spinal injury - web viewhangman’s fracture: extension +/- distraction injury; bilateral...
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Spinal Trauma
Anatomy
Anterior column: Ant long lig, ant part annular lig Ant ½ vertebraeMiddle column: Post long lig, post part annular lig Post ½ vertebraePosterior column: Interspinous lig, lig flavum IV facet joint, pedicles, laminae, spinous processes, neural arch
Epidemiology
Unstable when: 2/3 columns affected>3mm displacement of vertebral bodyAngle >11° between vertebraeAnterior height <⅔ posterior height (>25% height of affected vertebral body)Fanning of interspinous distance
Post lig involvement suggested by: avulsion # tip spinous process, wide separation of vertebral spines, facet joint fracture, neural arch fracture, shift of 1 vertebrae on another, shearing fracture of vertebral body. If present = ?unstable, ?neural involvementMovements: C3-7 all directions C1-2 rotation Atlanto-occipital joint flexion/extensionSpinal cord: spinal cord ends at L1-2; lumbar and sacral segments of spinal cord lie between T10-L1 (T12 vertebrae = L1 spinal cord)Spinothalamic Crosses at spinal cord; cervical sensation medial, sacral sensation at periphery Anterior: touch and pressure Lateral: pain and temp Dorsal Crosses at medulla; sacral sensation medial, cervical peripheral Touch, pressure, vibration, proprioceptionCorticospinal Anterior crosses at spinal cord, lateral crosses at medulla Anterior: axial and proximal muscles, posture, gross motor, 20% Lateral: distal muscles, fine motor, 80%
C spine: Male:female 4:1; risk factor from MVAs are HI (most important), ejection, roll over, no seat belt, facial burns, extensive car damage, death of occupant; C2 most common fracture (25%); C5-6 / 6-7 most common dislocationT/L spine: T/L junction most at risk; 65% fractures between T12 and L2, 90% between T11 and L4; 95% are vertical / oblique, 5% horizontal; 20% with fractures have 2nd fracture; 50% have other injury
Paediatrics Lower incidence; more upper C spine and atlanto-occipital (large head, lax ligaments, horizontal plane of facet joints); dens fuses at 6-8yrs; treat children >8yrs as would adults; use CT sparingly
NEXUS Criteria
Not applicable to infants; 99% sensitivity for any injury, 99.6% sensitivity for significant injury, 13% specificity; results in 12% C spine imagingNo XR if blunt injury and: no FND No ETOH No Xtra (distracting) injury No Unconscious (ie. Normal LOC) No Spinal tenderness of neck
Assess rotation 45° only XR if can’t do
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C1
15-20% associated with
C2 injury
25% associated with lower C spine injury
Jefferson fracture: vertical compression injury; blowout fracture anterior and posterior arch, disrupts transverse ligament; lateral masses C1 driven laterally; wide pre-dental space, but post spinal line may be OK; displacement of lateral masses >2mm or unilateral displacement; unstable; 50% survive without deficit; ⅓ associated with C2 fracture; ½ associated with other C spine fracture
Fracture posterior arch atlas: extension injury; maybe unstable; treat in collar / traction for 6/52Atlanto-occipital dislocation: flexion injury; fatal; unstableAnterior atlanto-axial dislocation: flexion injury; rupture of transverse ligament of dens; often fatal; unstablePosterior atlanto-axial dislocation: extension injury; unstableRotatory atlanto-axial dislocation: rotational injury; torticollis; may be associated with anterior displacement; unstable
C2
Most commonly fractured vertebrae
Usually associated with
C1 injury
Canadian C Spine Rule
Incorporates MOI and examination findings; for alert, stable patients; sensitivity 100%, specificity 43% for clinically important injury; results in 15% C spine imaging; compares favourably with NEXUSHigh risk therefore do XR if: >65yrs / extremity paraesthesia / fall >1m / fall >5 stairs / axial load to head / high speed MVA, roll over, ejection / bike collision / motorised recreational vehicle Low risk therefore no XR needed if: walking after injury / sitting in ED / simple rear shunt / delayed onset neck pain / no midline tenderness
If low risk criteria fulfilled, assess rotation 45° only XR if can’t do If low risk criteria not fulfilled, do XR
Investigation
