Spinal Immobilization

[HERBIE1]

OK, because the prior string has gotten pretty long, I decided to break out with a new one- with a different spin. Describe a case that involved a spinal injury- suspected or not and we can discuss.

Here we go-

Recently I had a relatively minor crash- although it was at highway speed. A 21 year old man was clipped in his left rear and spun out, striking a guardrail head on. No different from thousands of similar scenarios I've seen. Damage to the car was minimal to the L rear, the front end damage was moderate. No intrusion, windshield was broken from the airbag deployment and he never lost consciousness. The driver was restrained, airbags were deployed. We encountered the victim sitting behind the wheel alert, with a bit of blood at his mouth- from the airbag deployment and this was the only visible injury. His initial complaint was he could not feel his legs- he had no other complaints. Based on the MOI and the condition of the car, his complaint seemed suspect- I've had hundreds of people with the same complaint and it turned out to be initial hysteria or panic. Looking at this guy and the look on his face- the look of absolute terror. It was clear this guy was legit. We did an initial survey and he indeed had NO feeling from the waist down. Strangely, he also had point tenderness at the base of his skull. Of course an injury at this level would make you suspect deficits higher up than his waist, this could have also been a muscular/tendon injury- but nevertheless, this was his presentation.

Obviously we proceeded very carefully, his vitals were rock solid and steady, and we transported him to a Level 1. Later, I learned they could not find any physical damage via Xrays, MRI, or CT or an explanation for his paralysis, but they immediately started him on steroids and transferred him to a spinal cord center. Cord shock, a missed injury- who knows. The hospital could not provide an explanation for his problems. His only PMH was HIV(not AIDS yet) and I have no idea how that condition may figure in this.

I will be following up to see what has happened to him.

So, I was thinking-of all the cord injuries that we see, how many occurred BEFORE we encountered them, and how many were the result of a missed vertebral injury that is made worse by handling or improper or a lack of immobilization?

What say you folks?

Edited June 29, 2009 by HERBIE1

[fiznat]

I'm not really sure what you are asking.

Maybe I'm stating the obvious here but I don't think anyone would omit spinal immobilization for the patient you described, who has mechanism, pain, and neurological deficits. That's three strikes when you really only need one....

[Lone Star]

The windshield bothers me....

Looking at the 'anatomy' of an automobile, the airbag tends to inflate explosively toward the driver, which is AWAY from the windshield. They're designed to inflate and push the occupant away from the windshield.

That being said, I would hesitate to say that the windshield was broken by the airbag.

Was the driver/patient wearing a seatbelt?

Could the pain/point tenderness come from hyperflexation/hyperextension of the neck?

Remember, there are 3 impacts in every motor vehicle collision:

1. The automobile striking something

2. The body striking the automobile interior. (seatbelt, windshield, steering wheel, back of the front seat [rear passengers]

3. Internal organs/structures striking the inside of the body

Could it be that the airbag actually inflicted the neck pain and subsequent neural deficit? Work with me here:

The driver's vehicle comes to a sudden stop, even restrained, the head and torso will keep moving forward until acted upon by the seatbelt (if they were wearing one). This is Newton's first law of motion: every object will remain at rest or in uniform motion in a straight line unless compelled to change its state by the action of an external force.

With that being proven and accepted, Newton's third law of motion states: that for every action (force) in nature there is an equal and opposite reaction.

The airbag 'explodes' and inflates violently, not only stopping the forward motion of the head, but snapping it backwards, thus causing cervical spine injury, 'cord shock, and even impingement.

Not only could we expect to see cervical spine injuries, but what about the trauma inflicted on the brain as well? Even though the brain is protected by the cerebral spinal fluid inside the skull, it's not a 'perfect cushion'. If it were, we wouldn't see coup contecoup injuries from the brain being 'sloshed around' inside the skull. Could there have been a cause for the neuro-deficit there?

Secondly, it's a known fact that airbags don't always deploy when they should. I don't know the exact speed at which an airbag inflates, but I've heard it's somewhere in the neighborhood of 120 mph. I haven't been able to find evidence to confirm or contradict this.

