Spine Flashcards
(39 cards)
How to clear a c spine in a trauma patient?
CT scan -ve is key in an unconcious patient
O/E no pain/tenderness
No neurology
Assess all movements of the c spine
What are spinal precautions in a trauma patient?
Blocks and collar
Log rolling
Hospital bed
Full lower limb neuro +ASIA monitoring
Saddle anaesthetesia + Anal tone
What are differentials for a patient with a spinal injury and decreased urine output?
Pre renal/ intrinsic/post renal causes
Cauda Equina
Shock- hypovolaemic/neuological
Pain
Urological trauma
What makes up the intervertebral disc?
Soft centre- neucleus propulsus
Firm outer ring- annulus fiborsis
Parts of the a vertebral body?
https://upload.wikimedia.org/wikipedia/commons/thumb/7/7c/Vertebra_Superior_View-en.svg/1200px-Vertebra_Superior_View-en.svg.png
Remember Lamina and pedicles
Pedicles lateral boarder of vertebral canal
What are the spinal column ligaments?
5 in total
Ant Longitudinal Lig
Post LL (Runs along post boarder of vertebral body
Lig Flavum- post aspect of spinal canal
Interspinous- connects spinous process bodies
Supraspinous lig- connects tips of spinous processes
What comprises the Posterior Ligament complex? And how do you assess if its damaged?
LF
SL
IL
Facet capsule
Use MRI to assess
What categories makes of the Thoracolumbar Injuy classification and severity score?
Morphoology of fracture:
Compression, burst, rotational, distraction
Neurology:
Intact, nerve root/complete cord, incomplete cord/cauda equina
PLC integrity- Intact, suspected, injured
How to manage spinal thoracolumbar fractures?
If TLICS <4 then non op
If >4 operative
If 4 then surgeon dependent
What is the cauda equina and what is CES?
Cauda equina is a collection of peripheral nerves that run in the verterbral canal beyond the end of the spinal cord from L2-S5
Because they are not surrounded by the spinal cord they are more at sensitive to compression and damage.
CES is the collection of signs and symptoms related to compression of the cauda equina
What are the causes of CES?
Disc herniation- commonest cause
Spinal epidural haematoma
Spinal cord tumour
Spinal epidural abscess
Trauma (retropulsion/dislocation/collapse)
Spondylothesis- slipping of vertebral bodies
What are theGIRFT syptoms and then red flags for CES?
GIRFT National guidelines- published in 2023
Recent onset within 2 weeks
Any bilateral sciatica +- Back pain
Bilateral paralysis/parasthetsia
Saddle Anaesthetsia
Difficult micturating/impaired sensation of flow
Loss of sensation of rectal fullness
Incontinence
Erectile dysfunction/loss of genitalia sensation
Associated red flags
Fever
Wt Loss
Night sweats
IVDU
Cancer
Previous spinal surgery
Immunosuppression
What is the thinking around PVRs in CES?
Not diagnostic nor can it exclude CES
Woodfield et al. 2023
60% of patients undergoing decompression for CES had a PVR of <200mls
A PVR of >200mls increases likelihood of CES by 20 times
If >600mls PVR then catheterise + tug test
How do you examine a patient with ?CES
Full lower limb neuro exam
Expose
Tone
Power- sharp vs blunt, proprioception
Reflexes
Coordination
Key investigation and urgency for CES?
Lavy et al. found a 43% false positive rate for the diagnosis of CES
MRI is gold standard for diagnosis
To be ordered within 1-2 hours of ED presentation
To be done within 4 hours of request
GIRFT
How do you classify Cauda Equina?
Lavy et al.
- CES Suspected (CESS): Patients are at risk of developing CES. There is bilateral sciatica or motor/sensory changes in the lower limbs but no sphincteric or perineal sensory changes. Includes anyone at risk of developing CES, e.g. due to a large disc.
- CES Incomplete (CESI): The above with one of altered bladder/bowel fnx, saddle anaesthesia, sexual dsyfnx (ejactulatory, erection, sensation)
- CES with retention (CESR): In addition to CESI, there is painless bladder retention
and overflow. - CES Complete (CESC): Insensate bladder with overflow incontinence, no perineal, perianal or sexual sensation, and no anal tone.
What is the management of CES + outcomes?
If confirmed on MRI requires urgent decompression
Catheterise and tug as needed
Analgesia
Bloods + 2xG&S
Consent and mark
Contact anaesthetist/CEPOD/consultant on call/transfer to spinal centre
Ahn et al. 2000 Optimum theatre time within 48 hours of symptoms starting for best outcomes
Operation dependent on aetiology- microdiscectomy vs laminectomy vs haematoma/abscess evacuation
How long can the recovery period of symptoms be from CES?
Motor 1 year
Bladder 16 months
Indication for CT c spine in trauma?
Within 1 hour:
GCS<13/intubated
abnormal plain films
Polytrauma
Clinical suspicion + >65/dangerous MOI (fall from >1m/5 stairs) + focal neurology
Indications for CT head?
Within 1 hour:
GCS <13 on initial assessment
GCS <15 after 2 hours of injury
Post traumatic seizures
Open or depressed skull fracture
Signs of basal skull fracture
Focal neurology
More than one discrete episode of vomiting
Within 8 hours if LOC or amnesia:
+>65 years
Bleeding/clotting issues
>30 mins of retrograde amnesia
Name some different types of incomplete spinal cord injury?
Central cord syndrome- Upper limbs worse than lower limbs, motor worse than sensory, elderly hyperextension type injury
Ant cord syndrome-Paralysis LL worse than UL, preserved prioprioception, loss of pain/temperature
Brown sequard- hemicord injury, BLT, ContraL loss of pain/temp, IpsiL loss of power/prioprioception
What is a complete spinal cord injury
Paraplegia and complete loss of sensation/prioprioception below injury
What is a Pars Defect?
Fracture through facet joint
Can lead to spondylolithesis
What is spondylolithesis?
Displacement of spinal vertebra compared to another
L5 is commonest
Due to trauma, dsyplasia, malignany and iatrogenic
