Good afternoon. I'm Chris Kaufman. I'm a trauma critical care surgeon and live in Myrtle Beach, South Carolina. I'd like to welcome you to this Trauma Center Association of America webinar, the first in a series on spinal cord injury. And I want to thank the TCAA Education Committee for this excellent and important topic and the privilege of moderating. Just some background. According to the National Spinal Cord Injury Database, approximately 18,000 new spinal cord injuries occur each year in the United States. And that only counts the patients who survive to the hospital. In recent years, inpatient length of stay has been about 12 days and then rehab for most patients can average 32 days. So clearly many, many providers care for these spinal cord injury patients over the first 12 days in particular, beginning really with the EMS providers. For this reason and the importance of this diagnosis, many health care providers have asked TCAA for an additional educational series on spinal cord injury. The Education Committee has put together a seven part series to provide education from EMS through rehabilitation. The series begins today and will conclude in the spring of 2024 with sections on coding injuries and how to prevent them. Our first speaker, we have two speakers, we have Dr. Eric Scribnik and we have Ms. Laura Holdren. And Laura will speak first regarding spinal cord injury patient in the pre-hospital setting. Laura is a nurse educator and serves as a full time coordinator for EMS outreach and education at Nationwide Children's Hospital in Columbus, Ohio. She received her master's degree in nursing in 2017 and is credentialed as an EMS continuing education instructor. She serves not only on internal PI committees at National Children's Hospital for Emergency Services Trauma and Burn, but also the local health care coalition and Ohio EMS for Children. Laura, plus paramedic instructors and an emergency medicine physician, comprise the EMS outreach and education team. This team provides well over 100 hours per year of pediatric continuing education to the community, private and aeromedical EMS agencies in the central Ohio area. Laura will now address the priorities of spinal cord injury patient in the pre-hospital setting. Thank you, Laura. Thank you for that introduction. Welcome, everybody, this afternoon. Again, I'm Laura Holdren. I'm going to get started. I'm going to turn off my video so it's not distracting. Please, if you guys have any questions, please feel free to put them in the chat. And let's get started. So. Educational statement for you guys to see today, as can read that to yourselves. Disclosures, I have no relevant financial relationships to disclose. Objectives. So we've got a couple objectives real quick. Reviewing the ideology of patients with pediatric spinal cord injuries and priority pre-hospital interventions for children with spinal cord injury. So I'm going to start out with a case study. So EMS gets a call for an adolescent male who went over the handlebars of a motorized bike or dirt bike, which was captured on a cell phone camera. Patient is alert and talkative on scene with multiple abrasions. He has movement and sensation in all extremities. He is complaining of back and chest pain and wants to sit up. What kind of questions would you ask? And should this adolescent sit up and or ambulate at the scene? Guys are going to think about that right over the next few minutes while I talk about pediatric spinal cord injuries. C-spine injuries in kids. When you think about the physiology of kids, you think about kids, they do have bigger head. They have a different center of gravity. So that fulcrum is more anterior for kids under eight. That high energy that dissipated quickly through trauma can cause fracture or subluxation of C1, C2. Displaced vertebrae can cause spinal tearing, dissection, pinching or swelling. This is why C-spine precautions, including C-collar, can help minimize those further injuries. And also thinking about, you know, sometimes people want to think, you know, kids are resilient. They bounce. Well, they have those bigger heads and they have smaller necks with underdeveloped spinal ligaments and muscles. And so they they're at higher risk for serious injuries and at higher risk of fatality from cervical spine injuries. The etiology of spinal cord injuries, about 10.1 percent of spinal cord injuries are related to sports. About 24.1 percent of sports related spinal cord injuries are in zero to 15 year olds. Diving is the sport most likely to contribute to spinal cord injury. Sports most likely to cause cervical fractures are cycling and horseback riding. There's some good back to school thoughts for everybody. I know probably lots of you guys who have kids or have other children in your family that are going back to school want to start thinking about those sports injuries. Recreational and sports injuries considerations for EMS. Kids might not wear adequate safety gear. Sometimes if they're playing sports that aren't organized as in, you know, high school football, things like that are very organized. But if they're doing something in a youth or recreational league or even if they're doing backyard sports, you know, even we're doing skateboarding, ATVs, motorized bikes, scooters. They may not have that safety gear. And then if they start to fall or feel like they're going to fall, they might put their arms up. They might turn their head or neck away to brace for that fall. And then they can potentially sustain more injuries. Another high incidence of c-spine injuries are bicycle related injuries. So that's about 400,000 kids on 19 and under treated emergency departments every year or about 25 kids per hour. Five to 14 year olds are going to be your biggest portion because they're the ones that are most likely to be riding a bicycle. 