spinal cord inj

Spinal Cord Injuries

Ahmed Al-sum R I

Content• Causes• Anatomy• Stability• Classification• Clinical feature• Diagnosis• Management• Disposition

Causes • MVC 40%• Falls• Violence ( GSW )• Sporting activities

Male

80%

Female20%

causes of SCI

Fruc-ture85%

peurly ligam-intus inj

10%

SCIWORA5%

Fructure peurly ligamintus inj SCIWORA

Stability• Resistance to displacement of fracture

fragments or, the entire vertebral unit , (in the case of ligamentous injury)

• It may occur at the time of injury or progressively over hours to weeks and can cause or worsen damage to the spinal cord or nerve roots

Stability• The anterior column is

formed by alternating vertebral bodies and intervertebral disks surrounded by the annulus fibrosus capsule and the anterior longitudinal ligament.

• The middle column consists of the posterior part of the annulus fibrosus and posterior vertebral wall, the posterior longitudinal ligament, the spinal cord, the paired laminae and pedicles, the articulating facets, the transverse processes, and the nerve roots and vertebral arteries and veins

Stability

Stability• The posterior column

consists of the spinous processes, nuchal ligament, interspinous and supraspinous ligaments, and ligamentum flavum.

Stability• Disruption of only a

single column usually preserves a high degree of stability but does not preclude SCI from displaced fracture fragments.

• Disruption of two columns results in an injury that is stable in one direction but unstable in another (e.g., stable in flexion but unstable in extension)

• Disruption of all three columns produces a highly unstable

• injury.

Stability

• All spinal injuries should be treated as potentially unstable, and spinal immobilization should be maintained

Classification of SCI By Mechanism

Flexion Flexion rotation

Extension Vertical Compression

Flexion

Pure flexion injuries of C1-C2 • Aatlanto-occipital or• Atlantoaxial joint

dislocation• with or without # of

odontoid• UNSTABLE because of

their location and the relative lack of muscle and ligamentous support

Flexion

Pure flexion injuries of C1-C2

Flexion

SIMPLE WEDGE # Pure flexion injuries below C2

• Because the posterior column intact, this injury is usually STABLE and rarely cause damage.

• However, spinal instability may occur with sever Wedge #

Flexion

SIMPLE WEDGE # • Radiographically, there

is a diminished height and increased concavity of the anterior border of the vertebral body, an increased density of the vertebral body, and prevertebral soft tissue swelling

Flexion

Flexion Teardrop #• Because this injury

commonly involves anterior and posterior ligamentous disruption, it is often associated with neurologic injury and is highly UNSTABLE

Flexion

Clay Shoveler’s #• Abrupt head flexion

against the supraspinous ligament resulted in an avulsion fracture of the spinous process.

• Because this injury involves only the spinous process, it is STABLE

Flexion

Pure Spinal Subluxation• occurs when the

ligamentous complexes rupture without an associated bony injury.

• rarely associated with neurologic damage, this injury is potentially UNSTABLE.

Flexion

Pure Spinal Subluxation The LRG of neck• Neutral position may

show a widening of both interspinous and intervertebral spaces posteriorly at the level of injury,

• Oblique views may demonstrate a widening or abnormal alignment of the facets

Flexion

Pure Spinal Subluxation The LRG of neck• These findings are

often subtle and may be missed if flexion and extension views are not obtained.

Flexion

Bilateral facet dislocations • occur when a greater

force of flexion causes soft tissue disruption to continue anteriorly to the annulus fibrosis of the intervertebral disk and the anterior longitudinal ligament.

• It’s an extremely UNSTABLE condition.

Flexion

Bilateral facet dislocations • Radiographically the

anterior displacement will appear to be greater than one half of the AP diameter of the lower vertebral body with the superior facets anterior to the inferior facets

Flexion

Shear Injury Type I• # of the odontoid process

above the transverse ligaments

• usually STABLE because they are an avulsion injury to the odontoid tip.

• BUT , if traction injure the apical and alar ligaments, then may become UNSTABLE

Flexion

Shear Injury Type II• # at the base of the

odontoid process where it attaches to C2.

• More common• UNSTABLE and often

complicated by nonunion. SCI is uncommon but can occur

Flexion

Shear Injury Type III• Slight angulation of the

force may result in extension of the fracture into the body of C2.

• Mechanically UNSTABLE as they can extend laterally into the superior articular facet of the atlas.

Flexion

Shear Injury

Flexion-Rotation

Rotary Atlantoaxial Dislocation• UNSTABLE injury• visualized best on open-

mouth odontoid radiographs

Flexion-Rotation

Unilateral Facet Dislocation• both flexion and rotation• Simultaneous flexion and

rotation cause the contralateral facet joint to dislocate.

• The dislocated articular mass is mechanically locked in place, making this a STABLE injury

Extension

Posterior Neural Arch # of C1• Compression of the

posterior elements between the occiput and the spinous process of C2 during forced neck extension.

• This fracture is potentially UNSTABLE because of its location.

Extension

Hangman’s fracture• Cervicocranium is

thrown into extreme hyperextension as a result of abrupt deceleration.

