Makindo Medical Notes

💡 Spinal fractures range from low-energy osteoporotic wedge fractures to high-energy fracture–dislocations with cord injury. Your priorities are: ATLS, spinal precautions, early imaging, and neurology. Stability and neurological status drive management.

📖 Initial Priorities (ATLS + Spinal Precautions)

• ATLS first: Airway with in-line stabilisation, Breathing, Circulation. Avoid neck manipulation until cleared.
• Spinal precautions: Rigid collar (if not contraindicated), head blocks, scoop/slider, log-roll with team lead; avoid prolonged hard-board time (pressure sores).
• Analgesia & VTE: Early multimodal analgesia; LMWH when safe (balance with neuraxial procedures / haematoma risk).
• Safeguarding red flags: In the elderly, consider fragility fracture; in non-ambulant or inconsistent histories, consider non-accidental injury.

🧠 Neurological Assessment (drives urgency)

• Screen: Pain site, paraesthesia, power, sphincter tone, priapism (spinal shock), saddle anaesthesia.
• Classify: Use ASIA Impairment Scale (A–E); document dermatomes/myotomes (C5–T1, L2–S1) and perianal sensation/voluntary anal contraction.
• Red flags — act now: New deficit, suspected cauda equina (bilateral sciatica, urinary retention/incontinence, saddle anaesthesia), progressive weakness → urgent MRI and spinal/ortho-neuro referral.

🩻 Imaging Strategy

• CT whole spine is the workhorse in trauma — high sensitivity for bony injury; include reformats.
• MRI if neurological deficit, suspected ligamentous/cord injury, epidural haematoma, occult fracture, or for cauda equina; also in persistent pain with normal CT.
• Plain films only for low-risk scenarios (e.g. outpatient osteoporotic pain) where CT is not needed.

🧩 Injury Patterns — What they mean

• Cervical: – C1 Jefferson (axial load; burst of atlas) — assess transverse ligament on MRI. – C2 Odontoid (Type I tip; II base — unstable; III into body). – Hangman’s (C2 pars) — hyperextension/axial load. – Facet dislocations (unilateral/bilateral) — often with cord risk.
• Thoracolumbar (T/L): – Compression/wedge (anterior column) — often stable, esp. osteoporotic. – Burst (retropulsed fragments) — canal compromise, variable stability. – Chance (flexion–distraction seat-belt injury) — posterior ligamentous complex (PLC) injury → unstable. – Fracture–dislocation — multidirectional instability, high cord risk.

🧮 Classifying Stability (helps decisions)

• Denis 3-column model: Middle column injury ⇒ likely unstable.
• AO Spine (simplified): – A (compression), B (tension band failure/PLC), C (translation/rotation). Higher letter = higher instability; add neurological (N0–N4) and modifiers (M).
• C-spine clearing: Use validated rules (e.g., Canadian C-Spine) in low-risk; in the ED, most trauma goes straight to CT.

💊 Acute Medical Management (what you can start now)

• Pain: Paracetamol + short NSAID course if renal/GI risk acceptable; early short-course opioids; calcitonin can help acute osteoporotic pain (short-term).
• Immobilisation: Collar/halo for selected C-spine; TLSO brace for selected T/L stable patterns. Avoid over-immobilising frail patients (delirium, sores).
• Neurogenic shock: Hypotension + bradycardia (above T6). Treat with cautious fluids, vasopressors (e.g., noradrenaline). Maintain MAP targets (often ≥85–90 mmHg early) if cord injury suspected (local protocol).
• Steroids: Routine high-dose steroids are not recommended for acute cord injury in UK practice.
• Cauda equina syndrome: Emergency MRI and decompression — time-critical.

🔧 Surgical vs Conservative — The principles

• Operate for: unstable patterns (AO B/C), progressive or significant neuro deficit, significant canal compromise (burst with retropulsion + deficit), failure of conservative care, polytrauma requiring early mobilisation.
• Conservative for: stable compression fractures without deficit; good pain control; brace + physio + early mobilisation.
• Cement augmentation (vertebroplasty/kyphoplasty): selected painful osteoporotic compression fractures refractory to optimal medical therapy (exclude posterior wall breach/neural compromise).

🧱 Osteoporotic (Fragility) Vertebral Fractures

• Presentation: Sudden thoracolumbar pain after minimal trauma, height loss, kyphosis; neurology usually intact.
• Assess secondary causes: Ca²⁺, PO₄, ALP, 25-OH-vit D, TFTs, coeliac screen, SPEP/UPEP (myeloma), steroids history.
• Management: Analgesia, short rest then mobilisation, spinal orthosis if helpful, falls assessment, DEXA. Start bone protection per FRAX/DEXA (oral bisphosphonate first-line; IV zoledronate if adherence/GI issues); ensure calcium/vit D repletion.

🧪 Associated Syndromes to Spot

• Diffuse idiopathic skeletal hyperostosis / ankylosing spondylitis: “Long-bone” spine — fractures are highly unstable after minor trauma; require CT/MRI and specialist fixation strategies.
• Pathological fractures: Metastases, myeloma, infection — look for lytic lesions, constitutional symptoms; consider MRI and oncology/ID input.

🧰 Practical Ward Checklist

• ATLS done; C-spine protected; analgesia charted; bowel regimen started; LMWH considered.
• CT whole spine reported; MRI requested if neuro/PLC concern.
• ASIA grade documented; neuro obs frequency set; MAP goals communicated if cord injury.
• Bracing instruction written; PT/OT referrals; pressure-area care; delirium prevention.
• Bone health: FRAX/DEXA plan, Ca/vit D, bisphosphonate where indicated; falls clinic referral.

⚠️ Red Flags — Don’t Miss

• New neuro deficit; sphincter dysfunction; saddle anaesthesia → urgent MRI/consult.
• High-risk mechanisms (fall from height, high-speed RTC), midline tenderness, intoxication, distracting injuries → image liberally.
• Frail patient on the trolley for hours with collar → pressure sores and delirium: expedite clearance or appropriate padding.

📚 Teaching Pearls (why it works)

• Stability + Neurology are the two axes that predict deterioration and dictate fixation vs bracing.
• Middle column injury (Denis) or PLC failure (AO B) usually means instability even if pain seems modest.
• Early mobilisation (with safe bracing) reduces complications: VTE, pneumonia, deconditioning — particularly in older adults.
• Don’t chase x-ray “heights” alone: correlate pain, PLC signs, canal compromise, and the patient’s goals.