Transcript
Page 1: Copy of c Spine Trauma

Cervical Spine TraumaCervical Spine TraumaDr. Martin Leahy PGY-1Dr. Martin Leahy PGY-1

Dr.Norah Duggan - FacultyDr.Norah Duggan - Faculty

Diagnosis and Management of Cervical Spine Trauma

Dr. Otman Siregar, SpOT(K)-SpineH. Adam Malik General Hospital - Medan

Gleni International Hospital - MedanHaji General Hospital - Medan

Page 2: Copy of c Spine Trauma

IntroductionIntroduction

Diagnosa cedera tulang belakang dan Diagnosa cedera tulang belakang dan penanganannya tidak mudah.penanganannya tidak mudah.

Kesalahan penanganan dapat berakibat Kesalahan penanganan dapat berakibat kecacatan seumur hidup kecacatan seumur hidup

Anggapan terjadinya cedera tulang Anggapan terjadinya cedera tulang belakang harus diperhatikan sampai betul-belakang harus diperhatikan sampai betul-betul tidak terbuktibetul tidak terbukti

Page 3: Copy of c Spine Trauma

Kesalahan atau keterlambatan diagnosis Kesalahan atau keterlambatan diagnosis sering terjadi seperti sarana radiologi yang sering terjadi seperti sarana radiologi yang tidak adekuat atau interpretasi dalam tidak adekuat atau interpretasi dalam pembacaan radiologi.pembacaan radiologi.

Oleh sebab itu dibutuhkan suatu guidelines Oleh sebab itu dibutuhkan suatu guidelines untuk memaksimalkan sensitifitas dan untuk memaksimalkan sensitifitas dan spesifisitas dalam mendiagnosa suatu spesifisitas dalam mendiagnosa suatu cedera tulang belakangcedera tulang belakang

Page 4: Copy of c Spine Trauma

Spinal stabilization and Spinal stabilization and managementmanagement

Semua pasien dengan riwayat mengalami Semua pasien dengan riwayat mengalami kecelakaan berat atau nyeri pada leher dan kecelakaan berat atau nyeri pada leher dan punggung harus dicurigai adanya cedera punggung harus dicurigai adanya cedera pada tulang belakang.pada tulang belakang.

Dapat dipketahui dari mekanisme terjadinya Dapat dipketahui dari mekanisme terjadinya trauma (MOI)trauma (MOI)

Page 5: Copy of c Spine Trauma

Techniques of immobilization and Techniques of immobilization and patient handlingpatient handling

Protect spine at all times during the management Protect spine at all times during the management of the multiply injured patient.of the multiply injured patient.

Up to 5% of spinal injuries have a second, Up to 5% of spinal injuries have a second, possibly non adjacent, fracture elsewhere in the possibly non adjacent, fracture elsewhere in the spinespine

Ideally, whole spine immobilised in neutral Ideally, whole spine immobilised in neutral position on firm surface. position on firm surface.

Can be done manually or with a combination of Can be done manually or with a combination of semi-rigid cervical collar, side head supports and semi-rigid cervical collar, side head supports and strapping strapping

Page 6: Copy of c Spine Trauma

Immobilisation in the pre hospital settingImmobilisation in the pre hospital setting

Application of definitive Application of definitive immobilisation devices immobilisation devices should should notnot take take precedence over life precedence over life saving proceduressaving procedures

If neck not in the neutral If neck not in the neutral position, attempt should position, attempt should be made to achieve be made to achieve alignment. alignment.

If the patient awake and If the patient awake and cooperative, encourage to cooperative, encourage to actively move their neck actively move their neck into lineinto line

Page 7: Copy of c Spine Trauma

Abandon procedure if Abandon procedure if pain, neurological pain, neurological deterioration or deterioration or resistance to resistance to movement movement

Long spine boards are Long spine boards are valuable primarily for valuable primarily for extrication from extrication from vehicles. vehicles.

Page 8: Copy of c Spine Trauma

Penolong pertama melakukan stabilisasi helm, kepala danleher untuk mencegah gerakan pada tulang leher.

Tehnik Membuka HelmTehnik Membuka Helm

Page 9: Copy of c Spine Trauma

Penolong kedua melonggarkan pengikat helm di leher.

