Neck and Spinal Trauma

Question 1

Define Neck Trauma
penitrating neck trauma
zones

Answer 1

Penitrating Neck Trauma: anything that violates the platysma

Anatomical Zones of the Neck
Zone I: suprasternal notch & calvicale boarder –> inferior cricoid cartialge

Zone II: inferior cricoid cartilage to the angle of mandible the worst

Zone III: angel of manidble to base of skull

Question 2

Penitrating Neck Trauma
- evaulation of airway
- vasculature evalauation
- esophageal evaulation

Answer 2

Evaluation
- knives, bullets, FB = left in place beucase they can provide local tamponade
- CT is done to assess injury
- surgery used to be standard ofc are –> now selective (usually only for zone II injuries is exporatory surgery needed)

Evaluate airway
- look for leak, PTX, air in mediastium
- often = need endotracheal or surgical airway
- should do a bronchosopcy to evalute airway
- often need C-collar stabilization

Vasucalture Evaluation
- bleeding control
- hematomas can compromise airway
- need to identify injury via angiogrpahy or CT angio
- nerve injury needs to be assessed to for focal deficts

esophageal evaluation
- often esophagus can be aymptomatic but lead to nek space infections or mediastinitis
- crepitus, hematemesis, NG-tube blood etc. can be signs
- water-soluable contrast esophagram can evaultae damage

Question 3

Blunt Neck Trauma
- types of injury
- imaging

Answer 3

Types of Injury
- blunt trauma = tracheal, laryngeal and c spine injuries
(less likely will these have vascualr or esophagela injuries)
- if they do; shearing vessels (break apart)
- Carotid and vertebral arteries shear = hematoma, dissection or CVA

Imaging
- CT PLAIN
- if all injury can be ruled out these pts. can be d/c

Question 4

Spinal Truama
Etiology
Assessment of spine

Answer 4

Etiology
- spinal cord or spinal nerve root injuries
- bone injuries to spine
- deceleration MVAs, compression (diving)

the pt. who presents with significant head trauma, unconscious, neuro deficts or spinal tenderness = assume C-spine trauma untile ruled out

Assessment
- Primary survery: when assessing airway can assess C spine
- spinal immobilization should be done
- mechanism will guide type of imaging

How to Assess
- inspect for step-offs, tenderness, edema, brusing, muscle spams
- through neuro exam
- arm abduction (C5,C6) & elbow flextion
- Wrist Extension (C6,C7)
- Elbow extension (C7, C8)
- Finger abduction (C8, T1) & Hand Grip
- Hip flexion (L1, L2, L3)
- Knee Extension (L2, L3, L4)
- Knee Flexion (L4, L5, S1, S2)
- ankle dorsiflexion (L4, L5)
- big toe extension (L5, S1)
- ankle plantarflexion (S1, S2)
- Rectal Tone (S2, S3, S4)

Question 5

Spinal Trauma: C Spine
how is Imaging guided
criteria?

Answer 5

NEXUS criteria & Canadian cerical spine rule decide who need imaging

NEXUS
- absent tenderness in posterior midline
- no intoxication
- GCS = 15
- no neuro deficts
- no painful injuries

anyone who fails this: gets imaging

Canadain C spine= also takes into account the mechanism of injury and teh examination findings

(neither for peds!!!)

Imaging
CT is the test of choice
- plain film xray can help but they miss c-spine fractures
- MRI can he used in those with negative CT but have signs of a SC injury

Question 6

C-Spine Fractures

Answer 6

Etiology
- due to hyperflexion (chin to chest)
- axial loading (diving) or hyperextension (MVA)

Classification
- stable or unstable: depends on the 3 columns of the SC
- anterior column : anterior ligament, anterior aspect of vertebra & anterior disc
- middle column: posterior ligament, posterior verebra, posteriod disc
- posterior column: the pedicles, trasnverse processes, laminae and teh posterior ligamentous complex

inturruption of 2+ of these columnc = UNSTABLE C-Spine

Question 7

C-Spine Fracture
Occipital Condyle fx.

Answer 7

UNSTABLE: need CT + neruologic deficts
- a fracutre of the base of the skull and articualtion with the C1
- three types (dont need to know)

Question 8

C-Spine Fracture
Jefferson Fx.

Answer 8

UNSTABLE
- fracture of the C1 (atlas) due to compression type injury displacing the lateral aspects of C1 to the sides

(a burst of C1)
- on xray: odontoid view: see the fx.

Question 9

C-Spine Fracture
Odontoid Fracture

Answer 9

UNSTABLE (usually)
- a fracture of C2 dens
- neurologic deficts

3 types
type 1 : avulasion of the tip
type 2: fracture at the base
type 3 : fracture line extends to the body of C2

Type II and III are unstable

Question 10

C-Spine Fracture
Hangman’s fracture

Answer 10

unstable
- fracture of teh pedicles of C2 bilaterally: so teh spinous processis completelt removed
- due to MVA (or hanging…) and hyperextension (backward)

Question 11

C-Spine Fracture
Burst Fracture

Answer 11

unstable
- cord disruptuion
- a burst fracture = C3-C7 shattering of teh vertebral body
- due to axial loading (head-firsy dive)
- causes retropuslion of the pieces : impacting the SC
- disrupting middle and anterior columns

Question 12

C-Spine Fracture
Clay Shoveler’s Fracture

Answer 12

Stable : an avulsion fracture of teh end of teh spinous process of the lower cervical vertebrae

• due to abrupt flexion of the neck
• the ligaments essentailly are pulled so tight they pull the bone off

Question 13

C-Spine Fracture
Flexion Teardrop

Answer 13

UNstable
- extreme flexion causes the fracture of the anteriorinferior vertebral body
- these are super unstable as this alos the ligaments in the back to become disconnected from the rest of teh spine