C spine XR: anterior intervertebral line, posterior intervertebral line, spinolaminar line, interspinous line (displacement of 2 lines suggests unstable injury; <1mm anterior subluxation (<3mm in children) may be normal); predental space (<3mm adult, <5mm children); vertebral body height (posterior height should be at least 3mm more than anterior height); soft tissue swelling (present in 60% anterior fracture, 30% posterior fracture, 15% patients with no injury – due to ETT, pooled pharyngeal secretions, child) Penning’s criteria: C1 <10mm / C2 <7mm / C6 <22mm (15mm in children) (or <width vertebral body) Sensitivity 95% if adequate films (70-85% with lateral shoot-through in trauma room); 0.2% risk of missing unstable injury; inadequate views in up to 35% Flexion/extension views not recommended, risk of neurological injury, false negative from spasm, no clinically validated criteria for interpretation, do MRI insteadC spine CT: Indications: any fracture/?fracture on XR (25% will have 2nd fracture, 35% will not have been visible on XR), head CT, high index suspicion despite normal XR Sensitvity >95% for fracture / dislocation; may miss ligamentous injury at C1-2; if altered LOC, no FND, normal CT false neg rate 0.1%C spine MRI: better than CT for ligaments, discs, spinal cord; Sensitivity 100% for cord injury, 55% for fracture, 80% for dislocations; in spinal cord, hypoattenuation = haemorrhage, hyperattenuation = oedema / transection; investigation of choice if neuro symptomsL/T spine XR: widened mediastinum; displacement of L paraspinal line; pleural cap; interpedicular distances should gradually increase from L-5; lack of concavity of post vertebral body cortex (?burst fracture); sensitivity 75%L/T spine CT: sensitivity 95%
Hangman’s fracture: extension +/- distraction injury; bilateral fracture of pedicles of axis (through pars interarticularis) anterior movement of C2 on 3 of >2mm, avulsion of ant-inf corner of C2 associated with rupture of ant long lig; prevertebral soft tissue swelling; unstable; cord injury rare; causes Horner’s syndrome (ipsilateral constricted pupil due to damage of sympathetic trunk); treat with external immobilisation
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C2(cntd)
Dens Fracture: flexion injury; 10-15%; complicated by soft tissue swelling I = 5-8% = tip, above transverse ligament II = 55-70% = junction of body and dens; unstable; needs OT if displaced >6mm III = 30-35% = through body of dens; unstable but good prognosis
Extension teardrop fracture: usually involves axis; extension injury; unstable; causes central cord syndromeOs odonotoideum: failure of fusion of tip to body of dens (ossification centre should appear at 2yrs, fuse by 12yrs); unstable, requires post fusionC2-3 pseudosubluxation: common in infants and children (40% <8yrs) – will disrupt posterior interspinous line but spinolaminar line conserved, will cause pre-dental space in children; less commonly occurs at C3-4, 4-5 levels
C7Clay shoveller’s fracture: flexion injury; avulsion / direct blow to lower spinous processes; ghost sign on AP view (displaced fractured spinous process); stable; cervical collar 2-3/52
Anterior Teardrop Fracture
Flexion injuryWedge-shaped antero-inferior fractureLigamentous (anterior longitudinal ligament) and neurological involvement common due to retropulsion of fragmentsUnstable
Anterior Wedge /
Compression Fracture
C spine: Flexion injury; Stable; cervical collar 6/52T/L spine: major; flexion / axial load; most common at T12-L2; middle and posterior column intact; may be associated with ant-sup marginal shearing #; neural injury rare (more common if lateral wedging and nerve root involvement; if post wedging present, suggests more violence, ?burst fracture and ?spinal cord involvement); stable usually; unstable if anterior margin reduced >50% and posterior ligament injured; symptomatic treatment
Flexion/distraction injury, seatbelt injuyry, distraction injury occurs as pivot pushed more anteriorly, around anterior abdominal wall; major; failure of posterior column: complete disruption of spinous process, laminae, transverse process, pedicles, vertebral bodies; oblique / horizontal splitting of spinous process and neural arch, pushing post-sup aspect of vertebral body into intervertebral disc; widened interpedicular distance seen; suggested by vacant appearance of vertebral body on AP film, discontinuity of cortex of pedicles / spinous processes on AP failure of posterior and middle columns; ligamentous involvement; unstable; 65% have intestinal / mesenteric injury
Chance Fracture
POSTERIOR INVOLVEMENT
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Horizontal Fissure
FractureSimilar to Chance fracture, but fracture line extends horizontally through vertebral body to anterior aspect
Smith Fracture Fracture through superior articular processes, arch and sup-post vertebral body, but spares posterior spinous processes; posterior ligaments disrupted
Burst Fracture
C spine: Vertical compression injury; comminuted but ligaments intact; fracture fragments may still injure cord; stable unless severe (>15-20°); traction 6/52T/L spine: major; vertical compression injury; loss of vertebral height anteriorly and posteriorly pedicles widened on AP; fracture fragments may injure cord; failure of anterior and middle columns; unstable
Transverse Process Fracture
Associated with renal / ureteric / splenic / hepatic / pancreatic injury, adrenal haematoma, diaphragmatic hernia, pelvic fracture; L3 most common (30%)