Page 10: Copy of c Spine Trauma

Penolong kedua melakukan manual stabilisasi tulang leher dengan cara memfiksasi mandibula dan belakang leher.

Page 11: Copy of c Spine Trauma

Sesudah helm dibuka, penolong pertama melakukan traksimanual di kepala untuk immobilisasi tulang cervical.

Page 12: Copy of c Spine Trauma

Segera memasang rigid collar

Page 13: Copy of c Spine Trauma

Penderita setelah terpasang rigid collar.

Page 14: Copy of c Spine Trauma

Tidak dianjurkan memakai soft collar pada cederatulang cervical.

Page 15: Copy of c Spine Trauma

Rigid cervical collar.

Page 16: Copy of c Spine Trauma

Log Roll TechniqueLog Roll Technique

Page 17: Copy of c Spine Trauma
Page 18: Copy of c Spine Trauma
Page 19: Copy of c Spine Trauma
Page 20: Copy of c Spine Trauma
Page 21: Copy of c Spine Trauma
Page 22: Copy of c Spine Trauma
Page 23: Copy of c Spine Trauma
Page 24: Copy of c Spine Trauma

Immobilisation in hospitalImmobilisation in hospital

Remove spine board as soon as possible Remove spine board as soon as possible once patient is on a firm stretcher once patient is on a firm stretcher

Full immobilisation, however, should be Full immobilisation, however, should be maintained and manual protection should be maintained and manual protection should be reinstated if restraints have to be removed reinstated if restraints have to be removed for examination or procedures (eg. for examination or procedures (eg. intubation)intubation)

Page 25: Copy of c Spine Trauma

Agitation, shock, restlessness, or Agitation, shock, restlessness, or intoxication may make adequate intoxication may make adequate immobilization impossibleimmobilization impossible

In these situations, forced restraints or In these situations, forced restraints or manual fixation of the head may risk further manual fixation of the head may risk further injury to the spine injury to the spine

Consider removing immobilization devices Consider removing immobilization devices allowing the patient to move unhindered allowing the patient to move unhindered

Page 26: Copy of c Spine Trauma

Clinical Clearance of Cervical Clinical Clearance of Cervical Spine InjurySpine Injury

Key PointsKey Points 1. Spinal immobilization is a priority in multiple 1. Spinal immobilization is a priority in multiple

trauma, spinal clearance is not trauma, spinal clearance is not 2. The spine should be assessed and cleared when 2. The spine should be assessed and cleared when

appropriate, given the injury characteristics and appropriate, given the injury characteristics and physiological statephysiological state

3. Imaging the spine does not take precedence 3. Imaging the spine does not take precedence over life saving diagnostic and therapeutic over life saving diagnostic and therapeutic proceduresprocedures

Page 27: Copy of c Spine Trauma

Numerous large prospective Numerous large prospective studies have described the large studies have described the large

cost and low yield of the cost and low yield of the indiscriminate use of c-spine indiscriminate use of c-spine radiology in trauma patientsradiology in trauma patients

Page 28: Copy of c Spine Trauma

Who needs an x-ray??Who needs an x-ray??

Page 29: Copy of c Spine Trauma

Recent paper has attempted to Recent paper has attempted to address this questionaddress this question

NEXUS -The National Emergency X-NEXUS -The National Emergency X-Radiograph Utilization StudyRadiograph Utilization Study

This was a prospective study put forth to This was a prospective study put forth to validate a rule for the decision whether to x-validate a rule for the decision whether to x-ray in low risk patientsray in low risk patients

Page 30: Copy of c Spine Trauma

Criteria were as follows…..Criteria were as follows…..

1. Absence of tenderness in the posterior 1. Absence of tenderness in the posterior midlinemidline

2. Absence of a neurological deficit2. Absence of a neurological deficit 3. Normal level of alertness (GCS15)3. Normal level of alertness (GCS15) 4. No evidence of intoxication4. No evidence of intoxication 5. No distracting pain elsewhere5. No distracting pain elsewhere

Page 31: Copy of c Spine Trauma

Any patient who fulfilled all 5 of the Any patient who fulfilled all 5 of the aforementioned criteria were considered aforementioned criteria were considered low risk for C-spine injury and as such did low risk for C-spine injury and as such did not receive C-spine radiographynot receive C-spine radiography

