THE GENERAL METHOD FOR A SPINAL INJURY

This extends what has already been said about caring for a patient with multiple injuries in Section 51.3.

MOVING AND UNDRESSING A PATIENT When you move or turn a patient with a suspected spinal injury you will need at least 2 helpers, and preferably 4. Try to move him ’in one piece’. Minimize the movement of his spine, especially its cervical region.

If he is on the ground, carefully turn him onto one side as you roll him onto a stretcher, or a stretched blanket, as in Fig. 64-4. As you turn him, take the opportunity to examine his back and his spine, as described below.

If you suspect that a patient has a neck injury, place one hand under his chin and the other under his occiput, as in A, Fig. 64-5, expert gentle traction on his neck, and lift and turn his head while you turn his body—don’t let his head drop to one side. Holding his head is the task for the most skilled person in the team. When you have finished turning him onto his back, wedge his head between sandbags, or rolled up sheets or blankets, as in B, Fig. 64-5, or fit him with a collar as in C, in this figure.

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Figure 64.5: SUPPORTING AN INJURED CERVICAL SPINE. A, holding a patient’s head is the task for the most skilled person in the team. B, when you have finished turning him onto his back, wedge his head between sandbags, or rolled up sheets or blankets. C, or fit him with a collar. Adapted from de Palma with kind permission.

CAUTION! (1) Keep his spine stretched and as straight as possible. Don’t move his head. Keep it in a neutral position at all times. Never let anyone carry an injured patient with his head hanging down as in B, Fig. 64-4. Unfortunately people often do. (2) If there is any possibility of a spinal injury, especially a cervical one, this careful handling must go on until you have made sure the patient’s spine is rad!ologically stable. (3) Fit him with a temporary cervical collar as soon as possible and never transport him anywhere without one. Failure to do so may: (a) convert a patient with a normal cord into a quadriplegic, (b) convert a partial transection into a total one, or (c) deprive a partially quadriplegic patient of a few critically useful segments.

If you suspect that a patient has an injury of his thoracic or lumbar spine, transport him prone with a pillow under his shoulders and pelvis to hyperextend his spine at the site of the injury, unless he has multiple injuries or his airway is in doubt. If it is in doubt, transport him supine.

THE HISTORY AND EXAMINATION OF A SPINAL INJURY

Leave the patient on his stretcher until you have examined him. Enquire carefully about the circumstances of the accident. This will tell you what type of injury to suspect. If he is conscious, ask him "Where is the pain?" He may be able to say that he has a pain in his back, pains round his body, or that his body feels dead below a certain level. Signs of injury on his face and skull may help you to decide the kind of force responsible.

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Figure 64.6: EXAMINING A SPINAL INJURY Feel for any local bruising, swelling, or tenderness along the patient’s spine. Examine his spinous processes systematically from his neck to his sacrum. Look for a break in the line. Feel for any soft ’doughy’ areas. Kindly contributed by Ronald Huckstep.

SPINE Carefully slide your hand underneath the patient’s back, or turn him very carefully while an assistant holds his head. (1) Feel for any local bruising, swelling, and tenderness along his spine. Examine his spinous processes systematically from his neck to his sacrum. (2) Look for any break in the line. (3) Feel for any soft ’doughy’ areas between his spinous processes into which your fingers can sink. You may feel a palpable gap. These last two signs indicate an unstable fracture.

CAUTION! Don’t test the movements of his spine!

NEUROLOGICAL EXAMINATION This has two stages, and if a patient has an associated head injury, interpreting either of them may be difficult.

A rapid test to exclude a spinal injury

Use this to exclude quickly a spinal injury in any severely injured patient (50.4). Can he move his legs? Are they equally strong? Can he feel anything when you pinch them?

A more extensive examination if you suspect a spinal injury.

Test the sensation on the patient’s trunk with a pin, starting from below and working upwards. Find the sensory level, using the dermatome chart in Fig. 64-3. Can he recognize movements of his feet or knees? Test his knee and ankle jerks and his plantar responses. Test to find out if his sacral segments have been spared by pricking the skin beside his anus with a pin.

If the patient has severe continuous pain radiating from his neck to both occipital regions, suspect a fracture dislocation of his atlas on his axis.

Assess the level of a fracture dislocation like this: Dislocations between C1 and C2 cause severe continuous pain radiating from the neck to the occiput. Dislocations between C3 and C5 cause quadriplegia. If C5 is dislocated on C6, a patient’s biceps is weak or paralysed. If C6 is dislocated on C7, his biceps is normal. In dislocations above C7 and T1 Horner’s syndrome (ptosis, a constricted pupil, anhydrosis on the affected side of his face, and enophthalmos) may be present.