Translational Injury Shear forces; AP/PA trauma; affects neural canal
Subluxation Flexion injury; loss of normal cervical lordosis, fnaning of interspinous distance; only anterior intervertebral ligament intact; unstable; requires reduction / fusion
Rotational injury; disruption (>2mm) of spinolaminar line and spinous processes on AP / lateral film; wide interspinous distances; widening of disc space; subluxation <½ vertebral body width of vertebra above over vertebra below; angulation of spine by >11° on AP view; better view available on oblique films; unstable if associated facet fracture; treat by reduction
Unilateral Facet Joint Dislocation
Flexion injury; Disruption of anterior ligament and annulus of disc; bow tie / bat wing appearance of locked facets; subluxation >½ vertebral body width; unstable; require reduction / fusion
Unilateral Facet Joint Dislocation
C Spine Immobilisation
Indication: recommended if for XR; no evidence of efficacy in prevention of spinal cord injury in conscious patients (may worsen outcome by uncontrolled reduction); optimal position with 2cm occiput elevationMethod: Use C spine collar, sandbags + tape (better than collar), headblock and spinal board, strapping, Vac PacComplications: ICP, access to neck, discomfort, prompts unnecessary investigation, patient anxiety, cutaneous pressure ulceration (especially if prolonged use), requirement for log rolling, aspiration, DVT, may worsen neurological injury (if displaced fracture, pre-existing cervical deformity), masks other injuries, pulmonary function
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Cord Injury
Usually associated with bony / ligamentous injury (SCIWORA rare, more in children, more in C spine); most common in C5-T1, mid-thoracic, L1-T12, close to bony fusion; “level” refers to last unaffected level; “complete” if ongoing symptoms after reflexes return (implied incomplete if sacral sparing); paralysis flaccid and areflexia in spinal cord injuryMOI: direct trauma, 2Y oedema, excitatory neurotransmitter release, epidural haematoma, vascular injury, delayed apoptosis of oligodendrocytes
Central Cord Syndrome
Anterior Cord Syndrome
Posterior Column Syndrome
Motor Sensory Autonomic
Brown-Sequard Lesion
Neurogenic Shock
Spinal Shock
Autonomic Dysreflexia
Bilat arm > leg weak Bilat prox > distal weak
Reflexes variable
Bilateral leg > arm weakness
No motor involvement
Ipsilateral weaknessReflexes variable
Quadriplegia / high paraplegia
Loss of voluntary movement and reflexes
As per old lesion
Bilat arm > leg numbBilat prox > distal numb
Bilat pain, temp, coarse touch (some dorsal column
sensation still OK)
Bilat vibration, light touch + proprioception
Ipsilat vibration, light touch and proprioception; contralat pain and temp
?
Loss of sensation
As per old lesion
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-
-
No sphincter involvement
HR/BP; vasoD; poikilothermia; no sweating; erection; paralytic ileus; sphincter paralysis; flaccid bladder
paralysis
autonomic reflexes below level of lesion
Impaired total body SNS, pelvic PNS; HR; BP; headache;
sweating; erection; flushing above lesion; cold; piloerection below
lesion; bowel/bladder contraction; mydriasis; headache
Hyperextension injury in elderly; 50% good
recovery
Flexion / vertical compression; 10-15% full
recovery
Hyperextension / penetrating inj from back
Penetrating injury / unilateral facet joint inj;
mod outcome
Temporary cessation of SC neuro function
Complete injury above T1-4; resolves in 48hrs
Lasts few hrs - several wks
Any lesion at/above T6; trigger eg. Bladder distension, p sore
Treat: elevate head, 10mg SL nifedipine,
remove cause
Cord Injury
Treatment:A: insert NGT (high risk of aspiration); consider ETT; have atropine available as exaggerated vagal response to instrumentation; C spine immobilisation; pre-vertebral haematoma can obstruction; RSI best if urgent, fibreoptic if notB: paradoxical breathing; assess vital capacity; O2 to prevent 2Y injury (as in HI)C: assess GCS, UO, CVP; early insertion of IDC; suspect hypovolaemia until proven otherwise if BP bolus IVF; may require inotrope / chronotrope; neurogenic shock makes it hard to assess degree of bleedingD: look for Horner’s if injury at/above T4; PR; anal and bulbocavernosus reflex; analgesia; attention to temperature; place IDC early to avoid bladder overdistensionE: care for pressure areas
Steroids: indicated if <8hrs / recommended by spinal unit; 30mg/kg IV methylpred over 15mins 5.4mg/kg VI infusion over 23hrs; contraindicated if heavily contaminated wounds, bowel perforation, sepsis, diabetesPrognosis: 50% good recovery if preservation of S4-5 sensation at 3-7/7 (10-15% without); areas of sparing in dermatome gives 50% chance recovery in that myotome; incr age, worse prognosis