Consult.\ Dr. Essam Abdelmenam Anbar

Dr. Mahmoud Ahmed Zidan

Spinal injury

Spinal injury may be defined as injury to the spinal column (bone column)/spinal cord or both

Improper management can have horrible and permanent result

Appropriate use of immobilization can mean difference between a patient who fully recovers and other spent whole life paralyzed.

Introduction

Ateiolgy and Distribution

Most common cervical region(55%)Mortality rate 40-50%Between the ages 16-30. M:F=4:1Most frequent age is 19Current estimates are 250,000 - 400,000 individuals living

with Spinal Cord Injury or Spinal Dysfunction60% of all spine injuries in children; upper

cervical spine.C5-C6 is the most commonly injured level in

adults.

Epidemiology

Ranges of Motion (in degrees)

Normal Spinal Anatomy

33 separate irregular bones

Cervical Vertebrae

Small vetrebral body Extensive joint surface

Thoracic Vertebrae

Designed to remain stiff and straight

Lumbar vertebrae

Weight bearing vertebrae

Spinal Ligament

Mechanisms of injuries Compression injuries

Flexion Injuries

Extension Injuries

Rotational

Vertebral body fractureDisc herniation Displacement of post. wall of thee vertebral body

Tearing of interspinous ligaments . Disruption of post. Ligament . Tearing of Ant. Long. Lig. Separation of vertebral bodies .Avulsion of upper vertebral body from disc. Associated with unilateral facet dislocation .

Flexion injury

Extension injury

• ant. Long. Ligament + ant. One half of the vertebral body, disc, annulus.

Ant. column

• Post. Long. Lig. + post. Half of the vertebral body, disc, annulus.

Middle column

• facet joints, ligamentum flavum , post elements and the interconnecting lig.

Post. column

The Three- Column Theory

Types of

Fractures Seat belt

fractures

Wedge fractureBurst

dislocation

STABLE AND UNSTABLE FRACTURES :

GENERALLY , A FRACTURE IS CONSIDERED STABLE IF ONLY THE ANT. COLUMN IS INVOLVED, AS IN MOST OF WEDGED FRACTURES.

WHEEN THE ANT. AND MIDDLE COLUMNS ARE INVOLVED THE FRACTURE MAY BE CONSIDERED MORE UNSTABLE.

WHEN ALL THREE COLUMNS ARE INVOLVED THE FRACTURE IS CONSIDERED BY DEFINITION UNSTABLE.

Types of Fracture Column Affected Stable Vs. UnstableWedge fracture Ant. Only STABLEBurst fracture Ant. And Middle UNSTABLEFracture / dislocation injuries

Ant. MiddlePost.

UNSTABLE

Seat belt fractures Ant.MiddlePost.

UNSTABLE

Cutting compression or stretching of spinal cord

Causing loss of distal function sensation or motion

Caused by: -unstable or sharp bony fragment

pushing the cord - Pressure from bone fragments or

swelling that interrupts the blood supply to the cord causing ischemia

Spinal Cord injury

▪Primary spinal cord injury - cutting, compression or stretching of spinal cord

▪Secondary spinal cord injury -occurs later due to swelling, ischemia or movement of unstable bony fragments

Spinal cord injury

Incomplete lesions : any residual motor or sensory fxn more than 3 segments below the level of injury.

- Sacral sparing ; sensation around the anus, voluntary rectal sphincter contraction , or voluntary toe flexion

- an injury does not qualify as incomplete with preserved sacral reflexes alone .

Complete lesion : NO preservation of any motor and/or sensory fxn more than 3 segments below the level of the injury.

( the persistence of a complete spinal cord injury beyond 24 hrs indicates that no distal fxn will recover . Only 3% will recover within 24 hrs . )

Completeness of lesion ..

High speed crashCompression injury (diving, fall on buttock)Significant blunt traumaVery violent mechanismUnconsciousNeurological deficitSpinal pain/tenderness

Suspected Spinal Injury

Aims of Management :

Prevention of further injury to spinal cord . Reduction and stabilization of bony injuries .Prevention of complications .Rehabilitation .