15 to 18 year olds are injured less frequently, but their injuries are more serious and they are four times more likely to die from a bicycle related injury. Why do you guys think that? It may be risk taking, riding in the street or riding at dawn and dusk where it's dark. And they may be less likely to wear safety gear. Arms and legs are injured most frequently, but head injuries are the most serious and can cause the most deaths. ATVs and motorized scooters be a high source of c-spine injuries. Riders under 16 are most likely to be injured in single vehicle rollover crashes. And they're more likely to ride without helmets. Children six and under sustain the highest proportion of those riders under 16 that have face, head and neck trauma. In reviewing scooters, so those electronic scooters like in the picture for the Lime or Bird scooters, or you can actually you could buy one for yourself versus having a rental scooter. So about 27.4 of non-motorized and 23.4 percent of motorized scooter injuries occur in children under 12. Spending with the rental scooters, do those kids have a credit card? Probably not, right? So somebody is giving them access to be able to rent those things by providing a method of payment. And do they come with helmets if you guys drive by them on the street? No, so they're less likely to have safety gear. Seatbelt injuries and spinal cord injuries, so chance fractures. A chance fracture is a flexion distraction of the lumbar spine can be associated with abdominal injuries as well. The level of injury can be between L1 and L4. Spinal cord injuries can occur with these injuries. Sometimes it's just a fracture. Sometimes it's a fracture and a spinal cord injury. Why does this happen in children? They have those bigger heads. They have a higher center of gravity. And in the case of these kids that are not restrained in a booster seat or restrained appropriately, that force gets applied. That seatbelt slides up off of their hip bones and causes a lot of force at the umbilicus. So the trauma chain of survival, so EMS, the pre-hospital role, BLS skills are key. Good BLS skills can make a huge difference with regards to pediatric trauma of any type. They need to assess, recognize, and prioritize traumatic injuries, monitor that child, and get them to that advanced level of care or their trauma center. So that's that goal. Considering some of those mitigating factors, is there somebody more qualified? What is the local facilities capabilities and where is your local facilities? I know some of you guys may not be quite as local, but quite a bit of Ohio has a lot of rural areas. There are several counties that don't have a hospital at all. So in that transport time and distance, you have to consider transport directly to a trauma center or pediatric trauma center, transport to the community hospital, or engage aeromedical support to transport them directly to that trauma center. Family also can be involved, have to consider, can you get that information from family? Are they on scene? Should they go with? Sometimes you have a lot of people on scene, so that can confound those kind of transports. That view from the door in that initial pediatric assessment, the appearance, their work of breathing, and their circulation by skin color, how does this kid look during that initial assessment? Some physiologic differences in kids of trauma of any kind, they have a large body surface area versus mass. So when they are injured or sick, they will become cold very quickly. Even though it's a nice warm day in Columbus right now, those kids that are injured severely will lose their ability to thermoregulate. Also, when you're removing clothing to do that assessment, they're going to become cold. If they bring water, mud, things like that will make them become cold faster. You have to think about things and do math, right? Normal heart rate in children can be age dependent. They have decreased glycogen stores in the liver, so they're going to become hypoglycemic quicker, because they're going to burn through that reserve. They have decreased oxygen reserves, and they're going to decompensate quickly. And then their blood volume is weight dependent, so that's about 80 milliliters per kilo. EMS or prehospital interventions is really getting those C-spine precautions in place to prevent further injury and doing a quick ABCD assessment, looking for those injuries, getting those baseline vitals, getting baseline glucose, providing supplemental oxygen and having a low threshold for supplemental oxygen and bag valve mask, looking for signs of brain injury along with C-spine, so looking for normal oxygen, using that capnography to check to see if that child is starting to retain CO2 or having a lower SpO2. IV and IO access and fluids as needed. And considering C-spine and brain injuries, you want to have normal oxygenation, normal capnography. I'm going to try to keep their vital signs, including their blood pressure, as normal as possible. And then promoting normothermia, so once you've done that assessment and stabilization, you're going to provide some warmth to that child. So you're going to put blankets on them. I'm going to turn up the temperature in the truck. Do what you can do. The picture in the corner to help keep those C-spine precautions in place, that's a vacuum sling. The vacuum slings are super useful for kids. You know, the old standard is the backboard. The difficulty with the backboard in kids is they don't exactly fit on them very well, and there may be spaces and voids, and they won't have good C-spine control. So those vacuum slings kind of just conform around their body and prevent excessive movement during transport. So some more examples of that spinal motion restriction. The vacuum splints, sometimes if you see that second picture with the baby, not all EMS have a good C-collar that will fit an infant under the age of two. So sometimes you have to improvise. In that case, they're using some towel rolls and tape and what they can to help have some spinal motion restriction. So here's another reason why backboards aren't so great for kids. If you look at that first picture, they tend to flex their neck on a flat surface. Those small kids that are real little, you know, especially those kids that are under the age of six, that occiput in the back sticks out the most. So that's where getting that padding or using vacuum splints can be super helpful in maintaining a neutral C-spine. Other considerations that go along with that backboard is that airway, because if you've got that where their head is tilted forward, they can crimp off their own airway. The tongue can be a potential site of obstruction. If it's an infant with a C-spine injury, anything in their nose can limit their ability to oxygenate because they're obligate nose breathers. And when when considering airway, their airways are narrow and large ET tubes can cause more damage and cause more harm