abdominal muscles from T1-L2. That coupled with reduced sympathetic innervation to the lungs can lead to increased secretions and respiratory compromise.
These patients should be monitored closely with SaO2, etCO2 and supplemental O2 as required. In the context of rib fractures and pain which may further limit respiration, the role of analgesia cannot be overstated. Make sure analgesia is titrated to good effect. Did we mention analgesia?
Investigation
ASIA. ASIA. ASIA.
See the American Spinal Injury Association ISNCSCI documentation here. This is the international standardised assessment tool for spinal cord injury. It’s vital for emergency department physicians to have this completed fully and thoroughly prior to any transfer as it will go on to be checked subsequently to monitor for any changes over the hours and days to come.
Imaging
CT will be the first step for the diagnosis of the osseous fragment and can show retropulsion into the canal. A normal CT does not rule out a spinal cord imaging. So if suspicion remains, MRI should be performed. It can demonstrate cord oedema and ligamentous disruption that would not show on a CT. In patients who have contraindications to having an MRI, a CT myelogram can sometimes be of assistance but usually this is in accordance with spinal orthopaedics and ultimately, none of these investigations should delay transfer.
Bladder Volume
Get a bladder volume before insertion of a catheter. This is important to establish if the patient is in urinary retention. If this is not possible ensure the amount drained immediately on insertion is documented in the notes. This can be difficult if spinal precautions need to be maintained but at least asking if a patient feels if they need to pass urine is helpful information. In severe conus medullaris syndrome, this sensation is lost and there may be evidence of overflow incontinence.
Management
Management of any spinal cord injury with any neurological deficit especially those demonstrated in conus medullaris syndrome is for rapid discussion with your orthopaedic colleagues or ultimately, a spinal trauma orthopaedic centre. Early decompression of these fractures result in better outcome for patients and time is cord. However, depending on the clinical situation, there may be thoughts towards conservative management. In this case,
Pearls and Pitfalls
Aim for a slightly higher MAP with 85mmHg in order to maintain cord perfusion in traumatic injuries. Check in with spinal colleagues because this should be used with caution in the case of haemorrhage into the cord region.
NASCIS Trials (National Acute Spinal Cord Injury Study II and III) did show some evidence and support for the use of IV methylprednisolone but it’s controversial. Consult Orthopaedic or Spinal services to see what they want if there is going to be a delay to transfer.
Minimise rolling. Preferably a senior clinician should be examining the back and if there is any evidence of trauma or skin breakdown, document and sometimes use clinical photography if appropriate.
Inability to perceive pain can mask distal injuries - careful examination of the lower limbs is crucial, and have a low threshold for imaging if there is a clinical suspicion
Get a collateral history from a family member of an older person in trauma especially as they may report to you whether the patient is at their baseline in terms of any weakness.
Secondary prevention is key
Early diagnosis and maintaining a high degree of suspicion is vital
Maintain normothermia, normoxia and avoid hypercarbia
Insert an arterial line where appropriate for regular arterial blood gas sampling
Aim for normal electrolytes such as sodium and good glycaemic control
Analgesia is essential not optional. This is not a PRN situation. Get a good baseline of analgesia and consider top-ups there after.
Reverse anticoagulation and discuss with haematology where appropriate. Although there may not be signs of bleeding elsewhere, bleeding from a fracture site can cause a haematoma which would result in further cord compression and deterioration in neurological function.
Talk to the patient.
They suspect what’s going on and they are terrified. They can hear you.
Involve them in the conversation.
Spinal Cord Syndromes
Central Cord Syndrome
This is a spinal cord syndrome that is more common than conus medullaris syndrome. It usually occurs in elderly patients who have had a fall with a hyperextension injury to their neck. It can also be seen in those younger than 50 in high-speed RTAs or assaults. It is an incomplete spinal cord injury. In some cases, it can be caused by a cervical spine fracture or an osteophyte with displacement and ligamentous disruption but it can also occur due to tumours or formation of fluid filled abscesses or syrinxes in the spinal cord.
It results from an injury to the lateral corticospinal tracts which are responsible for pain and temperature sensation predominantly for the hand and forearms. Classically, CCS presents with weakness in the arms > legs. There can be some bladder dysfunction.
The prognosis for this is fairly good over a 1-2 year period. However, many patients go on to experience a persistent neuropathic pain and difficulty initiating voiding. MRI Cervical Spine is the most sensitive investigation for central cord injury.
Brown Sequard Syndrome
Brown-Séquard Syndrome is usually caused by a penetrating injury resulting in a hemi-section of the cord. That patient injures their ipsilateral dorsal columns and corticospinal tract and contralateral spinothalamic tract. This results in ipsilateral loss of motor function and proprioception or vibration. They have also lost contralateral pain and temperature due to decussation.
Collars?
Collars are controversial to say the least. Many suggest that they actually do very little to immobilise the spine. Instead, they can cause intraacranial hypertension and agitation and distress. Lying patients flat for a long period of time is also associated with higher rates of delirium and pressure sores. We definitiely avoid them in the older person. For patients who have a suspected cervical spinal cord injury and are holding their neck in flexion, do not try and lie them flat. They may have a background of ankylosing spondylitis or
