spinal injury

Done by \ malika hameedSupervision by \ dr - Anwer Naif Group D

Spine fracture

Clinical Anatomy

• Vertebral Column:– Extends from skull

to the pelvis– 33 total vertebrae:

• Superiorly: 24 individual vertebrae (separated by intervertebral discs)

• Inferiorly: 9 fuse to form 2 composite bones

– Sacrum (5)– Coccyx (4)

Clinical Anatomy

• Vertebral Column:– Functions:

1. Transmits weight of the trunk to the lower limbs

2. Surrounds/protects spinal cord

3. Attachment point for the ribs and muscles of neck and back

Vertebral Anatomy

Body2 Lamina Spinous

process2 Transverse

process2 PedicleFacet joints

Vertebral Anatomy

Vertebral Anatomy

• Intervertebral Discs:– 23 intervertebral discs– No disc between skull and C1 or between

C1-C2– Discs are thickest in the lumbar vertebrae

and cervical regions (enhances flexibility)

• Functions:– Shock absorbers

• walking, jumping, running

– Allow spine to bend– At points of compression, the discs flatten

out and bulge out a bit between the vertebrae

Vertebral Anatomy

Clinical Anatomy

Clinical Anatomy

• Major Supporting Ligaments– Anterior Longitudinal

Ligament– runs vertically along

anterior surface of vertebral bodies

• Neck - Sacrum• Attaches strongly to both

vertebrae and intervertebral discs (very wide)

• Prevents back hyperextension

Clinical Anatomy

• Major Supporting Ligaments– *Posterior Longitudinal

Ligament

– - runs vertically along posterior surfaces of vertebral bodies

• Narrower, weaker

• Attaches to intervertebral discs

• Prevents hyperflexion

• Major Supporting Ligaments– Ligamentum Flavum - strong

ligament that connects the laminae of the vertebrae

• Protects the neural elements and the spinal cord

• Stabilizes the spine to prevent excessive vertebral body motion

• Strongest of the spinal ligaments

• Forms the posterior wall of the spinal canal with the laminae

• Stretches with forward bending / recoils in erect position

Clinical Anatomy

Clinical Anatomy

sporting Ligaments– Intertransverse Ligament

- located between the transverse processes

• Cervical region: consist of a few irregular, scattered fibers

• Thoracic region: rounded cords connected with deep muscles of the back

• Lumbar region: thin and membranous

Clinical Anatomy

Supporting Ligaments– Interspinal Ligament

- connect spinous processes (spans the entire process)

• Meets the ligamentum flavum in front and the supraspinal ligament behind

Clinical Anatomy

Supporting Ligaments– Supraspinal Ligament

-connects together the apexes of the spinous processes

• Extends from 7th cervical vertebra to sacrum

• Strong fibrous cord• At points of attachment

(tips of the spinous processes) fibrocartilage is developed in the ligament

Supraspinal Ligament

Clinical Anatomy

vertebral column

Significance

Unstable if middle column + either Anterior or Posterior column

is damaged

Rupture of interspinous ligament is :

- associated with avulsion of spinous process

- Unstable spine

- Further flexion increases neurological injury

• Cervical 40%

• Thoracic 10%• Lumbar 3%• Dorso lumbar

35%

Incidence :-

-More in males 20-40 (more exposure to mechanism of injury) .

Most frequently injured spinal regions C5-C7 (Mid cervical)C1-C2 (Upper cervical) T12-L2 (Dorso-lumbar)

Mechanism of injury

:Penetrating trauma as knives bullets. Or blunt trauma as car accident

I. Direct trauma

:

A. Hyper-flexion trauma:

-Fall in bent position.

-Deceleration.

II-indirect Trauma

-Wedge fracture

-Stable

-No spinal cord injury

B- Hyper-extension injuries

-sudden acceleration

Blow on forehead-

INCLUDE

hangman’s #

# of arch of atlas and axis

ant. Longitudinal tear

-stable except hangman fracture-

-Spinal cord may be damage

C- compression trauma

-fall from height on foot .

-Fall on head

-fall something on head

-burst fracture

-Stable #

-No spinal nerve

injury

D-Shearing (specially rotation)-rotation cause ligaments Damage , usually associated with flexion.As:-Fall from height with the body twistedOrWeight fall asymmetrically onto the back**Wedge shape # with shearing of posterior ligament.

spinal usually affectunstable #

Denis classification 1.Compression fracture (wedge)2.Flexion compression (Burst)3.Flexion distraction4.(Seat belt fracture, Chance fr.)5.Fracture Dislocation

Classification

• I- according to morphology• II- according to stability

I- according to morphology

1. Wedge compression fracture:Hyper-flexion trauma crushes the vertebral body into the shape of a wedge.

2. Fracture dislocation:

Commonly there is damage to the spinal cord and nerve roots.

3. Dislocation:

Pure dislocation without fracture is common in cervical vertebrae because its

articular processes are rather horizontal.