than good. Breathing. So in your ABCs, are they talking? Are they crying? What are you observing? Are they more agitated, less agitated? Are their respirations effective? And that's where with kids you have to use their references because their vital signs are age dependent. Uncooperative kids can be an early sign of hypoxia. Kids that are asleep. Sometimes you hear, hey, they went to sleep. Are they asleep? Are they unconscious? So that's the important point of assessing and reassessing and route. And then for that injury, having that low threshold for managing their their airway with bag valve mask and supplemental oxygen. That capnography, how are you going to tell? So those getting them on that wave form, you know, are they are they ventilating too slow, too quick? Are they hypercapnic? Are they obstructed? Normal capnography. As c-spine and brain injuries often go hand in hand to keep their vital signs and their capnography in that normal range. We're going to try to preserve brain by keeping them normal. So circulation, mentation, you said, is a good sign of circulation. You've got that child that's starting to get tired, starting to get less responsive. Say, are they not are they not circulating? Are they not perfusing? So you'd be looking for poor skin color, pale kids, modeling, cyanotic kids. If you look at this baby in the picture, their extremities look a little mottled. So that would be a bad sign. Why are they mottled? Are they are they hypothermic? Are they not perfusing their pulse qualities and assessment? They feel can they feel those pulses, you know, and what is their pulse rate? Kids, when they're upset, kids, when they're hurt, kids, when they're compensating can get very tachycardic. By the time that they get to the point where they're going bradycardic, they're really having a hard time and they're no longer able to compensate. With skin temp, hypothermia, potentiates hypoxia. So it's this big circle that goes all together. We want their vital signs to be normal for their age. We want them to be warm and transport. So I know somebody, you know, sometimes you think about all these huge interventions that are on your ambulances and in your your ERs. And one of the most important things is keeping that child warm. Blankets are actually pretty important. Disability or neurologic status and transport, assessing and reassessing the adult scale. Many of you guys are probably familiar with the pre-hospital pediatric. GCS is a little bit more difficult unless you've had a chance to use your reference and kind of think about what is normal for that child. And say an example of bad documentation would be giving a child a GCS of six because they're a baby. Right. Are they are they at the GCS of six? Probably not. It's just more difficult to score them on the adult scale. So it's important to have those pediatric references. And you may not remember them, but it's always good to take a look. Use your cheat sheets. You know, an infant tends to be sitting up. They're having they're moving around. They're going to interact with the environment. So exposure in the pre-hospital setting. They want to check for additional injuries. They want to expose that child. They're going to look at them from head to toe. You look at this group. This is one of my simulation patients. I'm not I'm not breaking any HIPAA rules here. So they're they're preparing. They're holding C-spine and they're preparing to roll that patient to check their back to look for additional injuries. So in exposure, they got a good assessment and look for their breathing patterns, looking for abdominal chest injuries, burns, injuries on the back of them. And any any signs that they are deteriorating. So, again, hypothermia, I'm going to. You know, assess and reassess on that and just kind of remind anybody in the pre-hospital setting. And anybody when you're you're looking at are these kids abnormal? Well, if they're if they're hypothermic, is it because they haven't had those warming measures initiated. So evaporation can cool them if they're sweaty, if they're wet, if they need to get IV fluids due to abnormal vital signs, low blood pressure, the need to have fluids to flush in IV medications or pain control, those fluids are colder than body temperature and they will cool the patient. A lot of pre-hospital agencies don't have any kind of warming device to warm their fluids, so they're going to have to turn up the temperature in the truck and they're gonna have to warm the patient. So other considerations with kids with trauma, kids with C-spine injuries is did they assess and reassess en route? And are they looking for signs of further injury? If they're looking, are they looking for signs of decompensation, as in changes of inmentation, changes in vital sign, changes in agitation or sleepiness? So EMS role in determining that destination, as I said, ultimate goal is to get them to the most appropriate facility. Some of that can be difficult for EMS. Overall, some of them may be limited to not being able to leave their district. I have ran into some agencies and some of it is because they are the only ones, so they can only transport to their local community hospital and then it is their job to engage those services, to let that community hospital know that this child is coming to you because they need to come to you for stabilization or for immediate care, but they are most likely going to need that pediatric trauma center. And arriving to the emergency department, we really want some advocation. We want the medics to be able to discuss what did they do? What was the patient's response? What meds did they give? What did they see on the scene? Were there any other factors? Another source of C-spine injuries can be from motor vehicle crashes. Were there other injuries? Were there deaths on the scene from the same accident? It's important to pass that along to the receiving emergency department or trauma center. The graphic I have up is the EMS timeout report that we use locally in Columbus. There are similar mnemonics in several other states. Part of that is just getting that reiteration for that transfer from pre-hospital to hospital care. And to finish off, some pre-hospital care documentation. There are some PI, there's some advantages and there's some PI challenges. I know if you guys work with that trauma data, you guys definitely have your work cut