Question 14

C-Spine Fracture
extension teardrop

Answer 14

UNSTABLE
- hyperextension causes the anterior longitudinal ligament to avulse the anteriorinferior portion of the vertebral body to fracture

Question 15

C-Spine Fracture
simple wedge fracture

Answer 15

stable: unless significant ligament issues
- flexion and compression of teh anterior vertebral body get smushed between teh above and below one
- this could inturrupr the posterior lig relaly ad

Question 16

C-Spine Sprain
“Whiplash”

Answer 16

Whiplash
- abrupt hyperextension from MVa usually
- pt = pain, neck spasm and HA
- no neruologic deficts and NO fracture of c-spine

Treatment
- immoblize them with C collar and follow up

Question 17

Spinal Cord Injury
Etiology

Answer 17

Etiology
- commonly co-occur with spinal fractures, etc.
- these pts. ahve permanent neuro deficts
- Primary: SCI as a result of mechanical disruption, transection or distraction of the natural elements = primary = as a result of fracture or dislocation of the spine
- secondary : result of a vascualr, chemical or inflammatory process following a primary injury = like edema or hemorrhage causing decreased blood flow leading to inflammation and continued damange

Question 18

SCI: how is the neurologic imparied decided

Answer 18

the level, location and complete or incompleteness of the injury determiens the outcome of impairment

Complete Lesion = the absence of motor or sensory function below the level

Incomplete Lesion = lesions where there is some motor, sensory or both functions below the level of the lesion

Spinal shock is different: because the inflammation and stuff can temporarily cause complete loss but it can resolve with decreased inflammation

remmeber…
- corticospinal tracts: run laterally (and ventral)
- spinothalamic tract runs ventrally
- dorsal column runs posteriorly
- decending = motor
- ascending = sensory
- spinothalamic: synpase and cross at spinal cord level (pain and temperature)
- dorsal = travel up and cross & synpase at medulla
- corticospinal = cross at medulla travel then synpase at SC

Damange to Corticospinal
- lossof motor function on the ipsilateral side

Damage to the spinothalamic tract
- loss of sensory function on the contralateral side below the lesion level

Damange to the dorsal column
- loss of vibration, proprioception and two point touch on the ipsilateral side

Question 19

SCI
Diagnosic Imaging

Answer 19

Spinal Cord INjruy: MRI is needed to visualize the cord

a complete lesion: can show no motor or sensory function at level and below: if this doesnt return within 24 hours, recovery is poor

Question 20

SCI: Anterior Cord Syndrome

Answer 20

Anterior Cord Syndrome
- corticospinal and spinothalamic tracts are here
- injury = impaired motor and pain/temp. at the level and below
- doral column is preserved

due to…
- mass
- thrombosis of anterior spinal artery
- hyperextension injury

• prognosis and recovery is poor

Question 21

SCI: Central Cord Syndrome

Answer 21

Etiology
- a lesion to the central cord: most often damage to the corticspinal tracts and the spinothalmaic
- +/- effected dorsal column

Symptoms
- the UE fibers of the corticospinal tract are more medial, thus loss to UE&raquo_space; LE
- sensory loss is varibale, more likely affecting pain and temperature

Due to…
- yperextension injruy
- decreased perfusion
- spinal stenosis (squeezed cord with degeneration)

recovery and prognosis is good after decompression

Question 22

SCI: Brown Sequard Syndrome

Answer 22

Brown Sequard Syndrome : lateral cord lesion

If its a lateral lesion = impact all the three spinal tracts but only half the SC

Symptoms
- ipsilateral loss of proprioception & vibration (dorsal)
- ipsilateral loss of motor function (corticospinal)
- contralateral loss of pain and temperature sensation distal to the lesion (spinothalamic)

Due to..
- lateral compression of bone due to injury
- disc protrusion
- hematoma
- mass
- penitrating GSW

Prognosis
- GOOD! with decompression

Question 23

SCI: Cauda Equina Syndrome

Answer 23

not a true spinal cord injury
- affects nerve roots of cauda equina

Symptoms
- bladder/bowel dysfunction
- sadle anesthesai
- decreased rectal tone
- lost motor and sensory of the extremities (lower)

Question 24

what is a SCIWORA?

Answer 24

Spinal Cord Injury without Radiologic abnormalities (SCIWORA)
- can be a tranisent or persistent symptoms of neuro deficts without evildence
- comony in kids sine they have flexible spines
- NEED MRI and neurosurg. evaluation

Question 25

Spinal Shock

Answer 25

temporary loss of spinal reflex activity that occurs below a complete or incomplete lesion

Symptoms
- flaccid quadraplegia - mimic SCI
- can resolve; needs to resolve before a SCI can be diagnoses
- this is different than neurogenic shock because spinal schok causes loss of ALL NEUROLOIGC function while neurogenic shockis just loss of autonomic dysfunction

Question 26

Neurogenic Shock

Answer 26

lack of autonmic function as a result of an injury ABOVE C6 (because this is where the autonmic nerves run)

Symptoms : dysautonmoia occurs
- hypotension
- bradycardia
- peripheral vasodilation

Treatment
- IV fluids to maintain MAP 85-90 x 7 days post injury
- pressors (dopamine, epinephrine, etc.) can be used to help ensure proper perfusion

if bradycardai is bad = atropine !!

Question 27

Treatment of SCI

Answer 27

first — ABCs
- hypotension : IV fluids
- blunt trauma: high dose methylprednisone (not for penitrating trauma!)
- antibiotics for penitrating

Cervical Orthoses: for well-reduced and stable cervical fractures/subluxations

surgical intervention for SCI and unstable spinal injuries

Indications for Surgery
- progressive neurologic deterioration
- spinal instability