64.3 Caring for a spinal injury

Spinal injuries are often missed for two reasons:

(1 An injured patient may be unable to say that he has lost the feeling in part of his body. His other injuries may be so much more visible than his fractured spine that, unless you routinely exclude a spinal injury in all severely injured patients, you can easily miss one. You may save a patient’s life by removing his spleen only to find bed sores developing because he is also paraplegic. A routine check is very quick. Can he move his legs? If you pinch one, does he move it away? If he cannot move his arms or legs, his cord is almost certainly injured.

Figure 64.4: MOVING A SUSPECTED SPINAL INJURY. If you don’t move a patient with a spinal injury correctly, you may convert a partial transection into a total one. Kindly contributed by James Cairns.

(2) A patient with an unstable injury of his cervical spine may walk into hospital after a seemingly minor injury. So beware of anyone who complains of a painful neck after an accident. Immediately fit him with a soft collar and X–ray his neck. He may only have a minor soft tissue injury, or he may have an unstable fracture and be in danger of instant paralysis.

A spinal injury is terrifying for a patient because he may be completely paralysed and yet fully conscious. His prognosis and management are determined by the following facts: (1) If his injury is severe enough to cause immediate total paraplegia, or quadriplegia, his spinal cord is almost certainly damaged beyond repair, and no treatment, surgical or otherwise, is going to make it recover. (2) If any function remains immediately after the injury, his prognosis is completely unpredictable. He may make a substantial recovery or he may make none at all. So one of your first aims in.examining him should be to see if any function still remains. (3) If he shows any signs of recovery during the first few days, his outlook is much better, so don’t give any prognosis for several days. The earlier and the more rapid his early recovery is, the more hope he has.

Should you refer a patient with a spinal injury? You will have to compare the care you can give him with the care he is likely to get in a referral hospital (1.8). Your care may be better—he is in much greater need of devoted nursing than of skilled surgery. There is seldom any advantage in referring a patient with a serious spinal injury immediately, because you can probably do as much for him, or more, than a referral hospital. Injured nerve cells cannot regenerate, so there is little to be gained by trying to decompress his spine in the hope that they will regenerate. Immediate laminectomy may do more harm than good. Some weeks later an operation to fuse an unstable spine may occasionally be useful. The only procedure that is practical in the acute phase is cervical traction. But although this needs only simple equipment, it needs great skill.