S3E12: Bonus: Prof Seamus Morris - Spinal Trauma
Leah sat down with Professor Seamus Morris, Consultant Orthopaedic and Spinal Trauma surgeon at the National Spinal Injuries Unit in the Mater Hospital in Dublin. He is also working at Cappagh National Orthopaedic Hospital and the National Rehabilitation Hospital. He is UCD’s Clinical Professor of Surgery at UCD and Course Director the MSc in Primary Care Orthopaedic and Musculoskeletal Medicine.
Prof Morris is a specialist in complex trauma and spinal surgery and has completed fellowships and training across specialist units in New York and St George’s Hospital in London. He is also an instructor on numerous trauma course faculties including the European Trauma Course.
This conversation is full of important questions that always arise in the Emergency Department regarding the management of the acute spinal trauma patient.
Assessment of the complex spinal patient
As with every trauma, start with the basics and get the ABCs right. So, life threatening and other injuries ruled out and we have a likely diagnosis of spinal cord injury - what now? As we discussed in our main segment, the approach to management of complex spinal patients is all about secondary prevention - nothing can be done to change the primary injury. Everything we do is primary prevention for the remaining neurons that may be viable
Principles of secondary prevention
Optimal oxygenation and perfusion of the area
The specific interventions and how imminently they may be required can be roughly estimated based on the level of injury. For example, in patients with a high cervical spine injury, urgent intubation may be required to prevent further decompensation. Patients with a thoracic spinal injury, while self ventilating, may require tracheostomies and urgent transfer to a spinal center.
MAP >85mmHg
Multiple studies have shown improved outcomes when the mean arterial pressure is kept >85mmHg. This can be a tricky target to achieve, particularly in the context of polytrauma where patients may have other injuries or bleeding which may preclude the use of vasopressors, and when patients are being transferred by road or air to a primary spinal unit. As with all the principles of secondary prevention in spinal trauma, it is important to apply them in the context of the whole patient and their presentation.
Decompress the cord as soon as possible
Time is spine. Studies from animal models have shown that patients have much improved outcomes when operated on within 24 hours vs after 24 hours. Resource limitation can limit the feasibility of this target, and there is a constant re-triage of patients awaiting theatre in the National Spinal Centre based on their presentation and symptomology. Patients with a neurological deficit will be prioritised over those without.
Steroids - to give or not
The NASCIS studies remain our main basis of evidence for the use of steroids in spinal cord injury. They do not provide any significant evidence to support the benefit of steroids for long term outcomes. This coupled with all the known side effects of steroids - ulceration etc is the reason steroids are not used as standard.
So why is MRI so important?
Identification of epidural hematomas which may need to be evacuated
Qualifying damage to the posterior ligamentous complex - damaged or not - helps determine spinal stability
Identification of prolapsed discs in canal. This may change surgical management to a direct open decompression and stabilization rather than a closed reduction.
The key question when considering whether or not to MRI at a tertiary hospital pre transfer, is whether it will delay patient management. If there is a long wait for an ambulance, it would be beneficial to have the images for review, but if logistically the patient can be transferred immediately once accepted, the priority should be getting them moved for definitive intervention.
Determining who needs surgical intervention - The TLICS score
The Thoracolumbar injury classification and severity score is a useful tool to help decide who will need surgical intervention. It is split into 3 dimensions:
Morphology of the injury
Stability of the posterior ligamentous complex
Neurologic involvement
Each of these give a score based on the level of damage. As a general rule, if there is a cumulative score of >4 they will need surgical intervention, <4 they may be a candidate for a brace, and if they score exactly 4 it is at the discretion of the surgeon. Radiopaedia have a fantastic resource on this and the score itself can be found on the neuromind app.
ASIA score
An invaluable score which allows clinicians to quantify the level of neurological injury at the time and monitor for deterioration, which may indicate if surgical intervention needs to be done sooner. It doesn't matter who does the assessment - but it is important that it is done early, and that the person doing the assessment is competent in doing so.
From a prognostication point of view, functional outcomes are markedly different if a patient has an ASIA A vs and ASIA B, and can give an idea early on of the patients long term goals and needs, and can help plan for the care levels needed beyond the acute surgical.
There has been some debate of late regarding whether a DRE is required as part of an ASIA score, and the utility of a bladder scan. A A DRE is critical to determining to assessing if the injury is complete or incomplete. If deep anal pressure absent and sensation in s2 - s4 is absent, it is a complete injury.
Special consideration from an ED perspective - Ankylosing Spondylitis and DISH
Patients in this cohort may present with a simple fall with some neck pain, and x-ray imaging may initially appear entirely normal. These patients can have ossified discs and a brittle rigid spine, thus it is often hard to see the disc space. In these patients it is necessary to have a high index of suspicion and they require a dedicated MRI scan. Missing these injuries is devastating - a missed fracture is associated with a high risk of injury. Up to 75% who are discharged home will come back to ED with a neurological deficit.