out for you. There's a lack of uniformity even in, I have a graphic that's a generic run report. Not everybody uses the same program. So where you even find the information might be in some different spots. There also can be a lack of uniformity, multiple providers, multiple scopes of practice. So the care that they get from one agency may be different than another agency for the same injury, depending on the providers and their scope of practice. As well, agencies can be limited by their vehicle size and budget for what equipment is on the truck, what medication is on the truck and how much pediatric training that they've had. So you guys roll with the PI and standard of care, have these critical actions been taken? That child with the C-spine injury, they assess their airway, breathing, circulation, disability. They assess for C-spine, sensation, distracting injuries, their neurological status. And did they recognize that injury or that potential injury and initiate C-spine precautions, initiate tapnography, preventing hypothermia. They have any distracting injuries. Part of what can be important with that PI process and analysis after these events, they can find and identify needs for the agency. Now, is there something they can do better or is there something that maybe isn't on that truck that should be on that truck? And sometimes you don't know what you don't know until that's the patient you transport. So I'm gonna turn it over to Dr. Shribnick at this point. Thank you. Thank you, Laura. Really outstanding start to a long series of presentations, over seven different webinars. So thank you for the strong start to this series. It's my privilege next to introduce Dr. Shribnick. Dr. Eric Shribnick is a pediatric neurosurgeon at Nationwide Children's Hospital in Columbus. And he's principal investigator in the Center for Pediatric Trauma Research. He is also assistant clinical professor of neurologic surgery at the Ohio State University College of Medicine. Dr. Shribnick has published over 70 research publications, book chapters, reviews, and case studies. His research and clinical interests focus on surgical and medical interventions for traumatic brain and spinal cord injuries. Dr. Shribnick will address the pathophysiology of spinal cord injuries. Thank you, sir, for this presentation ahead of time. Yeah, thank you guys for having me. So when they asked me to do this talk, I was told about the seven part series. And really what I was asked to do was just to give some backgrounds on the spine, the spinal cord, the types of injuries that we see, just so that everybody has a fund of knowledge to draw from. So that when you're going through the remainder of these series, you know exactly what's going on. My only disclosure is that I have a research grant from NIH NINDS. And to sort of launch into it, my objectives review the normal anatomy of the spine, define both stable and unstable fractures, and discuss specific fracture and injury types that you might hear about or read in the chart, and then discuss spinal cord injury itself as it relates to spine trauma. So just a basic overview of the spine, and I'm a big fan of the laser pointer. So I'm gonna see if I can't get my laser pointer up. Can you guys see that? Yes. Okay, fantastic. So this is your spine, the spine being the bone that is surrounding the spinal cord. You have seven cervical vertebrae, three through seven, we'll talk about first. Those are your sub axial spines, and we'll leave these tricky ones, one and two for the end. Thoracic spine, you have 12 of those. Lumbar spine, you have five of those. And the way that we're made, these cervical spinal bones, your cervical spinal bones look very airy. They look very light. They're built for mobility. It allows me to rotate my head, flex and extend my head and move laterally. It allows us to say yes and no, and we'll go over that a little bit more later. The thoracic spine, the thoracic spine is really buttressed by the rib cage. You can have some pretty nasty fractures in the thoracic spine, and because of that rib cage and that stability that the rib cage provides, things that we'll see in the thoracic spine that we'll let be non-operative, we would never let be non-operative in the cervical spine just because the cervical spine has so much more mobility. And ditto the lumbar spine. The lumbar spine is similar to the cervical spine in that it's not buttressed by the rib cage, but whereas the cervical spine looks like a teeny tiny little ballerina, the lumbar spine is a big hefty bone. Its job is to really support the rest of the body. It's doing a lot of work, and so it supports the entire weight of that body. Now, breaking each vertebrae into its smaller pieces, let's talk about some of the different little parts of the bones that you'll see and some of the names that you may see in the chart, in an x-ray, CTs, that sort of thing. So the spinous process, what is the spinous process? The spinous process is just this back piece. As a matter of fact, if you're touching the back of someone's spine and you're feeling bone back there, you're touching their spinous process. You're not touching their spinous process, but you're touching the skin and the flesh overlying their spinous process. So that spinous process is that midline posterior extension of bone. You can see that in the cervical, the thoracic, and the lumbar spine. What are the transverse processes? Well, the transverse processes, we don't have any in the cervical spine. The transverse processes in the thoracic and the lumbar spine are right here. And these are those side pieces of bone that are extending out from the bone that makes up the spinal canal. In the thoracic spine, they articulate with the rib heads. And in the lumbar spine, who knows why they're there? That's a question I can't answer, but you have transverse processes in the lumbar spine. For me personally, I think of each of these spinal bones as being almost like a signet ring. And the vertebral body itself is the signet part of that signet ring, that big fat part of a signet ring. The lamina is that back piece of bone. So you can see lamina here and here in the cervical spine, here and here in the thoracic spine, and here and here in the lumbar spine. When we say we're doing a laminectomy, we're literally taking a drill and drilling here and here and taking that bone, the lamina, and