Management

Protect spine at all times during the management of patients with multiple injuries

Up to 5% 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

Cervical spine immobilization

Transportation of spinal cord-injured patients

Pre-hospital management

Initial evaluation and treat-ment

ABC's Stablization for transport don't move patient before stabilization of

cervical spine. In hospital Usual trauma protocol Traction rule of thumb is 5 pounds per spinal level

above the fracture/dislocation. 60-80 pounds are usually the upper limit in

any case.

Pharmacologic treatment of SCI

1.Hypertension adequate volume and normotension

2. Methylprednislone within 8 hours of the SCI protocol 30mg/kg initial IV bolus over 15 minutes followed by a 45 minute pause, and then a 5.4 mg/kg/hr continuous infusion.

3. Naloxone 

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) AABBCDS

• 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)

Open mouth view• Adequacy: all of the

dens and lateral borders of C1 & C2

• Alignment: lateral masses of C1 and C2

• Bone: Inspect dens for lucent fracture lines

Spinal and Neurogenic shock

Injuries of the Upper Cervical Spine

Odontoid Anatomy

Steele's rule of thirds The dens, subarachnoid space, and spinal cord each occupy 1/3 of the area of the canal

at the level of the atlas.

Ligaments

External1. posterior occipito-

atlantal ligament (ligamentum

flavum ends at C1).

2. anterior occipito-atlantal ligament.

3. ligamentum nuchae.

4. anterior longitu-dinal ligament.

 

Internal1. cruciform liga-

ment( transverse ligament )

2. accessory liga-ments

3. apical ligament 4. alar ligaments5. posterior longitu-

dinal ligament ( tectorial mem-

bane )

Types of injuriesI. Atlanto-occipital dislocation.II. Condylar fractures.III. Atlanto-axial dislocation.IV. Atlas fractures.V. Odontoid fractures.VI. Hangman's fractures.VII. C3 fractures.

Atlas fractures cervicomedullary junc-

tion remains un-changed because of ca-pacity of spinal canal.

Jefferson’s fracture Burst fracture of C1 ring cervical spine is subjected to

an axial load, as would occur from a direct blow to the top of the head

Unstable fracture Need CT scan

Imaging

Spence's Rule If, on plain films, the distance of excur-

sion of lateral masses is 7 mm or more, there is a transverse ligament rupture.

Treatment

Halo immobilization in virtually all cases except when Spence's rule exceeded

Odontoid Fractures

Odontoid frac-tures

are the M/C fractures of C2.

Classification

Clinical Features

need high index of suspicion in all trauma patients many signs and symptoms are non-spe-

cific vertebral artery compression may cause

brain stem ischemic symptoms. most patients unwilling to go from supine

to sitting position without supporting their

heads with their hands.

Odontoid Fracture Type II

Odontoid Fracture Type III

Treatment and results

Halo traction, maximum of 5-10 pounds to achieve reduction

Surgery Type I : no fusion required Type III : no fusion required (>90% fuse with Halo immobilization) Type II : several factors important in decision making

1. Patient age. sixty years of age is the usually quoted cutoff for conservative management.

2. Displacement If >6 mm and >60 years, 85% nonunion rate.

3. Age of fracture greater than 2 weeks seems to be the cutoff for high union rate

Hangman's Fracture

Unstable Hyperextension injury Pathophysiology and Classification Hangman's fracture involves a bilateral

arch fracture of C2 (pars interarticularis i.e,

the pedicle) with variable C2 on C3 displacement.

Treatment

type I may be treated in a rigid collar for 12 weeks. remainder are all treated initially with

Halo immobilization. up to 5% will eventually require surgery.

Surgical Procedures

1. C1-C3 arthrodesis 2. C2 pedicle screws. 3. C2-C3 anterior discectomy with fu-

sion and plate.

Injuries of the Lower Cervical Spine

Classification

I. flexion-dislocation II. flexion-compression

III. compression burst

IV. extension

Flexion Dislocation Injuries

A) unilateral facet subluxationB) bilateral facet dislocation

Indications for surgery

1. failure to obtain reduction 2. failure to maintain reduction 3. pseudoarthrosis 4. purely ligamentous injury 5. re-subluxation 6. any patient with jumped facets

Flexion Compression Injuries

A) wedge compression

B) teardrop flexion 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

Compression Burst Fractures

characterized by axial loading in-juries to a spine which is held in a neutral or very slightly flexed po-sition.

immobilized by traction with a Halo vest.