For patients who had any of the 5 criteria, For patients who had any of the 5 criteria, radiographic imaging was deemed indicated radiographic imaging was deemed indicated in the form of AP, lateral, and odontoid C-in the form of AP, lateral, and odontoid C-spine viewsspine views

Page 32: Copy of c Spine Trauma

Results of NEXUS studyResults of NEXUS study

34069 patients were enrolled34069 patients were enrolled 818 had significant C-spine injury818 had significant C-spine injury 810 were identified as potential spinal 810 were identified as potential spinal

injury patients by the decision ruleinjury patients by the decision rule 8 patients were identified as low risk but in 8 patients were identified as low risk but in

fact had radiographic injuryfact had radiographic injury

Page 33: Copy of c Spine Trauma

Sensitivity 99% Sensitivity 99% Negative predictive value 99.8%Negative predictive value 99.8% Specificity 12.9% Specificity 12.9% Positive predictive value 2.7%Positive predictive value 2.7% Study was well receivedStudy was well received But…..some felt criteria to be too But…..some felt criteria to be too

ambiguous and open to interpretationambiguous and open to interpretation

Page 34: Copy of c Spine Trauma

Plain Film RadiologyPlain Film Radiology

The standard 3 view plain film series is the The standard 3 view plain film series is the lateral, antero-posterior, and open-mouth lateral, antero-posterior, and open-mouth viewview

Page 35: Copy of c Spine Trauma

The lateral cervical spine film must include the The lateral cervical spine film must include the base of the occiput and the top of the first thoracic base of the occiput and the top of the first thoracic vertebravertebra

The lateral view alone is inadequate and will miss The lateral view alone is inadequate and will miss up to 15% of cervical spine injuries. up to 15% of cervical spine injuries.

If lower cervical spine difficult to see, caudal If lower cervical spine difficult to see, caudal traction on the arms may be used to improve traction on the arms may be used to improve visualisation visualisation

Repeated attempts at plain radiography are usually Repeated attempts at plain radiography are usually unsuccessful unsuccessful

If the lower cervical spine is not visible, a CT If the lower cervical spine is not visible, a CT scan of the region is then indicatedscan of the region is then indicated

Page 36: Copy of c Spine Trauma

How to read the Lateral Cervical How to read the Lateral Cervical Spine X-RaySpine X-Ray

Lateral cervical spine Lateral cervical spine x-ray must visualise x-ray must visualise entire cervical spine . entire cervical spine .

A film that does not A film that does not show the upper border show the upper border of T1 is inadequate of T1 is inadequate

Caudal traction on the Caudal traction on the arms may help arms may help

Page 37: Copy of c Spine Trauma

Lateral viewLateral view

Specific things to look for (7)Specific things to look for (7)– anatomic linesanatomic lines

– translation greater than 3.5 mmtranslation greater than 3.5 mm

– angulation 11° greater than contiguous segmentsangulation 11° greater than contiguous segments

– soft tissue swelling soft tissue swelling

– Facet jointsFacet joints

– Atlantodens interval (ADI) greater than 3-5mm Atlantodens interval (ADI) greater than 3-5mm indicates rupture of the transverse ligamentindicates rupture of the transverse ligament

– Anterior Occipitoatlantal DislocationAnterior Occipitoatlantal Dislocation ( (Powers Ratio)Powers Ratio)

Page 38: Copy of c Spine Trauma

Lateral viewLateral view Anatomic linesAnatomic lines

Page 39: Copy of c Spine Trauma

Lateral viewLateral view• Translation greater than 3.5 mmTranslation greater than 3.5 mm

Page 40: Copy of c Spine Trauma

Lateral viewLateral view• angulation 11° greater than contiguous angulation 11° greater than contiguous

segments (abnormal angulation)segments (abnormal angulation)

•Disruption of the PLLDisruption of the PLL

•Subluxation of C3 on Subluxation of C3 on C4C4

Page 41: Copy of c Spine Trauma

Lateral viewLateral view

• Soft tissue swelling

C1 10 mm

C2 6mm

C6 22mm

Page 42: Copy of c Spine Trauma

Lateral viewLateral view Bilateral facet dislocationBilateral facet dislocation

• 50% Subluxation50% Subluxation

• Fracture 70 - 80%Fracture 70 - 80%

• Disc Herniation 10-40%Disc Herniation 10-40%

• May Compress Cord Post ReductionMay Compress Cord Post Reduction

Page 43: Copy of c Spine Trauma

Lateral viewLateral view•Unilateral Facet DislocationUnilateral Facet Dislocation

