🦴 Chapter 66: Spinal Cord Trauma

SCIWORA · Upper cervical spine (C1-C4) most common in children · Immobilisation · Jaw thrust for airway · Neurogenic shock (hypotension + bradycardia) · Methylprednisolone controversy · Cervical spine clearance · MRI for SCIWORA · DVT prophylaxis

🔍 Core Concepts: Spinal Cord Trauma

📌 SCIWORA
Spinal Cord Injury Without Radiographic Abnormality. More common in children due to ligamentous laxity. MRI for diagnosis. Normal X-ray/CT does not exclude injury.
🦴 Paediatric Predisposition
Large head-to-body ratio, ligamentous laxity, incomplete ossification, horizontal facet joints. Upper cervical spine (C1-C4) most commonly injured (70%).
🩺 Neurogenic Shock
Hypotension + bradycardia due to loss of sympathetic tone. Differentiate from haemorrhagic shock (tachycardia). Treatment: fluids, vasopressors (dopamine, norepinephrine), atropine for bradycardia.
🫁 Respiratory Management
C3-C5 innervate diaphragm (phrenic nerve). Injury above C3 → ventilator dependence. C5-T1 → intercostal weakness, may need ventilation. Early tracheostomy for high lesions.
💊 Methylprednisolone
Controversial. Cochrane review: no strong evidence. May be considered within 8h of injury (30 mg/kg bolus, then 5.4 mg/kg/h for 24h). Complications: infection, GI bleeding.
🛡️ Immobilisation & Clearance
Hard collar + spine board. Clearance: alert, no pain, no neuro deficit, no distracting injury → clinical clearance. Otherwise CT. MRI for SCIWORA.

🩺 Stepwise Approach: Spinal Cord Trauma

1
Immobilisation & primary survey
Hard collar, spine board, head blocks. Airway: jaw thrust (avoid head tilt). Breathing: assess respiratory effort (diaphragm vs intercostals), O2. Circulation: treat hypotension — distinguish neurogenic (bradycardia) vs haemorrhagic (tachycardia).
2
Neurological examination
ASIA score (motor, sensory, sacral sparing). Level of injury. Bulbar function (cough, gag). Priapism, loss of anal tone indicate spinal shock. Complete vs incomplete injury.
3
Radiological evaluation
Lateral cervical spine X-ray (C1-T1). CT spine for suspected fracture (more sensitive). MRI for SCIWORA (neurological deficit with normal X-ray/CT).
4
Cardiovascular management
Neurogenic shock: fluid bolus (20 mL/kg), vasopressors (dopamine 5-10 mcg/kg/min, norepinephrine), atropine for bradycardia. Avoid phenylephrine (unopposed vagal tone).
5
Respiratory support
High cervical (C1-C3): intubation, mechanical ventilation, early tracheostomy. Low cervical (C5-T1): monitor vital capacity, NIPPV if needed. Ineffective cough → suction, chest physiotherapy.
6
Spine clearance & rehabilitation
Clear cervical spine if alert, no pain, no neuro deficit, no distracting injury. MRI for obtunded patients with concerning mechanism. DVT prophylaxis (LMWH). Early physiotherapy.