• Bilateral # of the pedicles of C2 W or WO dislocation.

Extension

Hangman’s fracture• Although this lesion is

UNSTABLE, cord damage is often minimal because the AP diameter of the neural canal is greatest at the C2 level

Extension

Extension Teardrop Fracture• occurs when abrupt

extension of the neck• Often occurring in

lower cervical vertebrae (C5-C7) from diving accidents

• May be associated with a central cord syndrome

Extension

Extension Teardrop Fracture• Because the posterior

elements remain intact, this injury is STABLE in flexion but potentially UNSTABLE in extension.

Vertical Compression

Burst Fracture• occur in the cervical

and lumbar regions, which are capable of straightening at the time of impact.

• It’s is a STABLE fracture because all ligaments remain intact

• However, fracture fragments may impinge on or penetrate the ventral surface of the spinal cord and cause an anterior cord syndrome


Burst Fracture• The lateral radiograph

shows a comminuted vertebral body, and there will typically be greater than 40% compression of the anterior vertebral body which help in differentiation between simple Wedge #.


Jefferson fracture of C1• Vertical compression

force drives the lateral masses of C1 outward, resulting in fractures of the anterior and posterior arches of the atlas and a disruption of the transverse ligament.

• Extremely UNSTABLE injury.


Jefferson fracture of C1• Often associated with

prevertebral hemorrhage and retropharyngeal swelling.

• lateral film may demonstrate a widening of the predental space between the anterior arch of C1 and

• the odontoid.


Jefferson fracture of C1• The open-mouth view

will demonstrate a bilateral offset of both right and left lateral masses of C1 more than 7mm.

• The Jefferson fracture is difficult to recognize, and (CT) may be necessary.

Classification of SCI By Etiology

Primary Secondary

Primary Spinal Cord Injury• FIRST

• Penetrating trauma • Massive blunt trauma with disruption

of the vertebral column may cause the transection of neural elements.

• such injuries are IRREVERSABLE• Less severe blunt trauma may have

similar effects resulting from a displaced bony fragment or a herniated disk.

Primary Spinal Cord Injury• SECOND

• In elderly patients with osteoarthritis and spondylosis when subjected to forcible cervical spine extension

• This injury frequently results in a central cord syndrome.

Primary Spinal Cord Injury• THIRED

• Primary vascular damage to the spinal cord.• Compressed by an

extradural hematoma.• discrepancy between the

neurologic deficit and the known level of spinal injury

Secondary Spinal Cord Injury• The maximum neurologic deficit after

blunt SCI Often not seen immediately and may progress over hour.

• It is now thought that primary SCI initiates a complex cascade of biochemical events that result in progressive ischemia of gray and white matter during the postinjury period .

• Other factors, such as hypoxia, hypotension, hyperthermia, hypoglycemia, and mishandling by medical personnel, also affect the ultimate extent of SCI

Clinical Features

NEUROLOGIC EVALUATION • Hx

• Talk to the pt.• pain in the sensory dermatome

corresponding to the injured spinal level .

• C2 lesion may cause occipital pain.

• discomfort in the trapezius muscle, suggests a C5 injury. in the absence of signs of local trauma

NEUROLOGIC EVALUATION • Hx

• PMH.• Down Syndrome predisposed to

atlanto-occipital dislocation, • Rheumatoid Arthritis are prone to

rupture of the transverse ligament of C2.

NEUROLOGIC EVALUATION • Inspection

• Significant head and facial trauma have a 5 to 10% incidence of associated cervical spine injuries .

• Scapular contusions suggest a rotation or flexion-rotation injury of the thoracic spine.

• Seat-Belt sign associated W carotid , vertebral and intra- abdominal inj.


• In case of fall inj.• injuries to the gluteal region,

calcaneal fractures, and severe ankle fractures suggest a compression type of spinal injury.


• abnormal abdominal breathing pattern may provide an important clue to a cervical injury.

• Horner’s syndrome, (unilateral ptosis, miosis, and anhidrosis) may result from disruption of the cervical sympathetic chain, usually between C7 and T2.

• Priapism may occur with severe SCI, and it is often associated with spinal shock.

NEUROLOGIC EVALUATION • Palpation

• areas of tenderness, deformity, or muscle spasm.

• A “gibbus” deformity or step-off may be appreciated with severe subluxation.

• Widening of an interspinous space indicates a tear in the posterior ligament complex and a potentially unstable spinal injury.

NEUROLOGIC EVALUATION • Motor Examination

• rapid baseline assessment. • When a deficit is noted, the motor and

neurologic examination should be repeated at frequent intervals because progression of dysfunction may occur.

NEUROLOGIC EVALUATION • Sensory Examination

• An accurate baseline sensory examination is imperative because a cephalad progression of hypesthesia is the most sensitive indicator of deterioration.

• When this is observed in the cervical region, should anticipate impending respiratory failure and stabilize the airway

Complete Spinal Cord Lesions• Total loss of motor power and sensation

distal to the site of an SCI.• Functional motor recovery is rare in a

patient with a complete cord syndrome that persists for longer than 24 hours after the inj.