Page 44: Copy of c Spine Trauma

Lateral viewLateral view

• Bilateral facet dislocation of C5-C6Bilateral facet dislocation of C5-C6

Page 45: Copy of c Spine Trauma

Shows C1 burst fracturesShows C1 burst fractures C1-2 alignmentC1-2 alignment Dens fracturesDens fractures

Odontoid viewOdontoid view

Page 46: Copy of c Spine Trauma

Atlanto –occipital dissociationAtlanto –occipital dissociation

Atlanto-occipital dissociation can be Atlanto-occipital dissociation can be very difficult to diagnose and is easily very difficult to diagnose and is easily missed. missed.

The distance from the occiput to the The distance from the occiput to the atlas should not exceed 5mm anywhere atlas should not exceed 5mm anywhere on the filmon the film

Page 47: Copy of c Spine Trauma

Odontoid peg must also be Odontoid peg must also be examined for fracturesexamined for fractures

Soft tissue swelling anterior Soft tissue swelling anterior to arch of C1 suggests to arch of C1 suggests fracture at this level.fracture at this level.

Atlanto-Dens Interval Atlanto-Dens Interval (ADI) in adults should be (ADI) in adults should be <3mm (in flexion)<3mm (in flexion)

Shift of > 3.5mm implies Shift of > 3.5mm implies injury to transverse injury to transverse ligament, and > 5mm ligament, and > 5mm indicates complete rupture indicates complete rupture and instability and instability

C1-C2 interspinous space C1-C2 interspinous space should not be >10mm wideshould not be >10mm wide

Page 48: Copy of c Spine Trauma

The Antero-Posterior ViewThe Antero-Posterior View

Antero-posterior Antero-posterior view must include view must include spinous processes of spinous processes of all cervical vertebrae all cervical vertebrae from C2 to T1from C2 to T1

Page 49: Copy of c Spine Trauma

The addition of two oblique views to The addition of two oblique views to the standard 3 view series does not the standard 3 view series does not increase the sensitivity of plain film increase the sensitivity of plain film evaluationevaluation

Page 50: Copy of c Spine Trauma

CT ScanningCT Scanning Thin cut CT scanning Thin cut CT scanning

should be used to evaluate should be used to evaluate abnormal, suspicious or abnormal, suspicious or poorly visualised areas on poorly visualised areas on plain radiologyplain radiology

The combination of plain The combination of plain radiology and directed CT radiology and directed CT scanning provides a false scanning provides a false negative rate of less than negative rate of less than 0.1%0.1%

Page 51: Copy of c Spine Trauma

MRIMRI Ideally (ie. U.S.) all patients with an Ideally (ie. U.S.) all patients with an

abnormal neurological examination abnormal neurological examination should be evaluated in a specialist unit should be evaluated in a specialist unit and have an MRI scan of the spineand have an MRI scan of the spine

Patients who report transient Patients who report transient neurological symptoms but who have a neurological symptoms but who have a normal exam should also undergo an normal exam should also undergo an MRI assessment of their spinal cordMRI assessment of their spinal cord

Page 52: Copy of c Spine Trauma

Radiographic Examination and Radiographic Examination and Clearance of Cervical Spine Injury - Clearance of Cervical Spine Injury -

Unconscious, Intubated PatientsUnconscious, Intubated Patients

Key PointsKey Points1. The odontoid view is unreliable in intubated 1. The odontoid view is unreliable in intubated

patients patients

2. Clinical examination is impossible in the 2. Clinical examination is impossible in the unconscious patientunconscious patient

3. Plain film radiology cannot exclude 3. Plain film radiology cannot exclude ligamentous instabilityligamentous instability

Page 53: Copy of c Spine Trauma

Standard radiological examination of cervical Standard radiological examination of cervical spine in unconscious, intubated patients is spine in unconscious, intubated patients is

1. Lateral cervical spine film1. Lateral cervical spine film2. Antero-posterior cervical spine film2. Antero-posterior cervical spine film3. CT scan of occiput - C33. CT scan of occiput - C3