the spinous process off. When I describe it to patients, what I always say, with a laminectomy, we're turning a sedan into a convertible. We're just taking off that back part of bone and allowing us to see into that spinal canal. On the front side, what makes up that front side of bone? That's what's called the pedicle. And you can see in your cervical spine, you have teeny tiny little pedicles, and your thoracic and your lumbar spine, they're a little bit fatter. And so if somebody talks about putting in pedicle screws, so in the thoracic spine, it would start here, it would go through the pedicle, and it would end up in the vertebral body. And then in the lumbar spine, it would start here, it would go through the pedicle, and it would end up in the vertebral body. And we'll talk about that a little bit more in one of the cases that I'm gonna present. So those are just a few parts of the spine bone, the vertebra itself. The vertebral body, we already sort of talked about, but that's that big piece in the front, okay? And you can see that on the side here. Now, how do all of these vertebral bodies interact with each other? Because it's not gonna be bone on bone, obviously, that would be very painful. And so you have multiple, multiple joints that allow for articulation between these vertebrae. One of the joints that you have is the facet. And the facet is just a fancy way of saying where the back part of one spine bone meets the back part of another spine bone, okay? And so this part right here is the superior articulating process and the inferior articulating process. And so one, the bone above, that inferior articulating process kisses the superior articulating process of the bone below. And you can see, this is just a little fancy graphic showing exactly what that looks like. So you have one bone and the other bone, you have some ligaments that are connecting those bones, and then you have that facet, okay? And that facet is just that joint that allows for there not to be bone on bone contact. The intervertebral disc. So you can think of the intervertebral disc as being the shock absorber of the spine. Now, when you jump up and down, you're jumping on a trampoline, you're doing skydiving, hitting the ground. What's gonna absorb that impact are these intervertebral discs. And looking at these intervertebral discs very closely, you can see that there's a nucleus pulposus right here. That's the soft part of the disc. That's what's gonna actually absorb that impact. I'm not sure why doctors make everything sound like food, but I'm guilty of that as well. And I'll tell you, the nucleus pulposus looks and feels like cooked crab meat. So it's very white and it has that crab meat consistency. And the reason why I've seen it a couple of times is because sometimes the annulus fibrosus will break down and that nucleus pulposus will herniate out. And if it herniates out backward, that's where your spinal cord is or your nerve roots, and it can be very painful. And so we have to go in and do what's called a partial disc ectomy. We have to take out some of that nucleus pulposus. So that's what's happening there. So one of the ways that we sort of think about the spine as caregivers, as people who operate on the spine and really make the decision, this is operative, this is not, is the concept of three columns. There's an anterior, a middle, and a posterior column to the spine. The anterior most column is the first half of that vertebral body, okay? So that makes up that first anterior column. And if you fracture this, that's what happens when you get what's called a compression fracture, okay? So if you've ever seen a compression fracture, you're just kind of dinging the front half and maybe a little bit of that back half of the vertebral body. So if you increase the stress on that vertebral body, maybe you've cracked the anterior and the middle column, okay? And now we're in what's called a burst fracture, okay? So that's the front part and the back part. The entire vertebral body is cracked, okay? And sometimes those fracture fragments can actually go into the back and they can hit the spinal canal. And that's bad, that's really bad. And that's when we need to kind of go in there and take those bone fragments out and relieve some of that pressure. The back part of the spine, sort of the remainder of the spine, facet and back, is essentially the posterior column. And that posterior column is made up of the facets. It's really made up of the pedicles, the lamina, the spine is processed, and all of those small inter-articulating ligaments that we'll talk about a little bit later. So that's sort of what we think about when we think about, you know, patient comes in, they fractured their spine, which part of these three columns? Is it just the anterior? Is it just the posterior? Do they have an anterior and a middle? Have they fractured all three columns and they're grossly unstable? These are the types of questions that we're gonna be asking ourselves when we try and figure out what we're gonna do with an injury. And there are a ton of ligaments that connect all of these spinal bones together. Because, you know, think about it. I mean, you're doing a lot of activities. You're running, you're dancing. You know, you're getting into a fight. You're falling down stairs. You know, that spinal column really has to remain both mobile, but it has to be safe and it has to keep your spinal cord protected. So there are a ton of ligaments. There's ligaments covering every part of those bones. The big ones that we talk about that you might wanna know about, and that you'll see on occasion, that anterior longitudinal ligament, that's in the front, okay? So that's in front of that disc. The posterior longitudinal ligament, that's behind. So if this is the front of the vertebral body with that anterior longitudinal ligament, you have the vertebral body of the disc, and then you have that posterior longitudinal ligament. So if a disc is herniating out, it's going out past that posterior longitudinal ligament. If a bone is fractured and it's going into the canal, it's going past that posterior longitudinal ligament. On the back half of the spinal canal, you have a very thick ligament called the ligamentum flavum. Essentially, all of our medical ease is in Latin, and flavum is yellow, and this ligament is yellow. So that's why we call it the ligamentum