• Before diagnosis of a complete cord syndrome, however, two points should be considered

Complete Spinal Cord Lesions• First:

• any evidence of minimal cord function, such as sacral sparing, excludes the patient from this group. • Signs of sacral sparing include

perianal sensation, normal rectal sphincter tone, or flexor toe movement.

• The presence of any of these signs indicates a partial lesion, usually a central cord syndrome, and the patient may have marked functional recovery,

Complete Spinal Cord Lesions• Second:

• complete spinal cord lesion may be mimicked by spinal shock, which may persist from a few days to a few weeks which causes total neurologic dysfunction distal to the site of injury.

• during which time the patient’s prognosis cannot be accurately assessed.

• A complete spinal cord lesion will remain unchanged after the cessation of spinal shock.

Incomplete Spinal Cord Lesions• Approximately 90% of incomplete spinal

injuries can be classified as one of three clinical syndromes:• The central cord syndrome, • The Brown-Sequard syndrome, • The anterior cord syndrome

Incomplete Spinal Cord Lesions• Central Cord Syndrome

• The most common, seen in patients with degenerative arthritis of the cervical vertebrae when their necks are hyperextended.

• concussion or contusion of the central gray matter in the most central portions of the pyramidal and spinothalamic tracts.

• upper extremities are more severely affected than the lower extremities.

Incomplete Spinal Cord Lesions• Central Cord Syndrome

• With more severe injuries, patients may appear to be almost completely quadriplegic and have only sacral sparing.

• prognosis is variable, but more than 50% of patients become ambulatory and regain bowel and bladder control, as well as some hand function.

Incomplete Spinal Cord Lesions• Brown-Sequard syndrome

• hemisection of the spinal cord, usually results from penetrating trauma but may also be seen after lateral mass fractures of the cervical spine.

• ipsilateral loss of position and vibration sense as well as motor paralysis but contralateral loss of pain and temperature sensation distal to the level of injury

Incomplete Spinal Cord Lesions• Brown-Sequard syndrome

• Virtually all patients maintain bowel and bladder function and unilateral motor strength, and most become ambulatory.

Incomplete Spinal Cord Lesions• Anterior Cord syndrome

• results from hyperflexion injuries causing cord contusion, by the protrusion of a bony fragment or herniated disk into the spinal canal, or by laceration or thrombosis of the anterior spinal artery.

• Also after prolonged (longer than 30 minutes) cross-clamping of the aorta.

Incomplete Spinal Cord Lesions• Anterior Cord syndrome

• paralysis and hypalgesia below the level of injury with preservation of posterior column functions, including position, touch, and vibratory sensations.

• When suspecting ACS urgent neurosurgical consultation because it may be a result of a surgically correctable lesion.

Incomplete Spinal Cord Lesions• Other less common lesions :

• Posteroinferior cerebellar artery syndrome.

• Horner’s syndrome• acute cauda equina syndrome

Imaging

Cervical Plain Radiographs

Computed Tomography• The CT scan is the technique of choice for

the definitive evaluation of acute cervical spine trauma.

• CT permits examination without moving the patient from the supine position and is thus preferable in terms of fracture stabilization

• (EAST) recommend that CT from the occiput to T1 be used as the primary screening method in blunt cervical trauma patients

Magnetic Resonance Imaging• CT has a higher sensitivity than MRI to

detect fractures and dislocations at the craniocervical junction, as well as fractures of the posterior elements of the spine.

• MRI has the ability to directly image nonosseous structures, including intramedullary and extramedullary spinal abnormalities that potentially cause neurologic deficit.

Magnetic Resonance Imaging• MRI can identify three separate patterns of

SCI, including • acute cord hemorrhage, • cord edema or contusion, • mixed cord injury

• MRI is also viewed as the best diagnostic imaging modality for SCIWORA

• MRI, has superior resolution and lack of ionizing radiation.

• Has contraindication

Mannagement

Disposition

Cervical Sprain• Patients with musculoskeletal injuries of

the spine who have only mild to moderate discomfort without neurologic impairment or abnormal radiographic findings are best managed as outpatients.

• Treatment should include analgesics and referral for follow-up evaluation.

Minor Fractures• Most patients with spinal fractures require

hospitalization.• Patients with isolated cervical vertebral

body compression fractures or spinous process fractures may be managed as outpatients if the mechanism of injury is not significant.

• For patients with minor wedge fractures (<10% wedge fractures) who do not have an associated neurologic deficit, outpatient management may also be possible.

Thank you

Flexion

Bilateral facet dislocations • Radiographically the

anterior displacement will appear to be greater than one half of the AP diameter of the lower vertebral body with the superior facets anterior to the inferior facets

Flexion

Shear Injury Type III• Slight angulation of the

force may result in extension of the fracture into the body of C2.

• Mechanically UNSTABLE as they can extend laterally into the superior articular facet of the atlas.


Burst Fracture• The lateral radiograph

shows a comminuted vertebral body, and there will typically be greater than 40% compression of the anterior vertebral body which help in differentiation between simple Wedge #.

spinal cord inj

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