Spinal Trauma

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Spinal trauma refers to any injury to the spinal cord, vertebrae, or surrounding tissues resulting from an external force. Such injuries can lead to varying degrees of neurological impairment, ranging from transient pain to complete paralysis.

Aetiology

Spinal trauma can result from various causes, including:

• Road traffic accidents: The most common cause, especially in high-speed collisions or those involving pedestrians or motorcyclists.
• Falls: Particularly in the elderly or in occupational settings with a risk of falls from height.
• Sports injuries: Common in contact sports (e.g., rugby, American football) or extreme sports (e.g., skiing, diving).
• Violence: Including gunshot wounds, stabbings, or physical assaults.
• Occupational hazards: Injuries related to heavy machinery, lifting, or construction work.

Pathophysiology

The pathophysiology of spinal trauma involves:

• Primary injury: Direct damage to the spinal cord, vertebrae, or surrounding structures at the time of trauma. This may include fractures, dislocations, or direct spinal cord injury.
• Secondary injury: Occurs after the initial trauma, involving a cascade of biochemical and cellular events leading to further tissue damage. This may include ischemia, inflammation, oedema, and apoptosis of spinal cord cells.
• The extent of neurological damage depends on the level and severity of the injury. Cervical injuries are generally more severe, potentially leading to quadriplegia, while thoracic and lumbar injuries may result in paraplegia.

Risk Factors

• Participation in high-risk sports or recreational activities
• Occupation involving heavy lifting, machinery, or work at heights
• Advanced age, particularly with osteoporosis or other degenerative bone conditions
• Previous history of spinal injury or surgery
• Conditions that predispose to falls, such as balance disorders or muscle weakness

Signs and Symptoms

The signs and symptoms of spinal trauma can vary widely depending on the level and severity of the injury:

• Neurological deficits: This can include weakness, numbness, or paralysis in the limbs below the level of the injury. For example, a cervical injury may result in quadriplegia, while a thoracic injury may cause paraplegia.
• Pain: Severe pain at the site of injury, which may radiate along the affected nerves.
• Loss of sensation: Reduced or absent sensation below the level of the injury.
• Autonomic dysfunction: Including loss of bowel and bladder control, hypotension, and bradycardia, especially in higher spinal injuries.
• Spinal deformity: Visible deformity or abnormal alignment of the spine, particularly with fractures or dislocations.
• Respiratory compromise: Seen with high cervical injuries, which may impair the function of the diaphragm and accessory muscles of breathing.

Investigations

Specific investigations to diagnose and assess spinal trauma include:

• Imaging studies:
  • X-rays: Often the first imaging modality used to assess vertebral fractures, dislocations, or spinal alignment abnormalities.
  • CT scan: Provides more detailed images of bony structures and is often used to assess complex fractures or when X-rays are inconclusive.
  • MRI: The gold standard for assessing soft tissue damage, including spinal cord injury, disc herniation, or ligamentous injury.
• Neurological examination: A thorough assessment of motor and sensory function, reflexes, and autonomic function to determine the level and extent of neurological impairment.
• Blood tests: To assess for any underlying conditions that may have contributed to the injury, such as osteoporosis or clotting disorders, and to monitor for potential complications such as infection or renal dysfunction due to rhabdomyolysis.
• Spinal cord monitoring: In cases of suspected spinal cord injury, monitoring of spinal cord function using somatosensory evoked potentials (SSEPs) or motor evoked potentials (MEPs) may be performed.

Management

Initial Management

• Immobilisation: Immediate immobilisation of the spine is critical to prevent further injury. This may involve the use of cervical collars, spine boards, or other immobilisation devices.
• Airway management: Ensuring a patent airway is particularly important in high cervical injuries, which may compromise respiratory function. Endotracheal intubation may be required in cases of respiratory compromise.
• Fluid resuscitation: To manage hypotension, particularly in the case of neurogenic shock, which may occur with high spinal cord injuries.
• High-dose corticosteroids: The use of high-dose corticosteroids within the first eight hours of injury is controversial but may be considered in certain cases to reduce inflammation and secondary spinal cord injury.
• Urgent imaging: Early imaging is essential to assess the extent of the injury and guide further management.
• Consultation with a spinal specialist: Immediate consultation with a spinal or neurosurgical specialist is recommended for decisions regarding further management, including surgical intervention.

Definitive Management

• Surgical intervention: Surgery may be required to decompress the spinal cord, stabilise the spine, and/or repair fractures. The timing and type of surgery depend on the specific injury and the patient's overall condition.
• Rehabilitation: Long-term rehabilitation involving physical therapy, occupational therapy, and psychological support is essential for maximising functional recovery and quality of life.
• Pain management: Chronic pain following spinal trauma may require a multidisciplinary approach, including medications, physical therapy, and psychological support.
• Monitoring for complications: Regular monitoring for complications such as pressure sores, urinary tract infections, deep vein thrombosis, and autonomic dysreflexia in patients with spinal cord injuries.

References

1. NHS (2024) Spinal Cord Injury. Available at: https://www.nhs.uk/conditions/spinal-cord-injury/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Spinal Injury: Assessment and Initial Management. Available at: https://www.nice.org.uk/guidance/ng41 (Accessed: 24 June 2024).
3. American Association of Neurological Surgeons (2024) Spinal Cord Injury. Available at: https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Spinal-Cord-Injury (Accessed: 24 June 2024).
4. British Medical Journal (2024) Management of Spinal Trauma: Clinical Features and Guidelines. Available at: https://www.bmj.com/content/350/bmj.h3700 (Accessed: 24 June 2024).

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