flavum. You have a bunch of inner spinous ligaments that connects these little spinous processes, and you have ligaments that connect your transverse processes. You have the ligaments that cover the facets, but the real big one in the back is the supraspinous ligament. So if we're going to do a laminectomy, got to go through that supraspinous ligament, got to go through those inner spinous ligaments on both sides of that lamina, and then you cut off the bone before you get to the facet. So what about the spinal cord? So we talked a lot about the spine, but I mean, the real goods in there are the spinal cord, and that's what everybody is worried about with spinal cord injury. So the spinal cord extends from the base of the brain, generally down to as low as T1 or L1-2, okay? So it extends usually through the thoracic spine down to, usually at the lowest, it's going to be about L1-2, and then past that, you still have spines, so it's in there. So here's your spinal cord, you've got a nerve root coming out here, going into your primary plexi, past that is what we call the cauda equina, and that is just a tangle of nerve roots that is essentially about L1-2 down through the sacral elements. And this is all important stuff, and that cauda equina is what allows us to walk, it's what innervates our legs, it's what allows us to have urinary and bowel continence, and so anytime that that cauda equina is at risk, you can have nerve root compression, which anybody who's had it knows how bad it is, and certainly you don't want the entire cauda equina to be compressed, that can be very bad. So beyond that, you have the nerve roots that go into plexi. This in particular is the brachial plexus. This is just the tangle of nerves that come out and become things like your axillary nerve, your radial nerve, your ulnar nerve. And I just include these to sort of show that when you're talking about nervous injury, you know, you're talking about more than just spinal cord injury. You can have an avulsion of those nerve roots, which probably won't get better. Or you can have a nerve injury, a peripheral nerve injury, which oftentimes will get better. Okay. So when you have a fracture, this is more of a compression fracture. Is it stable or unstable? And really the things that we're looking at are the degree of bone injury. So this is the first anterior column. This is the anterior and posterior column. And you've got some of that posterior bone going into, or I should say this is the anterior in the middle column, with some of that bone going into the spinal canal. So we're talking about what is the degree of bony injury? What is the degree of ligamentous injury? What is the degree of distraction? Is there any canal involvement? Do you have bone going into that canal? And do you have a neurological deficit following that spinal cord injury? So anterior column, anterior middle, anterior middle, and posterior. So this is a three-column injury going through those ligaments. This is going to be a widely unstable injury. This one probably unstable. This one would be definitely stable. But sometimes you can actually get away with non-operative management if you just have the anterior and the middle columns. This is clearly an unstable injury. You can see here thoracic vertebral body. This piece right here is supposed to be up here. This gentleman, this is the ATV that Laura talked about. He actually had a coronal distraction where his vertebral body, it literally fell off of the other vertebral body. Believe it or not, he had absolutely no neurological deficit. And as a surgeon, it's my job to make sure it stays that way and that we get him fixed. And so what did I do? I put in screws above and below the level of injury, not at that injured level. And then I distracted him. I raised these screws up, these screws down, and I allowed those broken bones to settle back on top of each other in the right configuration. And when we're doing this, really the principles are the same as fixing a table or chair leg. So you've got a broken chair leg. Take this. I'm going to let you all answer the poll. I already know the answer to this one. So you have a broken chair leg. You re-approximate that broken piece onto the chair. And you're going to put something in there. You're going to put a glue in there, but you also have to affix it so that that glue has time to heal. And that's what we're doing when we're doing an operation in the spine. We put in screws so that we have a place to hold onto the bone. We distract that bone, and we put in a rod to hold those screws tightly in place. That's like the clamps that you see here on that chair leg. And then what we do is we put in bone along where we want to fuse. And that bone over time will fuse those broken pieces together. And this is called an arthrodesis. What we're essentially doing is we're invalidating all of the movement at those levels. If you do this correctly, you guys are good. It's awesome. If you do this correctly, you should be able to take out all these rods and screws. We never do, but you should be able to, because that bony fusion after about a year or two should hold your spine stably in place. So complete or incomplete spinal cord injury. So when I think of the spinal cord, I think of it as a connection, like almost like a fiber optic cable that goes between the brain and the rest of the body. You have other ways to do that. Your vagus nerve is one way that your brain communicates with your body, but mainly it's through your spinal cord. So if you have an incomplete, when we talk about an incomplete injury, what we mean is that there are fibers of passage. So somebody has a spinal cord injury, they're weak in their legs, but they still have some sensation and they still have some movement in their legs. And we'll talk about different types of incomplete and complete spinal cord injury. When you have a complete spinal cord injury, it means that you have no motor and no sensation below that level of injury. And even with a complete spinal cord injury, you can have some improvement, but as a practitioner, it always makes me feel much better if we have an incomplete spinal cord injury, that gives you a much better prognosis for recovery. So one of the things that you may see is the Asia impairment scale. And this is the only test where you don't want to score an A. So an Asia A is a complete injury, no motor