Extension Injuries

may occur either in distraction or compres-sion.

Surgical Considerations absolute Indications 1. inability to obtain reduction 2. inability to maintain reduction indications for emergent surgery 1. progression of neurological deficit 2. complete myelographic or MRI CSF block 3. fragments in spinal canal in incomplete SCI 4. necessity for decompressing a cervical nerve

root 5. open or penetrating trauma 6. non-reducible fractures

Contraindications for emer-gent surgery

1. complete SCI 2. central cord syndrome. 3. medically unstable patient.

Surgical techniques

posterior ap-proaches

anterior ap-proaches

cervical orthoses

Thoracolumbar Spine Fractures

Epidemiology

represent 40% of all spine fractures majority due to motor vehicle accidents. grouped into thoracic (T1-T10) thoracolumbar (T11-L1) lumbar fractures (L2-L5) 60% occur between T12 and L2

Biomechanics

In general, compression causes burst fractures, flexion causes wedge fractures, rotation causes fracture disloca-

tions, shear causes seatbelt type fractures.

thoracic region is inherently more sta-ble

because of the rib cage and ligaments linking the ribs and spine.

the three column model states that failure of

two or more columns results in instability.

the middle column is crucial, its mode of

failure distinguishes the four types of spine

fractures.

Imaging most important initial study is a complete plain film series of the spine.

5-20% of fractures are multiple.

CT is used to define the bony anatomy in the

injured area.

MRI essential to define spinal cord anatomy

and also for assessing ligamentous injury.

Flexion Compression Fractures

most common type of fracture.

failure of the anterior column due to flexion and

compression.

a minimum of 30% loss of ventral height is necessary to appreciate a kyphotic defor-

mity on x-rays.

generally consid-ered

stable.

usually managed with bedrest analgesics early mobiliza-

tion

Burst Fractures

17% of major spinal fractures between T1-T10, most burst fractures are associated with complete neurological

deficit. bony fragments may be retropulsed into

the canal (25% of cases) and associated fractures of the posterior elements are common. failure of anterior and middle column de-

fines these as unstable.

Management

those fractures with canal compromise in the

presence of neurological deficit should be treated with surgical decompression and fusion.

the treatment of burst fractures with canal compromise and no neurological deficit is

controversial.

generally, management is based upon determination of stability.

those fractures with >50% loss of vertebral body height, or if the posterior column

injury includes a facet fracture or dislocation are

considered unstable.

commonly sited indications for surgery are either,

i) angular deformity >15-40 degrees ii) canal compromise >40-70%

Seat Belt Injuries

6% of major spinal injuries.

caused by hyperflexion and distraction of the posterior ele-

ments.

the middle and posterior columns fail in distraction with an intact anterior hinge.

unstable in flexion but will not present with an

anterior subluxation, which would indi-cate

that the ALL is disrupted (i.e. a fracture-dislocation).

PLL is also intact and sometimes fracture fragments are moved back from the canal simply by distraction.

Management

treatment of mainly osseous injuries is bracing while mainly ligamentous injuries

are treated with posterior fusion.

Fracture Dislocations

19% of major spinal fractures. anterior and cranial displacement of the superior vertebral

body with failure of all

three columns.

Extension Distraction Frac-tures

rare injuries.

hyperextension force tears the ALL and leads

to separation of the disc.

all are unstable and require fixation.

Treatment

By Degree

according to Denis, first degree is mechanical instability, second degree is neurolgical, and third is both.

first degree: manage with external or-thosis

i) >30 degree wedge compression fracture ii) Seat belt injuries.

second degree: mixed category

third degree: all require surgery i) fracture dislocations ii) burst fractures who fail non-operative manage-

ment iii) burst fractures who develop new neurological

deficit

Non-operative Therapy

external orthosis for 8-12 weeks serial radiographs every 2-3 weeks for the

first 3 months, then

4-6 week intervals until 6 months and

at 3 month intervals for 1 year.

Indications for operative therapy

1. progressive neurological deficit 2. spinal cord compression 3. dural laceration 4. unstable spine

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