This is why we should always consider MOI when considering spinal immobilization. Even if the patient hadn't been complaining of neck/head pain, the mechanical forces that have acted on the body can produce many 'hidden injuries'.

[fiznat]

That being said, I would hesitate to say that the windshield was broken by the airbag.

Just my observation, but I've found that front airbags very frequently will cause cracks in windshields. Not that I think it should be assumed that such was the case here, but just for the sake of argument...

[VentMedic]

Spinal cord injury without radiographic abnormality (SCIWORA)

SCIWORA is most common in children but definitely not that unheard of in adults and may be in the thoracic region.

Being a spinal cord center we do see this occasionally and extensive testing may need to be done since the injury is not visible on regular X-Ray or CT Scan. An MRI has a better chance of spotting most injuries but even with that the integrity of white matter tracts within the spinal cord are not well demonstrated. Thus additional steps in MRI are done if this is suspected.

On another note, it is sad to again see the numbers of the new HIV cases among the young.

Edited July 1, 2009 by VentMedic

[Jeepluv77]

Eccymosis from a seat belt may not be visible for awhile. I'm curious as to whether any developed and, if so, where. Is it possible that he had the lap belt on, either properly or improperly, but had placed the shoulder belt behind him as people often do? This could cause spinal damage lower than if he'd had on the shoulder belt.

[HERBIE1]

Spinal cord injury without radiographic abnormality (SCIWORA)

SCIWORA is most common in children but definitely not that unheard of in adults and may be in the thoracic region.

Being a spinal cord center we do see this occasionally and extensive testing may need to be done since the injury is not visible on regular X-Ray or CT Scan. An MRI has a better chance of spotting most injuries but even with that the integrity of white matter tracts within the spinal cord are not well demonstrated. Thus additional steps in MRI are done if this is suspected.

On another note, it is sad to again see the numbers of the new HIV cases among the young.

Thanks for the info.

I had no idea this was common enough to have a syndrome. Obviously there was some type of cord disruption- a small tear in a single fiber, swelling- whatever. I've seen a fair number of cases attributed to cord shock but generally the deficits began to subside fairly quickly after steroids. I want to follow up to see what happened in this case.

What is the prognosis of such cases- SCIWORA?

I'm not really sure what you are asking.

Maybe I'm stating the obvious here but I don't think anyone would omit spinal immobilization for the patient you described, who has mechanism, pain, and neurological deficits. That's three strikes when you really only need one....

I was asking about similar cases- unsuspected spinal injuries, not if the person needed to be immobilized.

Just my observation, but I've found that front airbags very frequently will cause cracks in windshields. Not that I think it should be assumed that such was the case here, but just for the sake of argument...

Agreed. It obviously depends on where the airbags are deployed from, and when the bags are located on top of the dash, the compartment doors usually crack the windshield when they open. Since airbags are deployed at well over 100MPH, damage to the windshield is logical. The damage in these cases is located at the level of those doors- the bottom portion of the windshield.

[VentMedic]

What is the prognosis of such cases- SCIWORA?

Here's some links to case studies on Goolgle.Scholar.

http://scholar.google.com

http://scholar.google.com/scholar?hl=en&am...rognosis+adults

Alot will depend on whether the injury is partial, complete or central.

Here are SCI classifications:

http://www3.umdnj.edu/stlibweb/dpts5312/maynard.pdf

I believe there is an updated version but the info is basically the same.

[HERBIE1]

Eccymosis from a seat belt may not be visible for awhile. I'm curious as to whether any developed and, if so, where. Is it possible that he had the lap belt on, either properly or improperly, but had placed the shoulder belt behind him as people often do? This could cause spinal damage lower than if he'd had on the shoulder belt.

No visible injuries at all- chest or otherwise except for the slightly bloody gums from the airbag deployment, and he was still restrained when we arrived. Even at the hospital, he still didn't have a mark on his body.

The state police officer found him in the same position and didn't touch him because the victim told the trooper the same thing he told us- he couldn't move his legs. The belts appeared to be correctly applied when we found him.

[spenac]

Could it be a psychological cause? Perhaps the fear, etc triggered him to shut down.