The lumbar nerve roots supply: (1) sensation to a patient’s legs, except that supplied by his sacral segments, (2) the muscles of his hip and knee, (3) his cremasteric reflexes, his knee and his ankle jerks. Lumbar or sacral root pain suggests a root rather than a cord injury.

The sacral nerve roots supply:

(1) sensation in his saddle area and a strip down the back of his leg and thigh, (2) the muscles controlling his ankle and foot, (3) his ankle and plantar responses, (4) his anal and cremasteric reflexes, (5) micturition.

The penile reflex

Squeeze his glans penis, and feel his bulbocavernosus muscles. If they contract, the reflex is positive.

The anal wink reflex

Scratch the skin round his anus. If his anus contracts and wrinkles, the reflex is positive. If either of these reflexes is positive immediately after the acciden in the absence of sensation in his legs, they indicate transection of his cord and are a poor prognostic sign.

X–RAYS Don’t send him for an immediate X-ray. Find the level of the lesion first. Some patients present with leg problems, but have an upper thoracic fracture, so examine his spine with care before you decide which part of it to X–ray. If you have enough film, X–ray his entire spine routinely, because spinal fractures are sometimes multiple. Otherwise, X–ray the relevant area only. See him onto the X–ray table yourself.

IS THE PATIENT’S FRACTURE STABLE? This decision is partly clinical and partly radiological. Make it by the criteria in Sections 64.4 and 64.5.

ASSOCIATED INJURIES About a third of patients have other severe injuries, particularly of the head (63.1) and abdomen (66.1), so look for them—this is critically important.

IMMEDIATE PROGNOSIS If a patient is paralysed with a sharp line of anaesthesia, no reflexes, and no bladder control, and with his anal and penile reflexes present, his cord is probably transected completely. Priapism (persistent, painful erection of the penis) is another bad sign.

Firmly hyperextend his big toe. Test his toes, heels, and perineum with a pin. If he is paralysed but can feel any of these things, his cord is probably only shocked, and its function will improve.

PROGNOSIS AT 24 HOURS If at this time he still has no perianal sensation, no voluntary control of his toe flexors, or rectal sphincters, he has a 90% chance of having a permanent paraplegia or quadriplegia. If any of these things are spared, or he shows any improvement in the first 48 hours, significant recovery is possible. If there have been no signs of improvement at 4 weeks, further recovery is very unlikely.

THE IMMEDIATE TREATMENT OF A FRACTURED SPINE

This varies with the level of the lesion.

Cervical spine

Apply traction to all patients with: (1) any unstable fracture or any dislocation, (2) any patient with incomplete paralysis or impending paralysis, whatever the X–ray findings. Use a halo or Gardner Wells tongs (5 to 7 kg), or a halter (3 to 4 kg), loosened periodically, to prevent the skin of his chin necrosing; a patient can only stand a halter for a few hours.

Lumbar and sacral spine

Lie him in his most comfortable position.

THE INITIAL TREATMENT OF PARAPLEGIA AND QUADRIPLEGIA

If a patient is paraplegic, immediately start 2 hourly turning to prevent bed sores. They can start in the first few hours after the accident only too easily. Don’t let his bladder fill up, start intermittent sterile catheterization, if you have the staff and committment to manage it (64.16).

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Figure 64.7: A NORMAL CERVICAL SPINE. Note: (1) The normal soft tissue shadow in front of the patient’s cervical vertebrae. (2) The relation his odontoid process to the rest of C2. (3) The posterior margins of his vertebral bodies form a smooth curve. (4) His spinous processes are in line. (5) His normal odontoid. Kindly contributed by John Stewart.

If he is quadriplegic, also pass a nasogastric tube and remove his stomach contents, so as to prevent them being aspirated.

Transection of his cord interrupts his sympathetic pathways and causes immediate hypotension. His blood pressure will not return to normal for several days, so set up a drip meanwhile.

Watch for abdominal distension and absent bowel sounds caused by ileus. This is a common complication of a spinal cord injury and of a lumbar spine injury, even if there is no cord lesion. So give him only intravenous fluids, or sips of fluid by mouth, until you can hear persistalsis. On the fifth to seventh day he will need an enema, or manual removal of his faeces.

SHOULD YOU APPLY TRACTION YOURSELF, IF HE NEEDS IT, OR SHOULD YOU REFER HIM?

Transporting a patient with a spinal injury is never easy, even by air. If the roads are bad, the journey long, and the quality of care at the other end uncertain, he will probably be safer with you, especially in the earlier stages. If you decide to refer him (and you may be wise not to), start his initial care (see above) before he goes. Fit him with an efficient collar, and send a competent medical assistant or nurse with him, who must understand that his neck must be kept straight, and not flexed, extended, or rotated.

IF YOU SUSPECT A NECK INJURY, APPLY TRACTION OR FIT A TEMPORARY COLLAR IMMEDIATELY