The open mouth odontoid radiograph is The open mouth odontoid radiograph is inadequate in intubated patients and will miss up inadequate in intubated patients and will miss up to 17% of injuries to the upper cervical spineto 17% of injuries to the upper cervical spine

Page 54: Copy of c Spine Trauma

Clearance of the spine in unconscious Clearance of the spine in unconscious patients is limited by the lack of patients is limited by the lack of clinical informationclinical information

Incidence of unstable spinal injury in Incidence of unstable spinal injury in adult, intubated trauma patients is adult, intubated trauma patients is about 10.2%about 10.2%

Incidence of unstable, occult spinal Incidence of unstable, occult spinal trauma (not visible on plain films) is trauma (not visible on plain films) is about 2.5%about 2.5%

Page 55: Copy of c Spine Trauma

Unconscious patient ….Unconscious patient ….

Continue spinal precautions until fully Continue spinal precautions until fully consciousconscious

If patient is expected to regain full If patient is expected to regain full consciousness within 24-48 hrs, patient consciousness within 24-48 hrs, patient can be nursed with full spinal precautionscan be nursed with full spinal precautions

Collar not necessary in adequately Collar not necessary in adequately sedated, ventilated patient, and may sedated, ventilated patient, and may increase intracranial pressure in patients increase intracranial pressure in patients with traumatic brain injurywith traumatic brain injury

Page 56: Copy of c Spine Trauma

Magnetic Resonance Imaging in Magnetic Resonance Imaging in Unconscious C-Spine TraumaUnconscious C-Spine Trauma

Extremely sensitive at detecting soft tissue Extremely sensitive at detecting soft tissue injuries without stressing cervical spine- injuries without stressing cervical spine- SIGNIFICANCE?? SIGNIFICANCE??

High false positive rateHigh false positive rate Few good studies on the use of MRI in clearing Few good studies on the use of MRI in clearing

the cervical spine in unconscious patients the cervical spine in unconscious patients

Page 57: Copy of c Spine Trauma

In any case, regardless of the In any case, regardless of the injury suspected, protect injury suspected, protect

yourself……yourself……

Page 58: Copy of c Spine Trauma

Four Basic Reasons Why Four Basic Reasons Why Cervical Spine Fractures Are Cervical Spine Fractures Are

Missed By ER PhysiciansMissed By ER Physicians

1. Failure to obtain indicated films1. Failure to obtain indicated films 2. Inadequate films2. Inadequate films 3. Misinterpretation of the films3. Misinterpretation of the films 4. Films fail to adequately visualize the 4. Films fail to adequately visualize the

injuriesinjuries

Page 59: Copy of c Spine Trauma

Excuses That Won’t Work In Excuses That Won’t Work In CourtCourt

““I felt the x-ray was I felt the x-ray was adequate even though adequate even though I couldn’t see the C7-I couldn’t see the C7-T1 area” T1 area” Never settle Never settle for inadequate films!for inadequate films!

““I didn’t immobilize I didn’t immobilize his neck because he his neck because he was drunk and was drunk and uncooperative”uncooperative”

Page 60: Copy of c Spine Trauma

““I didn’t think an open I didn’t think an open femur fracture would femur fracture would distract him from distract him from reporting tenderness on reporting tenderness on his neck exam” his neck exam” Any Any doubts of a distracting doubts of a distracting injury, order a C-spine injury, order a C-spine filmfilm

“ “ I wanted to get a lateral I wanted to get a lateral C-spine film before C-spine film before intubation…I had no way intubation…I had no way of knowing he would of knowing he would aspirate!” aspirate!” Don’t hesitate Don’t hesitate to use oral endotracheal to use oral endotracheal intubation with cervical intubation with cervical immobilization as it has immobilization as it has been proven safebeen proven safe

Page 61: Copy of c Spine Trauma

References

Mower W., Hoffman J., Pollock C, et al. Use of plain radiography to screen for cervical spine injuries.Annals of Emergency Medicine. 2001;38(1)

Brohi K. Initial assessment of spinal trauma. Trauma. Org.2002;7 (4)

Steill I, Wells G, VandemheenK, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17; 286 (15): 1841-8.

Tintinalli J, Krome R, Ruiz R. Emergency Medicine. A comprehensive study guide. 1992

Page 62: Copy of c Spine Trauma

Thank YouThank You


Top Related