4. Comminuted (burst) fracture:This is an uncommon injury due to vertical compression of the straight spine.

5. Avulsion fractures of transverse and spinous processes:Not accompanied by neurological injury and require no special treatment.

II- according to stability

1-Stable fractures: Have intact posterior ligaments, e.g., wedge compression,

comminuted and avulsion fracture of the transverse and spinous processes.

2-Unstable fractures: Have torn posterior ligaments and are liable to injure the

cord and nerve roots, these include fracture dislocation and pure dislocations

Spinal cord injury

classification

I- According to injury 1-Primary injuriesOccur at time of trauma.

2-Secondary injuriesOccur later due to:-Swelling-Ischemia-Movement of bony fragments

Type of injury:

Concussed

Contused

Compressed

Lacerated

Severity of injuries depends on:

Amount and type of force

Duration of injury

II – According to neurology DAMAGE

Complete Cord Lesions – Death --aboveC4-Quadriplegia below C4 -Paraplegia thoracic or lumbar level

Incomplete Cord Lesions - mixed loss - Anterior sc syndrome - Posterior sc syndrome - Central cord syndrome - Brown sequard’s syndrome - Cauda equina syndrome

Incomplete cord lesion:1-Central cord syndromeFlaccid weakness of arm and spastic weakness of the leg2- anterior cord syndromecomplete loss of muscle strength below the level of injury loss pain and temperature3-brown sequard syndromeMotor deficit on side of lesion while sensory deficit on the other side4-Posterior cord syndrome Loose of light touch andproprioception

Diagnosis :

History

• Mechanism of injury • Position of the patient when found

• Transient motor or sensory loss • Paradoxical breathing • Seat belt

Physical examination

• A- General examination:- -Vital sign- -Look for missed injury- -look for associated fracture

B-Local examination:

Inspection: Abrasion - hematoma- deformity

Soft tissue swelling and bruising

Palpation :

Point of spinal tendernessGap or Step-offSpasm of associated muscles

DON’T MOVE

C- neurological examination

1-Dermatome and myotome.2- superficial and deep reflex .

Is the patient awake or “unexaminable”?

• What’s the difference ?– Awake

• ask/answer question• pain/tenderness• motor/sensory exam

– Not awake• you can ask (but they won’t answer)• can’t assess tenderness• no motor/sensory exam

OW!

------

“Unexaminable”

≠

“No exam”

Neurogenic Shock

• Temporary loss of autonomic function of the cord at the level of injury– results from cervical or high thoracic injury

• Presentation– Flaccid paralysis distal to injury site

– Loss of autonomic function

• hypotension• vasodilatation• loss of bladder and bowel control• loss of thermoregulation

• warm, pink, dry below injury site

• bradycardia

42

Neurogenic Hypovolemic

Etiology Loss of sympathetic outflow

Loss of blood volume

Blood pressure

Hypotension Hypotension

Heart rate Bradycardia Tachycardia

Skin temperature

Warm Cold

Urine output

Normal Low

Comparison of neurogenic and hypovolemic shock

Cervical Spine Imaging Options

– Plain films• AP, lateral and open mouth view

– Optional: Oblique and Swimmer’s

– CT• Better for occult fractures

– MRI• Very good for spinal cord, soft tissue and

ligamentous injuries

– Flexion-Extension Plain Films• to determine stability

Radiolographic evaluation

X-ray Guidelines (cervical)

ABCDS

• Adequacy, Alignment• Bone abnormality, Base of skull• Cartilage• Disc space• Soft tissue

Adequacy

• Must visualize entire C-spine • A film that does not show the

upper border of T1 is inadequate

• Caudal traction on the arms may help

• If can not, get swimmer’s view or CT

Swimmer’s view

Alignment

• The anterior vertebral line, posterior vertebral line, and spinolaminar line should have a smooth curve with no steps or discontinuities

• Malalignment of the posterior vertebral bodies is more significant than that anteriorly, which may be due to rotation

• A step-off of >3.5mm issignificant anywhere

Lateral Cervical Spine X-Ray

• Anterior subluxation of one vertebra on another indicates facet dislocation– < 50% of the width of a

vertebral body unilateral facet dislocation

– > 50% bilateral facet dislocation

Bones

Disc

• Disc Spaces– Should be

uniform

• Assess spaces between the spinous processes

Soft tissue

• Nasopharyngeal space (C1)– 10 mm (adult)

• Retropharyngeal space (C2-C4)– 5-7 mm

• Retrotracheal space (C5-C7) – 14 mm (children)– 22 mm (adults)

AP C-spine Films

• Spinous processes should line up

• Disc space should be uniform

• Vertebral body height should be uniform. Check for oblique fractures.

