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Management of the Spine Injured Patient

 - See:
      - Exam for Spinal Cord Injury 
      - Head Injury 
      - Neuro Exam Menu

- C-spine (initial care):
    - ensure that patient has adequate C-spine immobilization;
          - a standard backboard is unsuitable in children since it places the head into extension (pediatric c spine);
          - in children, cervical traction of any kind should be avoided until an occipitoatlantal injury has been ruled out; 
          - halo collar
    - references:
          - Noncontiguous injuries of the spine.
          - Emergency transport and positioning of young children who have an injury of the cervical spine. The standard backboard may be hazardous
          - Penetrating Trauma Trumps Backboards

- Neuro:

    - steroids protocol:
    - anesthesia in the spinal cord injured patient:
    - autonomic dysfunction:
    - Neurological Deterioration (in 7%) - r/o syrinx
    - spasticity
    - Avoid tricyclics (unwanted anticholinergic side effects)
    - RSD may be underdiagnosed;
    - references:
           - Reflex sympathetic dystrophy in cervical spinal cord injury patients
           - A Randomized, Controlled Trial of Methylprednisolone or Naloxone in the Treatment of Acute Spinal-Cord Injury 
           - A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study.
           - Nerve root recovery in complete injuries of the cervical spine

- Pulmonary Care:

    - tracheostomy w/ humidified air is used if pt cannot clear secretions;
    - DVT prophylaxis (10% develop a clinically sig. PE)
    - roto Bed for reduction of pneumonia;

- Cardiovascular:

    - central monitoring: Bradycardia occurs due to parasympathetic response;
    - w/ spinal shock, pt may have low SBP from loss of sympathetics;
          - vascular tree expands, & the urinary output is usually low;
          - limit fluids during spinal shock
          - dopamine titrated to SBP

- Urologic:

    - foley Cather for initial 24-48 hrs, then intermittent rather than cont. catheter drainage (develops automatic reflex emptying of bladder)
           - w/ males tape foley to abdomen to prevent penoscrotal fistuala;
    - methenamine or mandelamine for UTI
    - do not prescribe antichoninergics for prolonged periods unless absolutely required (eg in some pts w/ intermittent catheterization);
    - references:
           - Undetected genito-urinary dysfunction in vertebral fractures.

- GI tract:
    - NG tube for prophylaxis of a gastrointestinal ileus;
    - H2 Blocker for PUD prophylaxis (10-40% - GI hemorrhage s more common in patients receiving steroids);
    - bowel regimen: Glycerine or Ducolax suppository qod; (No Enema'a)

- Skin Care: Decubit Ulcers

    - patient should be removed from spine board in the emergency room;
    - roto rest bed;
    - turn pt q 2hrs
    - padding over ulnar and peroneal nerves;
    - bunny boots or ABD's to heels;
    - duoderm to sacrum
    - care to avoid decubiti from Philli collar & halo jacket edges;

- Orthopaedic considerations:

    - burst fractures:
    - heterotopic ossification: below level of cord injury
    - orthosis:
           - hand splints:
           - AFO: to help avoid equinus contractures;
    - tendon transfer
           - a majority of patients w/ tetraplegia may benefit from tendon transfers;
           - transfers are based upon the involved spinal level:
                  - C-5
                  - C-5
                  - C-6
                  - C-7
                  - C-7
                  - C-8
                  - T-1
    - references:
           - Upper extremity fractures in the acute spinal cord injured patient.
           - Reflex sympathetic dystrophy in cervical spinal cord injury patients.
           - Heterotopic ossification around the hip in spinal cord-injured patients. A long-term follow-up study.
           - Single-stage reconstruction of key pinch and extension of the elbow in tetraplegic patients.
           - Upper-limb surgery for tetraplegia.
           - Development of useful function in the severely paralyzed hand.  
           - Clinical and Radiographic Evaluation of Surgical Reconstruction of Finger Flexion in Tetraplegia.
           - Pronating osteotomy of the radius for forearm supination contracture in high-level tetraplegic patients: technique and results.

Recovery of motor function after spinal-cord injury--a randomized, placebo-controlled trial with GM-1 ganglioside
Spine trauma and associated injuries
Neurapraxia of the cervical spinal cord with transient quadriplegia.
Spinal injury at the level of the third and fourth cervical vertebrae from football.
Pathophysiology of spinal cord injury. Recovery after immediate and delayed decompression.
Diagnosis and prognosis of acute cervical spinal cord injury
Catastrophic Cervical Spine Injuries in High School and College Football Players.
Initial Management of Patients With Traumatic Spinal Cord Injuries