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196 Craniocerebral and Spinal Trauma
Evaluation which there is neurological instability; and (3) third-degree instability,
Following resuscitation, a detailed history should be taken as soon as in which there is both neurological and mechanical instability.Those
possible, including mechanism and time of injury, severity of injury, the with stable and first-degree instability can be managed with bed rest for
first aid given, and mode of transportation. Examination should include 1–6 weeks followed by ambulation in an orthosis (e.g., thoracolumbar
all motor functions of the major muscle groups as well as a rectal exami- sacral orthosis (TLSO) or Jewett brace) for 3 to 5 months. Second- and
nation to assess sphincteric tone. Sensory functions, reflexes, and motor third-degree instability may require instrumentation.
functions of the diaphragm and intercostal muscles should be assessed.
Surgery
Treatment Operative management of spinal cord injury aims at decompression
Medical and stability. Emergency decompression has been associated with neu-
High-dose methylprednisolone administration within 8 hours of injury rological deterioration, although it is indicated in incomplete lesions.
is said to be beneficial to long-term outcomes. The patient is given Other indications are as follows:
30 mg/kg bolus over 15 minutes, followed by a 45-minute pause. • progressive neurological deterioration;
Maintenance infusion of 5.4 mg/kg per hour over 23 or 47 hours is
given. However, the efficacy has not been fully evaluated in children • complete spinal block (on MRI or myelogram);
younger than 13 years of age. Gastric erosion is prevented by the use of • bone fragment within the spinal canal;
H -receptor antagonists such as ranitidine.
2 • cervical root compression;
Attention is paid to the prevention of pressure ulcers, chronic
urinary tract infection, and contracture and deformities of the limbs. • compound fracture or penetrating spinal trauma;
Cervical injury
Besides collars, bracings immobilise the cervical spine (Table 30.4). • acute anterior cord syndrome; and
Cervicothoracic orthosis (CTO) incorporates a body vest to immobilize • nonreducible, locked facet causing compression.
the cervical spine and includes the Guilford brace, sterno-occipito- Complications of Spinal Cord Injury
mandibular Immobilisation (SOMI), and Yale brace.
Respiratory complications
Table 30.4: Recommended bracing for various cervical spine injuries.
Respiratory insufficiency is common in patients with injuries of the cer-
Condition Recommended brace vical cord. If the neurological lesion is complete, the patient will have
Cervical strain Philadelphia collar paralysed intercostals muscles and will have to rely on diaphragmatic
Jefferson fracture Cervicothoracic orthosis respiration. Partial diaphragmatic paralysis may also be present ab ini-
stable Halo tio or after 24–48 hours if ascending posttraumatic oedema develops.
unstable In thoracic spine injuries, there may be associated rib fractures, haemo-
Odontoid fracture Cervicothoracic orthosis pneumothorax, ventilation perfusion, mismatch, and so on.
type I Halo Patients need to be nursed in the recumbent position even after
types II & III
spinal stabilisation to ensure that diaphragmatic excursion is not
Hangman’s fracture SOMI compromised. Regular chest physiotherapy and respiratory function
stable Halo
unstable monitoring should be done.
A patient whose respiratory function is initially satisfactory after
Flexion injuries SOMI, cervicothoracic orthosis
mid cervical (C3-C5) Cervicothoracic orthosis injury but then deteriorates should regain satisfactory ventilatory
low cervical (C5-T1) capacity once spinal cord oedema subsides. Artificial ventilation should
Extension injuries Halo, cervicothoracic orthosis therefore not be withheld.
mid cervical (C3-C5) Halo Cardiovascular complications
low cervical (C5- T1)
Haemorrhage from associated injuries is the most common cause
of posttraumatic shock and must be treated vigorously. In traumatic
Traction quadriplegia, the thoracolumbar (T1–L2) sympathetic outflow paraly-
Skull traction is aimed at reducing cervical fracture or dislocation, sis gives rise to hypotension and bradycardia. Pharyngeal suction and
maintaining normal alignment, immobilising the spine, and decom- tracheal intubation stimulate the vagus, and in high spinal cord injuries,
pressing the spinal cord and nerve roots. It also facilitates bone healing. these can produce bradycardia and cadiac arrest. Hence, atropine and
Traction includes Crutchfield tongs, Gardner-Wells’ tongs, or halo trac- glycopyrronium should be used before such procedures or when heart
tion. The traction weight should be increased slowly under the guidance rates fall below 50 per minute.
of an image intensifier to achieve reduction. Three pounds per cervical Cardiac arrest from sudden hyperkalaemia following the use of
vertebral level is recommended (but not more than 10 pounds should be depolarising agents such as suxamethonium is a risk in these patients
used in children younger than 14 years of age). between 3 days and 9 months after injury. Hence, nondepolarising
Thoracolumbar injury agents are preferred.
Perhaps the most popular theory in terms of spinal stability is the three- Thromboembolism
column theory of Dennis. In this model, the anterior column includes
Newly injured quadriplegics or paraplegics are at risk of thromboembo-
the anterior longitudinal ligament, anterior portion of disc, and verte-
lism. Antiembolism stockings and anticoagulants must be started imme-
bra. The middle column incorporates the posterior portion of disc and
diately once medical contraindications and head injury are ruled out.
vertebra, posterior longitudinal ligament, and the pedicle. The posterior
column includes the posterior ligamentous complex and arch. The rib Bladder complications
cage-sternum complex serves as a fourth column of support unique to After severe cord injury, the urinary bladder is initially acontractile,
the thoracic spine. and if untreated this leads to acute urinary retention. A Foley catheter
Damage to more than one column of the spine renders it unstable. should be passed.
Thoracolumbar spine instability can be categorised into (1) first-degree Gastrointestinal tract complications
instability, which is mainly mechanical; (2) second-degree instability, in Paralytic ileus is a common accompaniment of severe spinal cord injury