Open mouth view

• Adequacy: all of : all of the dens and the dens and lateral borders of lateral borders of C1 & C2C1 & C2

• Alignment: lateral : lateral masses of C1 and masses of C1 and C2C2

• Bone: Inspect dens for lucent fracture lines

CT Scan

• Thin cut CT scan should be used to evaluate abnormal, suspicious or poorly visualized areas on plain film

• The combination of plain film and directed CT scan provides a false negative rate of less than 0.1%

MRI

• Ideally all patients with abnormal neurological examination should be evaluated with MRI scan

Management

• Primary Goal– Prevent secondary injury

• Immobilization of the spine begins in the initial assessment– Treat the spine as a long bone

• Secure joint above and below– Caution with “partial” spine splinting

Management

PREHOSPITALHOSPITALPOST HOSPITAL

Goal of spine trauma care

• Protect further injury during evaluation and management

• Identify spine injury or document absence of spine injury

• Optimize conditions for maximal neurologic recovery

Goal of spine trauma care

• Maintain or restore spinal alignment

• Minimize loss of spinal mobility

• Obtain healed & stable spine

• Facilitate rehabilitation

Pre-hospital management

1- ensure the ventilation and circulation

:2- CAREFUL transportation OF PATIENT if we Suspect Spinal Injury

When should we Suspect Spinal Injury

-High speed crash

-Unconscious

-Multiple injuries

-Neurological deficit

-Spinal pain/tenderness

• PROTECTION PRIORITY

• Detection Secondary

• Up to 15% of spinal injuries have a second (possibly non adjacent) fracture elsewhere in the spine

• Ideally, whole spine should be immobilized in neutral position on a firm surface

Clinical assessment

• Advance Trauma Life Support (ATLS) guidelines

• Primary and secondary surveys • Adequate airway and ventilation are the

most important factors

• Supplemental oxygenation• Early intubation is critical to limit secondary

injury from hypoxia

Principle of treatment

• Spinal alignment– deformity/subluxation/dislocation reduction

• Spinal column stability– unstable stabilization

• Neurological status– neurological deficit decompression

Stable # : -no reduction-immobilization with cervical collar or plaster jacket for 4-6 weeks .

Unstable #

Unstable cervical #1- reduction-close reduction : by skull traction –skin traction or manipulation Open reduction2- fixation:By cervical collar or halo vest(6-12 weeks) or internal fixation or post fusion.

Unstable lumbar #1- reduction:By gradual postural reduction by use of pillow or sand bags under appropriate spinal level for 12 weeks orOpen reduction 2- immoilization:By plaster jacket or By internal fixation

Local management

-Restore alignment-Decompress neural damage-Stabilize the spine by fixation and fusion-Allow early mobilization

-Restore alignment by tractionDecompress not retard - recovery or decrease further injury-No need for stabilization most injury stable-Mobilization achieved by active physiotherapy in confined bed pt

General management

1- care of skin:

-Trophic ulcer

-Skin keep dry by regular washing and powder

2- care of bladder:

Decompress by catheter-

Antibiotics if infection occurred

3- care of bowel:

By evacuation by enema and giving low residual diet

4- care of muscles and joints:

By passive movement twice daily

complication

• 1- Spinal cord and/or root injury including roots of cauda spina

• 2- Shock may be:

• a- Spinal shock• - Sympathatic affection leading to loss of

vascular tone & bradycardia• - loss of muscle tone ) venous pooling &

hypovolemia• b- Hemorrhage lead to true hypovolemia

FRECTURE OF CERVICAL

Jefferson Fracture

• Burst fracture of C1 ring

• Unstable fracture

• Increased lateral ADI on lateral film if ruptured transverse ligament and displacement of C1 lateral masses on open mouth view

• Need CT scan

the key radiographic view is the AP open mouth

Jefferson Fracture

Burst Fracture

• Fracture of C3-C7 from axial loading

• Spinal cord injury is common from posterior displacement of fragments into the spinal canal

• Unstable

Clay Shoveler’s Fracture

• Flexion fracture of spinous process

• C7>C6>T1

• Stable fracture

Flexion Teardrop Fracture

• Flexion injury causing a fracture of the

• anteroinferior portion of the vertebral body

• Unstable because usually associated with posterior ligamentous injury

Bilateral Facet Dislocation

• Flexion injury• Subluxation of dislocated

vertebra of greater than ½ the AP diameter of the vertebral body below it

• High incidence of spinal cord injury

• Extremely unstable

Hangman’s Fracture

• Extension injury

• Bilateral fractures of C2 pedicles

(white arrow)

• Anterior dislocation of C2 vertebral body (red arrow)

• Unstable

Odontoid Fractures

• Complex mechanism of injury• Generally unstable• Type 1 fracture through the tip

– Rare

• Type 2 fracture through the base– Most common

• Type 3 fracture through the base into body of axis– Best prognosis

Odontoid fracture Type I

fracture in superior tip of the odontoid.

potentially unstable.

It is a relatively rare fracture.

Odontoid Fracture Type II

Odontoid Fracture Type III

• This is an example of dens type III fracture. The first image is an odontoid view, which shows the fracture line extending beyond the base of the dens.

• The second image is a CT that confirms the fracture in the body of C2

Question

Which of the following fractures is caused by hyperextension?

Jefferson fracture.

Hangman's fracture.

Teardrop fracture.

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