or sensory below the level of the injury. B, you have sensory, but no motor below the level of the injury. So the anterior part of your spine is injured, but those posterior elements of that spinal cord may still be intact. So you still have fibers of passage and your prognosis is a little bit better as far as recovery. With a C, you have sensory and some motor, but your motor is not quite anti-gravity. You can't lift your legs against gravity, but you can move them side to side perhaps. With a D, you have sensory and motor. You're anti-gravity with your motor, but you're still not 100%. And then with an E, there's no deficit in motor or sensory. And you'll have people who come in as a B and they wind up as a D, they come in as a B, they wind up as an E, they come in as a C, they wind up as a D. By and large, if it's an incomplete injury, it is likely going to get a little bit better or a lot better. Sort of the timeline for that, what I always tell patients is the most recovery you're going to make is within that first year, but it can be five years before you finally see what you've got. So terms you might see for injuries, plegia, which is a complete loss of function. So if somebody is paraplegic, they've lost function in their legs. Paretic or paresis, that's a partial loss of function. So paraplegia generally refers to loss of motor function in the lower extremities. You can have bowel and bladder problems with this as well. Quadriplegia gives you everything that paraplegia gives you, plus it refers to loss of function in the upper and lower extremities. So hand function. And then remember, if you have quadriplegia that's high enough, you may cut off innervation to the diaphragm. And so you may need ventilation. Some other terms you might see, spinal cord contusion. This is when you bruise that spinal cord. You can see here, this is a gentleman who may have had a head on MVC. You can see some posterior ligament changes, much better in this part of the MRI. And you can see a little bit of damage to that spinal cord here. That's a spinal cord contusion. And then over time, this is what you're left with, a little hole in that spinal cord. Because unfortunately, if those neurons and those cells in the spinal cord die, they don't grow back. So a full transection. You may see spinal cord transection. This is a very unfortunate 50-year-old woman who fell downstairs while moving furniture, and the furniture fell on top of her. It caused a very bad three-column injury. You can see the posterior aspect of this vertebral body going right into the canal. And you see that a little bit better here, those cut ends of spinal cord. And she's essentially just focally transected that spinal cord at that level. Terms that you might see, especially in children, Skywara, or spinal cord injury without radiographic abnormality. Skywara really appears in the literature first in 1982. MRI was invented, I mean, basically first used in 1977. And for anyone who's been in healthcare for a while, you remember the time when it first came commercially available in the 1980s. So really this term was invented, it was tacked before we had common MRIs. And so Skywara really refers to an injury that you're not going to see with x-ray, you're not going to see with CT, you probably will see with MRI. And it's much more common in children. A very unfortunate 12-year-old female who was in a head-on MVC. You can clearly see here, three-column injury. She had dislocation at the intervertebral disc, dislocation in the back. But in fact, and you can see here in her thoracic spine, everything looks fine until you look at the MRI. And then you see that she has a spinal cord injury in the thoracic spine. And so what I ended up doing was I put in a plate in the front and some surcoge wires in the back to lock her down here. But believe it or not, her spinal cord injury wasn't here, it was way down here. And that's Skywara, spinal cord injury without radiographic outpouring. Central cord syndrome, this is seen in older patients. Often there's a longstanding history of compression and an acute injury. So typically it's a six-year-old male who's got spinal cord compression, doesn't know about it, falls down a flight of stairs, and you have an already tight canal that's disrupted by hyperextension from a fall. And so you can see that here. This is a very tight spinal canal, okay? It should all have this white cerebrospinal fluid above and below, but it does not right here. This is a disc herniation causing injury to that spinal cord when somebody falls. And this is what it looks like. You just have that knuckle ball of that disc herniation, which may have been there before the fall, really going into that spinal cord. And this is a little cartoon showing this. That ligamentum flavum that we talked about a little bit before, that's compressing the cord from the back. You have disc osteophytes that are compressing it from the front, and then you go ahead and do an acute fall. You really can impact that cord. Other terms, you might see brown saccade. This is when you have injury to half of the spinal cord. And you get a very interesting phenomenon of absence of motor and light touch below the level of the injury, and then pain and temp on the opposite side. And that's because of where pain and temp cross over within the spinal cord, whereas motor and light touch are on the same side as the injury. That's why you have some of your injury on one side, some of your injury on the other. But you may see that brown saccade. Very, very rare. We're just going to finish it up. And you guys let me know if I'm running out of time. Cranio-cervical junction. This is a very complex part of the spinal cord, or the spine. It's the cranium, the C1, and the C2. There's a lot of mobility that happens here, and you got to support that big fat head of yours on your spinal cord, on your spine. And so you have very dedicated articulations. Cranium here, C1 bone here, C2 bone here. And you can see that C1 bone, the atlas, is what supports your head. The axis is that C2 bone, and that's got a DENS process right here. Okay? 50% of your ability to say yes, and 50% of your ability to say no, all exist between the cranium, C1, and C2. So you can see an AOD, anti-occipital dislocation. When you see this in the press, they talk about an internal decapitation. 10 to 20% of fatal motor vehicular collisions will actually involve one of these. If you damage the spinal cord here, you're not going to breathe, and you could die on the scene pretty quickly. Fractures at the C1 atlas. Next time you're out at a bar, try and break a pretzel in one place. You can't do it. It always breaks in two places. And so oftentimes you get an arch injury. These are usually stable. You have an injury that happens near that transverse ligament. It can be unstable. And this is a Jefferson fracture. That's a burst injury at four different spots. Fractures of the DENS. You can have type 1, type 2, type 3. Fractures of the DENS process. And then hangman's fractures. We'll end on this. This is a fracture through the pedicle of C2. And oftentimes we just put somebody in a halo, treat these non-operatively. But if they really dislocate, you may need to put in screws from C1 down to C3. Any questions? I know we went through a lot. If you have any questions you want to reach out, I'm easy to find. I'm literally the only Sribnick in Ohio. And it's like a crib with a nick, except an S instead of the C. So Sribnick. And I can be reached at eric.sribnick at nationwidechildrens.org. Thank you, Dr. Sribnick. I especially appreciate the crystal clear explanation of the Asia scale, which I have seen and learned over and over because it's not very complicated. But I might remember it a little bit longer this time. There was a lot of clarity in your presentation. And I wanted to ask Laura a question. Since we just have a couple of minutes, we have about four minutes. So I would like to ask Laura a straightforward question, I think, regarding if you could teach all the parents in Ohio one thing that would save children from having a spinal cord injury. What would be the thing that you would like to be able to broadcast to all current and future parents in an effort to protect their children from a spinal cord injury? I think that the biggest thing is that age appropriate safety gear is more important than people think it is. In reviewing trauma, there's a lot more damage due to kids not having the appropriate safety gear and those things. I mean, you can't just say stay inside all the time, never ride a bike, never, you know, get on skates or anything. But you can say that the safety gear and adult supervision are two of the most important things you can do. I appreciate it. And a quick question for you as well, regarding what is, do you teach the medics for a preschool age child who's not really consolable and you need to immobilize them? How do you find the balance, the best balance between tying them down or holding them down where they're fighting and may hurt themselves versus just not completely immobilizing them like you would like? You know, there's different methods. Kids function well with distraction. So some, you know, one thing that they can do is one, having the caregiver and reminding them where their caregiver is or letting that caregiver touch them so they're not struggling to figure out where, where's my mom or grandma or whoever. Another useful thing more recently has been, you know, those vacuum splints being more available because they're, they're not as, as rigid. It doesn't feel like you're putting, you know, a child on something really hard and getting out these big, you know, physical restraint straps. So, you know, that, and those in distraction can go a long way and helping those kids get those C-spine precautions. And then after that, you know, it's, it can, you know, medication, sometimes it's a maybe, but the power of distraction is, is always there and it can be a strong one. Everybody has, you know, phones and tablets these days and those kinds of things can help as well. Thank you. I think that's helpful. So Dr. Srebnick, we have about two minutes left. Over the course of taking care of many spinal cord injury patients and worked with many different neurosurgeons, what persists to some extent is people using steroids for some spinal cord injury patients, but mostly not. I wanted to ask you about that. And then for whatever time we have at the end, what is the hope for the future that you know is going on experimentally or, or things that we might see a way out of this really dismal diagnosis? Yeah. So for steroids have been tried in both traumatic brain injury and spinal cord injury and not using steroids and traumatic brain injury is in the latest guidelines, the only level one evidence that we have, and that's from the crash trial. So they are contraindicated absolutely in traumatic brain injury. You could potentially make some argument for them in spinal cord injury. They have largely fallen out of favor because of the NASCIS one, two, and three trials, which were just really not very well designed, have not been well replicated. And there are a lot, I mean, you're talking about a ton of steroid. I mean, if you use the NASCIS criteria, you can end up giving a gram of methylprednisolone to a patient over the course. And so there are a lot of potential side effects from that. Neuroprotectants is something that I've done a lot of research in, I mean, it's where I cut my teeth with a PhD, and that really has fallen out of favor because we haven't really found anything that's given us reliable, good data in large clinical trials. So where I've seen the research start to focus is really on critical care and maximizing recovery after the fact. I mean, ultimately the best thing that you can do is prevent these injuries. So, you know, if you're in a car, wear a seatbelt. If you're in anything with wheels, it's not a car, wear a helmet, don't do dumb things. I think self-driving cars, they're going to have to be very bad to be as bad as human drivers. So I look forward to the day when, you know, it's like getting in an elevator, you push a button and you wind up at a McDonald's instead of potentially getting into a horrific car accident driving there. That's great. So we're at one minute past our hour. Thank you both for stellar presentations. Thank you for the Education Committee for starting this series of spinal cord injury education. Thanks to TCAA for sponsoring this and y'all have a great afternoon. Thank you. Bye. Thanks everyone.

spinal cord injury

educational series

pre-hospital setting

pediatric spinal cord injuries

risk factors

C-spine precautions

vital sign monitoring

anatomy of the spine

Asia impairment scale

prevention